bluuebunny/crossref_metadata_2025_split huggingface dataset:
206 Emergency department clinical leads’ experiences of implementing primary care services where GPs work in or alongside emergency departments in the UK: a qualitative study
Authors: Edwards Michelle , Cooper Alison , Davies Freya , Carson-Stevens Andrew , Hughes Thomas , Porter Alison , Snooks Helen , Edwards Adrian 
Published: January 2021

Aims/Objectives/BackgroundWe aim to describe ED clinical leads’ experiences of implementing and delivering ‘primary care services’ and ‘emergency medicine services’ where GPs were integrated into the ED team. NHS England policy has promoted services in which patients presenting to EDs with non-urgent problems are directed to general practitioners (GPs) and other primary care clinicians working within or alongside EDs to address increasing demand. Our findings describe variation in the ways that these primary care services are implemented and the ways in which GPs work within them. We also highlight successes and challenges in implementing such services.Methods/DesignWe conducted interviews with ED clinical leads in England (n=19) and Wales (n=2). We used framework analysis to analyse interview transcripts and explore differences across ‘primary care services’, ‘emergency medicine services’ and emergency departments without primary care services.Results/ConclusionsIn EDs with separate primary care services, success was reported with a distinct workforce of primary care clinicians, who improved waiting times and flow by seeing primary care-type patients in a timely way, using fewer investigations, and enabling ED doctors to focus on more acutely unwell patients. Some challenges were: aligning services with the policy guidance, inconsistent demand for primary care, accessible community primary care services, difficulties recruiting GPs, lack of funding, difficulties agreeing governance protocols and establishing effective streaming pathways. Where GPs were integrated into an ED workforce success was reported as managing the demand for both emergency and primary care and reducing admissions.To support successful and sustainable primary care services in or alongside EDs, policy makers and commissioners should consider varied ways that GPs can be employed to manage local demand and also local contextual factors such as the ability to recruit and retain GPs, sustainable funding, clear governance frameworks, training, support and guidance for all staff.
207 Patients’motivations and expectations when seeking urgent care at emergency departments and acceptability of primary care streaming: a realist study
Authors: Edwards Michelle , Price Delyth , Hepburn Julie , Harrington Barbara , Evans Bridie , Cooper Alison , Edwards Adrian 
Published: January 2021

Aims/Objectives/BackgroundWe aim to explain the contexts and mechanisms that influence patients’ motivations and expectations when accessing urgent care at an ED and their acceptability of being streamed to a primary care clinician working in or alongside the ED. Recent healthcare policy has encouraged the implementation of primary care services in or alongside emergency departments whereby patients with low acuity illness are streamed to a primary care clinician after a brief initial assessment. Our findings describe patients’ motivations, expectations, and acceptability of primary care streaming and their level of satisfaction.Methods/DesignWe recruited 24 patients to be interviewed after visiting an emergency department for one of five low acuity complaints. 12 patients were streamed to ED clinicians and 11 were streamed to primary care clinicians. We carried out semi-structured realist style interviews by telephone and carried out a realist analysis to create theories to explain motivations to attend, acceptability of streaming and satisfaction with care.Results/ConclusionsMotivations for attending the ED included patients’ perception of their complaint as an emergency which needed immediate treatment, and previous experience of receiving care at the ED. Acceptability of primary care streaming was related to patients’ past experiences accessing primary care services, their trust in initial assessment processes and their expectation to be seen by ‘expert clinicians’ on the ‘same day’. When patients’ expectations of waiting times, level of investigations and general quality of care were met or exceeded, they reported acceptability to being streamed to a primary care clinician and were satisfied with their care. Understanding why patients attend the ED for urgent care needs and their experience of primary care streaming is essential to addressing increasing ED demand and improving efficiency.
104 Management of sports-related concussion in UK emergency departments: a multi-centre study
Authors: Rashid Haroon , Dobbin Nick , Mishra Smarak 
Published: January 2021

Aims/Objectives/BackgroundIt is necessary for those working in emergency departments to have adequate knowledge and delivery of current sport-related concussion (SRC) management protocols including identifying patients with concussion, managing their symptoms, giving appropriate advice with regards to return to play and referring those at risk of further injuries to an appropriate service.This study aimed to establish the current practice, knowledge base and views towards SRC management of emergency department clinicians who have trained or are currently training in emergency medicine in the North West of England.Methods/DesignThis study was a multi centre, cross sectional study of 111 emergency department clinicians (EDCs) working across 15 centres in the North West of England A 21 item online survey was issued. The key questions focused on the advice given to patients on discharge, the importance of cognitive and physical rest, and knowledge of GRTP.Results/ConclusionsApproximately, 37% of the population responded to the invitation, with 111 responses included in this study. Only 27% of total respondents were aware of the Consensus Statements of Concussion in Sport guidelines, whilst 45% were unaware of any SRC guidelines. 57% of respondents had heard of a graded return to play (GRTP) protocol. Physical rest following an SRC was advised by 95% of respondents with 61% advising concomitant cognitive rest and 42% of respondents providing specific written advice. 90% of clinicians had not received any SRC training.There is a lack of knowledge amongst EDCs in the North West of England in managing and providing discharge advice according to recommendations for patients with SRC. This is likely a consequence of the limited training that these clinicians have received in managing SRC and suggests further work needs to be undertaken to educate EDCs on current SRC management guidance to ensure appropriate care and discharge advice is given to patients.
140 Killed in Action (KIA): an analysis of military personnel who died of their injuries before reaching a definitive medical treatment facility in Afghanistan (2004–2014)
Authors: Webster Stacey , Barnard Ed , Smith Jason , Marsden Max , Wright Chris 
Published: January 2021

Aims/Objectives/BackgroundMost fatalities from trauma, in civilian and military settings, die before reaching a hospital. However, no previous studies have comprehensively examined this phase of care. The aim of this study was to define the time interval between injury and death in UK military personnel who died pre-hospital from enemy action (Killed in Action, KIA).Methods/DesignThe UK Joint Trauma Theatre Registry (JTTR) was used to identify all UK military personnel who died in Afghanistan (2004–2014). Through novel linkage of medical and tactical databases, an accurate timeline of events was obtained. Cause of death was determined from post mortem review. The primary objective was to report time between injury and death. Secondary objectives: mortality at key timepoints, the temporal lethality of different anatomical injuries, and trends in the case fatality rate (CFR, defined as deaths/injuries x100). Data are reported as n(%), and median [inter-quartile range]. Proportions compared with a Fisher’s exact test, and survival was with a Gehan-Breslow-Wilcoxon test; level of significance was corrected by Bonferroni.Results/Conclusions2413 UK personnel were injured in Afghanistan from 2004–2014; 448 died, a CFR of 18.6%. 390 (87.1%) of total deaths (KIA + Killed Non-Enemy Action) were prehospital. Complete timeline data were available for n=303 (87.1%) KIA – this cohort had a median injury severity score of 75.0 [55.5–75.0]. The median time between injury and death in KIA was 0.0 [0.0–21.8] minutes; 173 (57.1%) died immediately, and by 10 min more than two-thirds had died. Primary injury to the head had a significantly shorter time to death compared to the abdomen and lower extremity (both p<0.01). Significant improvement in survival over the decade was due to a reduction in pre-hospital CFR without an increase in in-hospital CFR.Over two-thirds of KIA deaths occurred within 10 min of injury. Improvement in the CFR in Afghanistan was predominantly in the prehospital phase.
145 Point of care lung ultrasound in patient triage: integration of ultrasound into a streaming pathway for COVID-19
Authors: Craver Dominic , Ahmad Aminah , Colclough Anna 
Published: January 2021

Aims/Objectives/BackgroundRapid risk stratification of patients is vital for Emergency Department (ED) streaming during the COVID-19 pandemic. Ideally, patients should be split into red (suspected/confirmed COVID-19) and green (non COVID-19) zones in order to minimise the risk of patient-to-patient and patient-to-staff transmission. A robust yet rapid streaming system combining clinician impression with point-of-care diagnostics is therefore necessary.Point of care ultrasound (POCUS) findings in COVID-19 have been shown to correlate well with computed tomography (CT) findings, and it therefore has value as a front-door diagnostic tool. At University Hospital Lewisham (a district general hospital in south London), we recognised the value of early POCUS and its potential for use in patient streaming.Methods/DesignWe developed a training programme, ‘POCUS for COVID’ and subsequently integrated POCUS into streaming of our ED patients. The training involved Zoom lectures, a face to face practical, a 10 scan sign off process followed by a final triggered assessment. Patient outcomes were reviewed in conjunction with their scan reports.Results/ConclusionsCurrently, we have 21 ED junior doctors performing ultrasound scans independently, and all patients presenting to our department are scanned either in triage or in the ambulance. A combination of clinical judgement and scan findings are used to stream the patient to an appropriate area.Service evaluation with analysis of audit data has found our streaming to be 94% sensitive and 79% specific as an indicator of COVID 19. Further analysis is ongoing.Here we present both the structure of our training programme and our integrated streaming pathway along with preliminary analysis results.
188 Senior clinical and business managers’perspectives on how different mechanisms and models of employing general practitioners in or alongside Emergency Departments influence wider system outcomes
Authors: Choudrhey Mazhar , Edwards Michelle , Cooper Alison , Anderson Pippa , Hughes Thomas , Carson-Stevens Andrew , Porter Alison , Adrian Edwards 
Published: January 2021

Aims/Objectives/BackgroundWe aim to examine senior managers’ perspectives on funding mechanisms used to implement the policy and experiences of success or challenges in introducing models of using GPs in or alongside emergency departments. Health policy in England has advocated the use of primary care clinicians at emergency departments to address pressures from rising attendances. However, implementing large systemic changes such as placing GPs in or alongside emergency departments requires significant funding, consideration of the opportunity costs of the alternative uses of such funding, an available workforce and evidence of how it should be used. Our findings will inform policy adaptation and service development to improve the healthcare provided to patients by providing new evidence of the reported experiences of adopting models of using GPs in or alongside emergency departments.Methods/DesignThe perspectives of senior clinical, business and finance managers with responsibility for emergency department services and on-site primary care service implementation were investigated in semi-structured interviews with 31 managers at 12 type-1 emergency departments in England and Wales. Emergency departments operated one of three GP models or had prior experience of implementing a GP model. Interviews were thematically analysed.Results/ConclusionsSuccessful GPs models in emergency departments were perceived to be reliant on well-organised and unified funding mechanisms, appropriate staffing and governance, and consideration of population demands and needs. Funding mechanisms and the flow of funds were reported as complex, the most efficient mechanisms were described at departments where funding was unified, in collaboration with health and community care services. Staffing with local, experienced GPs was important. There were also cautions from experiences with private locum providers. Our findings contribute to debates about implementing policy on how primary care clinicians are effectively and safely deployed in emergency departments and how local context should be considered.
303 What goes bump in the night? A literature review and noise exposure experiment in a UK paediatric emergency department
Authors: Hall Lucy , Dando Sophie , Hanks Anthony 
Published: January 2021

Aims/Objectives/BackgroundIn the Emergency department (ED), noise is a frequent and often unavoidable consequence of work undertaken and levels can often be raised during the day and night. Raised ambient noise levels have potential implications for the workforce, patients and relatives.Investigation into the problem of noise levels in the ED follows feedback from a young patient who couldn’t sleep during a prolonged stay. His complaint focused on loud, irregular banging noises such as those from closing bins that kept him awake.The team felt work should be done to see if it was a wider spread problem or just isolated to his case. A simple sound recording experiment and literature search was conducted.Methods/DesignThe literature search was conducted using electronic/online databases (Medline; Cochrane library) with a fixed date range and specific inclusion criteria.The noise exposure experiment was conducted using a verified phone app to record the sound levels. They were measured at 3 times, during a night shift, in the paediatric emergency department of UHW. All measurements were at a fixed distance and were averaged and compared with WHO recommendations.Results/ConclusionsThere are many sources of noise pollution in the ED, some are unavoidable for safety and clinical reasons.The literature review produced a small number of papers all of which found that sound levels were raised above recommended levels. Similarly, all the sounds measured in the ED also exceeded the recommendations.The most consistent finding across the papers, matched by findings from recordings, was that human behavioural modification is an easy and effective way to reduce noise levels.There are simple steps that can be taken to reduce and eliminate soundsRaising awareness regarding this problem is of great importance and focussing future work on assessing the impact in younger patients within the Emergency Department is paramount.
217 The end-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after pre-hospital emergency anaesthesia: a retrospective observational study
Authors: Price James , Sandbach Daniel , Ercole Ari , Wilson Alastair , Barnard Ed 
Published: January 2021

Aims/Objectives/BackgroundIn the United Kingdom (UK), 20% of patients with severe traumatic brain injury (TBI) receive pre-hospital emergency anaesthesia (PHEA). Current guidance recommends an end-tidal carbon dioxide (ETCO2) of 4.0–4.5kPa to achieve a low-normal arterial partial pressure of CO2 (PaCO2), and reduce secondary brain injury. This recommendation assumes a 0.5kPa ETCO2-PaCO2 gradient. However, the gradient in the acute phase of TBI is unknown. Our primary aim was to report the ETCO2-PaCO2 gradient of TBI patients at hospital arrival.Methods/DesignA retrospective cohort study of adult patients with serious TBI, who received a PHEA by a pre-hospital critical care team in the East of England between 1st April 2015 to 31st December 2017. Linear regression was performed to test for correlation and reported as R-squared (R2). A Bland-Altman plot was used to test for paired ETCO2 and PaCO2 agreement and reported with 95% confidence intervals (95%CI). ETCO2-PaCO2 gradient data were compared with a two-tailed, unpaired, t-test.Results/Conclusions107 patients were eligible for inclusion. Sixty-seven patients did not receive a PaCO2 sample within 30 minutes of hospital arrival and were therefore excluded. Forty patients had complete data and were included in the final analysis; per protocol.The mean ETCO2-PaCO2 gradient was 1.7 (±1.0) kPa, with only moderate correlation of ETCO2 and PaCO2 at hospital arrival (R2=0.23, p=0.002). The Bland-Altman bias was 1.7 (95%CI 1.4–2.0) kPa with upper and lower limits of agreement of 3.6 (95%CI 3.0–4.1) kPa and -0.2 (95%CI -0.8–0.3) kPa respectively. There was no significant gradient correlation in patients with a co-existing serious thoracic injury (R2=0.13, p=0.10), and this cohort had a larger ETCO2-PaCO2 gradient, 2.0 (±1.1) kPa, p=0.01. Patients who underwent pre-hospital arterial blood sampling had an arrival PaCO2 of 4.7 (±0.2) kPa.Lower ETCO2 targets than previously recommended may be safe and appropriate. The use of pre-hospital PaCO2 measurement is advocated.
451 Children’s emergency department review clinic: what we have learnt in the covid-19 pandemic
Authors: Munday Charlotte , Jain Neha , Harrington Seamus , Darvill Benjamin , Perry Sophie , Irwin Alice , Deibel Francesca , Turck Richard , Barber Clarissa 
Published: January 2021

Aims/Objectives/BackgroundThe Children’s Emergency Department (CED) in the Bristol Royal Hospital for Children (BRHC) runs ‘Review Clinics’ by a Paediatric Emergency Consultant. These were suspended in March 2020 due to the Covid-19 pandemic and new patient pathways were put in place. Our aim was to assess the effectiveness of these pathways and to evaluate if they should continue once the pressures of Covid-19 have eased.Methods/DesignWe reviewed all the attendances to the ED Review Clinic over a six-week period in 2019 and identified common conditions that are seen in this clinic – abscesses, cellulitis, scaphoid fracture, toddler fracture, limp, headache, peri-orbital cellulitis, torticollis, and neck lumps (accounting for 66% of all attendances).We then identified all of the ED attendances with these conditions over the same six-week period during the Covid-19 pandemic and performed a service review using medical notes.Results/ConclusionsAll children presenting with a limp during the Covid-19 pandemic were discharged with a leaflet and advised to return in one week if the limp persisted. None of them re-attended.Scaphoid and toddler fractures that presented during the Covid-19 pandemic were followed-up by Orthopaedics with a combination of telephone and face-to-face reviews. The toddler fractures were put into soft casts to be removed at home - 93% of parents were happy to do this. Orthopaedic review was quicker than the previous ED Review Clinic (an average of 63 hours compared to 216 for scaphoid fractures and 67 hours compared to 235 for toddler fractures).The results suggest that ED Review Clinics can and should change. Children with a limp can be sent home safely with clear advice. There is a greater role for telephone reviews, in particular, for injuries such as toddler fractures. This would be quicker, less time-consuming for patients, parents and physicians and more cost effective for the department.
131 Rapid and sustained increase in #FOAMed based education during COVID-19 on the St Emlyn’s blog and podcast
Authors: Carley Simon , Jafar Anisa , Reynard Charlie , Beardsell Iain , Horner Dan , Liebig Ashley Voss , Body Richard 
Published: January 2021

Aims/Objectives/BackgroundCOVID 19 has resulted in a rapid and unplanned change in the way that education is delivered and consumed. The St Emlyn’s team published a range of webinars, blogs, podcasts and critical appraisal articles specifically focused on COVID-19 during the pandemic. Some webinar content was published in conjunction with the Royal College of Emergency Medicine and the University of Manchester.We reviewed how engagement with the free and open access medical education (FOAMed) St Emlyn’s blog and podcast changed as a result of the pandemicMethods/DesignWe compared the number of visits for the last 12 months against the previous 12 months. We obtained data from Wordpress and Podbean platforms for the blog and podcast respectively. We did not add data from other social media platforms such as Twitter and Facebook. Differences are expressed as a ratio to indicate an increase or decrease in the number of engagements from the previous year.Abstract 131 Figure 1Results/ConclusionsThe data shows similar levels of between year activity from July 2018 through to February 2019. It then shows a rapid and profound increase in activity from March 2019, coinciding with the rapid spread of the pandemic in Europe and an early blog/podcast with colleagues from Northern Italy. Since then activity has fallen but still remains roughly 1.5 times higher than in previous years. Combined visits to the blog and podcast peaked at 162,019 engagements, representing a near 6.9 fold increase in podcast engagement and a 2.7 increase in blog activity during May 2019.The COVID-19 pandemic resulted in a rapid and sustained engagement with the St Emlyn’s platform. The reasons for this are unclear from the data presented here, but we believe reflect the superior agility of modern educational tools such as blogs and podcasts to share and disseminate information as compared to traditional academic publishing methods.