bluuebunny/crossref_metadata_2025_split huggingface dataset:
Evaluation of a clinical handover simulation training session for junior doctors in psychiatry
Authors: Acharya Rupali , Thomas Gareth , Hellaby Mark 
Published: November 2016

BackgroundClinical handover is an important aspect of patient care and medical education, as identified by trainee surveys. There is a need for robust, standardised handover systems. Situation, Background, Assessment and Recommendation (SBAR) is a communication and empowerment tool for standardised communication in healthcare. The purpose of this study was to evaluate the educational impact of a simulation-based educational session in clinical handover for trainees in psychiatry, using SBAR.MethodA 3-hour session for trainees in psychiatry was designed with the North West Simulation Education Network and took place at the North Western Deanery School of Psychiatry. Presession and postsession questionnaires were completed, followed by a 6-week follow-up questionnaire.ResultsA significant improvement in participants' confidence and skills was demonstrated following the teaching session. Qualitative feedback also highlighted improved clinical application of the SBAR tool. Following the session, trainees reported an improvement in their appreciation of the role of other professionals in the handover process and a sense of empowerment when liaising with senior colleagues.ConclusionsThe training session potentially improved patient care by giving trainees structure, confidence and empowerment when talking to other colleagues while handing over. This may also help to meet the training requirements of the various Royal College curricula. This is the first study, to the best of our knowledge, which has evaluated a simulation session specifically designed to develop handover skills for trainees in psychiatry.
DETECTING HEPATITIS INFECTION IN THE EMERGENCY DEPARTMENT
Authors: Hunter LJ , Douthwaite S , Nebbia G 
Published: November 2016

Objectives & BackgroundHepatitis (HBV&HCV) testing in the UK is currently targeted at groups perceived to be at high risk. Late diagnosis is common. Initial infection may only be accompanied by a mild illness or be completely asymptomatic. Chronic infection can occur and may progress to liver fibrosis, cirrhosis, decompensated liver disease or hepatocellular carcinoma if untreated.1Early diagnosis and treatment are effective in reducing disease progression (HBV) or elimination of the virus (HCV).Our aim was to determine the potential for blood borne virus testing within the ED and to evaluate the burden of HBV/HCV in our local population.MethodsPatients over the age of 16 were offered Hepatitis B (Surface antigen) and Hepatitis C (IgG antibodies) testing, if they required venepuncture during their ED attendance, in a 6 week period from 15th February 2016–27th March 2016. Tests were ordered using a pre-configured order-set including a pre-selected Hep BsAg and HepC IgGAbs. Patients were informed of the intention to test all attendances and were able to opt out if desired. Positive test results were followed up at a rapid access one-stop clinic.ResultsOver a 6 week period, 3073 (49%) and 2982 (47%) accepted testing for Hepatitis B and Hepatitis C respectively. 1.1% (n=35) tested positive for Hepatitis B surface antigen, indicating acute or chronic infection. 2.2% (n=66) tested positive for Hepatitis C antibodies, indicating current or previous HCV infection. Hepatitis C antigen testing was positive in 1.2% (n=35) indicating current HCV infection.The median age of all patients tested was 45 years (16–100 years) female 51%.HBVantibody positive: median age 42 years (24–82 years), Gender: Male 70% Ethnicity: 40% Black or Black British.HCVantigen positive: Median age 41 years (22–77 years) Gender: Male 72%, 40% White British. Two newly diagnosed patients were eligible to be commenced on direct acting anti-virals. One patient had evidence of cirrhosis on initial fibroscan.ConclusionConsider the ED for opportunistic blood borne virus testing in areas of high prevalence. We achieved testing rates of approximately 50% by use of a pre-configured blood order set and an opt-out policy, resulting in identification of new diagnoses and lost to follow-up patients. Use of a one-stop clinic provides rapid entry to care for positive patients and reduces burden of follow-up for the ED.
TIME IS MUSCLE: MANAGEMENT OF CHEST PAIN IN THE EMERGENCY DEPARTMENT
Authors: Qureshi B , Llewelyn M , Freer J , Baptiste P , Harris T 
Published: November 2016

Objectives & BackgroundMany chest pain assessment protocols include delayed troponin assays, which makes assessment within the Emergency Department (ED) 4-hour UK national target difficult, and increases pressure on medical admissions. Our objective was to evaluate the effect of point-of-care (POC) troponin testing on successful risk-stratification of patients presenting with chest pain.MethodsAn audit in a district general hospital ED in London, in two phases: 14th April 2013–15th June 2013; and 15th April 2014–15th June 2014. Between the 2 phases, laboratory-based testing (Roche Cobas E602 multi-channel analyser; limit of detection 5 ng/L and a 99th percentile of 14 ng/L) was replaced by POC troponin (Radiometer ATQ90 analyser; limit of detection 10 ng/L and a 99th percentile of 23 ng/L). A new chest pain protocol was also introduced, with 3 categories:Redfor ST-Elevation MIs;Amberfor patients requiring inpatient assessment; andGreenfor low-risk management as an outpatient. In 2013, a non-random sample of patients with chest pain as a presenting complaint was identified from the case notes; in 2014 a non-random sample was extracted from the point-of-care machines.ResultsIn 2013, data were obtained for 194 patients, and 171 in 2014. In the initial audit, using a lab-based troponin assay, 72.7% (n=141) of patients were managed on theAmberpathway, which reduced to 14.62% (n=25) post introduction of the POC troponin assay (p=0.02). In the initial audit, 23.2% patients (n=45) were managed on theGreenpathway and discharged from the ED, compared to 83.04% (n=142) post introduction of POC troponin assay (p<0.001). The proportion of patients correctly put on theGreenpathway increased from 91.1% (n=41) to 99.3% (n=41) post introduction of POC assay (p=0.003). The proportion ofAmberpatients with a troponin measured on arrival increased from 39.7% (n=56) to 100% (n=25; p<0.001). On the green pathway, troponin on arrival had increased from 31.1% (n=14) to 72.5% (n=124; p<0.001).ConclusionPoint-of-care troponin testing was associated with a higher proportion of patients discharged from the ED and managed as outpatients. This most likely resulted from reduced waiting times for the troponin assay, reducing admissions to await these results. This may also explain the association between the introduction of POC troponin assays and a higher proportion of patients correctly assigned to the cardiac assessment pathways.
CONCUSSION IN THE EMERGENCY DEPARTMENT; UNCONSCIOUSLY INCOMPETENT?
Authors: Phillips TI , Guy K , Tompkinson A , Martin R , Phillips D , Sloan N 
Published: November 2016

Objectives & BackgroundSports related concussion is an increasingly common occurrence. Outside professional sport it is typically managed within Emergency Departments. The objective was to assess the level of knowledge and understanding of UK emergency medicine doctors of concussion; it's recognition, diagnosis and management.MethodsThis was a cross-sectional observational study using self-report questionnaires. Questionnaires were distributed at regional EM conferences in July 2015 and January 2016. The questionnaire asked respondents to correctly identify signs and symptoms of concussion according to the 2012 Zurich consensus statement. It asked whether there were differences in the management of adult and paediatric concussion together with questions regarding RTP guidelines and use of potentially protective equipment.Results156 questionnaires were completed. Illegible answers, defaced or incorrectly completed questionnaires were discarded. 134 were included in the analysis. Training levels represented were: Consultant (10%), Specialist Registrar (12%), Staff Grade (5%), Core Trainee (34%), Foundation Trainee (20%), Emergency Nurse Practitioners (1.5%), Medical Students (16%).Answers to the symptomology questions were differentially weighted to produce an overall “Symptom Score” which was used for comparison. Consultants obtained the highest score (6.2). The least correct were Specialist Registrars (2.0). Diagnostic accuracy did not differ between secondary and tertiary centers (p=0.67). 80% of participants incorrectly identified headguards as being protective against concussion. 35.4% of respondents acknowledged a difference between adult and paediatric concussion.ConclusionThis small yet representative sample highlights a lack of knowledge in concussion in health professionals working in EDs in the UK. Despite the recent high profile cases in the media regarding the recognition and management of concussion, the frontline clinicians most likely to see concussive injuries have insufficient knowledge to diagnose and manage the condition effectively. There is an opportunity for Public health bodies, acute medical trusts and sports organisations to work collaboratively to provide education and resources for front line personnel that will increase awareness of concussion and improve care to patients presenting with concussive injuries.
TRIAGE OF SEPSIS PATIENTS: SIRS OR QSOFA – WHICH IS BEST?
Authors: Gunn N , Haigh C , Thomson JR 
Published: November 2016

Objectives & BackgroundRecent consensus guidelines have suggested using the qSOFA score as a tool for the identification of patients with sepsis outwith the ICU setting. In the UK, we currently use the SIRS criteria as a means of identifying these patients in the ED. We wanted to look at whether the qSOFA would reliably identify septic patients in our ED population.MethodsWe retrospectively reviewed 200 cases of adult patients presenting to our ED over a six month period who had a sepsis 6 form completed. SIRS and qSOFA scores were calculated for all patients and the results compared. Patients identified as requiring critical care input and those who died were noted.Results200 patients were identified over a 6 month period–109 male, 91 female; age range 18–95 yrs; average 66.7 yrs; IQR 1–58 yr; IQR 3–79 yrs.Of these 200 patients, 4 were admitted to ITU and 17 were admitted to HDU from the Emergency Department. There were 22 deaths in total of whom 1 died on ITU with full escalation of care, and 8 died in HDU with a decision they were not for further escalation. Of those that died outwith critical care, 8 had a decision of ward as ceiling of care made in the ED.195 cases were positive for SIRS of which 4 were admitted to ICU; 16 to HDU and 22 died. SIRS identified all patients who died and all but 1 patient who received critical care input.SIRS test was 97% sensitive and 2.4% specific. The positive predictive value is 15.9%, the negative predictive value is 80%.29 cases were positive for qSOFA of whom 1 was admitted to ICU and 9 to HDU. There were 9 deaths in this group of which 5 were patients on HDU. 4 patients identified as qSOFA positive were determined as not for escalation of care and subsequently died.qSOFA was 90% specific for identifying patients who died or required critical care input but only 48% sensitive. The positive predictive value is 42%, the negative predictive value is 92%.ConclusionqSOFA is a more specific test to identify patients requiring critical care input or at risk of death. Although SIRS is more sensitive, its lack of specificity makes it a much less effective screening tool for severe sepsis.Practically, SIRS is useful as a triage tool to identify potentially septic patients but once identified qSOFA should be used to assess severity and need for critical care involvement.
PILOTING A RAPID ASSESSMENT TOOL IN CHILDREN'S ED
Authors: Issa S , Cole R , Alcock A , Sajjanhar T , Selby N 
Published: November 2016

Objectives & BackgroundThe Children's Emergency Department at University Hospital Lewisham sees up to 130 attendances daily. This can result in delays to triage and sick children being missed.In our department, 50–84% of children are triaged within 15 minutes (monthly variation). Peak median time to triage is 41 mins and can depend on skill mix.Our objective was to create a safe Rapid Triage Tool to assess patients rapidly and identify the most unwell patients early. Recent RCEM work on Vital Signs in Children Clinical Audit 2015–16 indicated the need for improvement. Our project supports standards 1 and 3. It can also help to meet the KPI for initial assessment of ambulance patients and the RCEM pain targets.MethodsRapid Assessment Tools were designed by extrapolating from the Manchester Triage System. One for trauma/injury and a second for medical illness figures 1 and 2.▸ Pilot of 40 patients triaged- weekdays, evenings, weekends and night shifts▸ Rapid Assessment was employed when the wait for triage was greater than 30 minutes and there were more than 3 patients waiting. It was done in one minute by a senior nurse with relevant training▸ The nurse assesses the patient using the proforma, assigns a priority and indicates what actions are required▸ Secondary nurse then acts on these and completes the triage- Figure 3.Results40 patients were assessed using the Rapid Assessment Tool.▸ Qualitative correlation to the traditional triage was made and the patients were shown to be given the same priority ranking in all cases▸ It takes less than a minute to perform the Rapid Assessment compared to 5–20 minutes for the traditional triage.▸ Flow through the initial stages in the department was quicker▸ There was better use of the nursing skill mix▸ The sickest patients were identified faster▸ Figure 4ConclusionThis Rapid Triage Tool may be a safe tool to use in replacement of the traditional triage method. The perception from staff was that this felt safer and reduced the workload when there was large volume of patients.Further work▸ Training is required to standardise the implementation of the Rapid Triage Tool▸ A larger pilot will be conducted to make quantitative conclusions about the effects this has on overall triage time, time to treatment and the on meeting the RCEM Vital Signs and Pain Standards and the KPI▸ This project has identified a number of areas for improvement such as an extra HCA at triage to facilitate the observations and providing all staff with mobile saturation probesFigure 1Rapid Assessment Proforma for Illness.Figure 2Rapid Assessment Proforma for Injury.Figure 3Results (Outcomes).
ANAESTHETIC CHARTS IN ACUTE ICU ADMISSIONS: DEVELOPMENT FOR USE IN THE EMERGENCY DEPARTMENT
Authors: Castell SA , Noble B , Leyden K 
Published: November 2016

Objectives & BackgroundAnaesthetic charts are an invaluable source of concurrent and retrospective information. They provide relevant history and events during surgical and/or anaesthetic procedures. Admission notes to the intensive care unit showed poor record keeping of events outside the theatre environment. In accordance with standards set by the Royal College of Anaesthetists (RCoA) and the Association of Anaesthetists of Great Britain and Ireland (AAGBI), we developed an 'Emergency Anaesthetic Chart', to be used in the Emergency Department by both emergency physicians and anaesthetists. The aim was to improve the quality and quantity of information recorded during an emergency requiring critical care input, in a recognisable and easy to use format.MethodsA retrospective notes based review of admissions to the intensive care unit from the Emergency Department provided comparison against standards set by RCoA and AAGBI. The results were presented at a departmental meeting and the development of an ‘Emergency Anaesthetic Chart’ was undertaken to drive improvement. This was based on the current trust ‘Day/23 hour Anaesthetic Record’ used in the theatre environment. A further review looked at admission data since the implementation of the new chart, with the final data collection ongoing.ResultsIn the initial audit 9 sets of notes were examined over 6 week period, in the re-audit 11 sets of notes over a 6 week period were examined, 7 using the new chart. All were patients admitted from the emergency department.Re-audit data (before, after) showed that demographic data remained well recorded at 100%. Improvement was seen in recording of medical history (56%, 100%) initial observations, (56%, 86%) and airway assessment (11%, 29%). Most importantly recording of procedural events (44%, 71%), repeat observations (33%, 100%) and subsequent drug administrations (22%, 86%) all showed significant improvement.ConclusionWe revealed poor record keeping during critical care involvement in the emergency department and identified the need for a more reproducible and standardised method of data recording. An adapted version of a current anaesthetic chart has been found to be effective in increasing the quality and quantity of information recorded for emergency admissions. This improves adherence to the required standards, and is also recognisable and user friendly for staff conditioned to use the Trust's anaesthetic charts.
PILOTING IN ED–EXTRA DIFFICULT OR EASILY DONE
Authors: Zee T , Thomas D , Jannaway N , Bassey S 
Published: November 2016

Objectives & BackgroundPatient Identification is fundamental to the success of safe transfusion. ABO incompatible blood transfusion has been classed as a Never Event by the Department of Health.In 2014, 680 Wrong Blood in Tubes (WBIT's) were reported nationally to SHOT (Serious Hazards of Transfusion). National Guidelines have changed (2013) to improve accuracy in sample labeling (two sample rule) but SHOT reports prove on going noncompliance with this procedure.Blood samples are rejected if ANY aspect of the labeling is incorrect. This can generate rejection rates for transfusion specimens >10%. Over 3000 samples were rejected in 2014 at RCHT. This results in loss of patient confidence due to repeated clinical procedures, delay to treatment, loss of staff time, and increased cost of equipment and reagents.Llama Safe is a unique application that enables healthcare professionals to guarantee positive patient identification and accurate transfusion sample labeling at the bedside. The decision to pilot the application in the Emergency Department (ED), beginning Jan 2015, was due to:▸Above average Tx samples rejected;▸Large multidisciplinary teams with high staff rotation;▸Unpredictable workload and stressful environment;▸60–70 thousand patients per year;▸Poor adherence to labelling at the patient's bedside, including Wrong Blood in tube events annually;MethodsPrior to the pilot, two months were spent shadowing a multitude of clinical staff in the ED to fully understand the sampling processes and the problems that arise.A simple system was designed in collaboration with ED staff, containing minimal steps, ensuring all safety measures had been considered and satisfied.Llama posters and stickers were placed throughout the department to remind staff to use the new labelling system.ResultsStaff were extremely invested and supportive in the Llama implementation allowing the pilot to be smooth and successful.ED very quickly took it upon themselves to cascade training and encourage the implementation on other wards.No WBITs have been identified in ED since the introduction of Llama (18 months).Rejections in ED have reduced 10 fold with Llama labelled samples, consequently improving patient care and proving concept for full roll out.ConclusionWith appropriate planning and collaboration, introducing new technology into an acute environment can be easily achieved.Staff pressure has been relieved from a tense clinical environment.Llama was very positively received in the ED.
RESUS ESTIMATED TIMES OF ARRIVAL – JUST HOW ACCURATE ARE THEY?
Authors: Turner C , Patten H , Williams M 
Published: November 2016

Objectives & BackgroundEffective use of staff and facilities is one of the cornerstones of good Emergency Departments (EDs). An accurate estimated time of arrival (ETA) at the point of the alert call to the ED allows us to prepare efficiently prior to patients arriving.If the patient arrives too early the receiving team may not be fully assembled and specialist equipment not readily available; too late and team members are inadvertently wasting time that could have been allocated to other tasks, or leave the Resuscitation Area (Resus).We aimed to compare estimated versus actual time of arrival (ATA) of patients to Resus at UHCW ED in order to determine and quantify any difference.MethodsWe analysed records of patients alerted into resus over a 17 day period between 22/10/15 and 07/11/15.We obtained call time and ETA from alert logbook and also noted presentation subtype: cardiac arrest, trauma, medical, FAST +ve, paediatric trauma or paediatric medical.We used individual patient Resus records for the ATA and then calculated the time difference. Ambulance PRFs were also used to identify which crew had transferred the patient.Ethical approval was waived as this was regarded as service evaluation.Results104 cases were analysed representing patients alerted by crews from both East and West Ambulances Services and the HeliMed Team. Across all cases the mean difference between ETA and ATA was 4.7±17.5 minutes (calculated to two standard deviations). This ranged from arriving 11 minutes early to 62 minutes late.The data demonstrates a normal distribution and as such we can calculate that the probability of a patient arriving at or before the ETA is 30%. The probability of a patient arriving within ten minutes of the ETA is 73% and by 20 minutes after the ETA we would expect 96% of patients to have arrived.Conclusion(1) There is significant variance between ETA and ATAs(2) Most patients arrive within ten minutes of their ETA(3) If we can develop more accurate mechanisms for predicting what time alerts arrive we would potentially improve care and reduce wasted time.
ATTENDANCE AVOIDANCE THROUGH APP BASED MEDICATION REVIEW
Authors: Muller JJ , Mcnamara R 
Published: November 2016

Objectives & BackgroundAdverse drug reactions represent a major burden on healthcare, causing between 3–5% of all hospital admissions.1 This impact is magnified in older patients; studies have shown that up to 51.3% of older patients were prescribed potentially inappropriate medications.1These findings are highly relevant to Emergency Medicine with ever increasing emphasis being placed on attendance avoidance, and increasing numbers of older patients.MethodsWe utilised the STOPP/START criteria2 and Anticholinergic burden scoring3 to assess the drug histories of all patients over the age of 65 who presented over the course of a year to a major London A+E department with three common presentations: bleeding, confusion and falls.ResultsWe found consistently high levels of potentially inappropriate prescribing with 64% of patients presenting post a fall, 92% with new confusion and 23% with bleeding, having drug histories that warranted a medications review. 22% of patients presenting after a fall also had clinically relevant anticholinergic scores and higher re-attendance rates than those with low anticholinergic scores.ConclusionWe designed a pilot study using a digital app designed by a Geriatrician to analyse and prompt potential medication changes for patients admitted to our Clinical Decision Unit with the aim of future attendance avoidance.