bluuebunny/crossref_metadata_2025_split huggingface dataset:
THE IMPACT OF PERIPHERAL INTRAVENOUS (IV) CANNULATION IN THE AMBULANCE AND EMERGENCY DEPARTMENT
Authors: Steel M , Goodacre S 
Published: November 2016

Objectives & BackgroundIntravenous cannulation in an emergency setting has significant potential benefits and harms to patients. Patients need to understand these in order to make an informed decision about cannulation. This research aims to improve knowledge and understanding of the benefits and harms of cannulation to patients, in addition to understanding the patient perspective of cannulation.MethodsEighty patients were recruited from a convenience sample in a large urban academic emergency department (ED). Patients were included if they attended the department by ambulance and had a peripheral intravenous catheter inserted. Participants were asked to complete a questionnaire whilst they were attending the department. A follow up questionnaire was sent to the patients assessing the frequency of complications from cannulation. The number of attempts, proportion of catheters that go unused, rate of complications, symptoms associated with siting a cannula, patient understanding of cannulation and the patient perception of potential benefits and harms of cannulation were assessed.ResultsThe study population was 50% (40/80) male, with a mean age of 65 years and 72.5% (58/80) had their cannula inserted in the ED; the remainder were inserted in the ambulance (22/80). Cannulae were used 60% (CI 51.4%–68.6%) of the time, cannulae inserted in the ambulance were much more likely to be used than those inserted in the ED, 92% vs 48%, p<0.001.Some 21.3% (CI 13.8%–28.8%) of patients did not know why they had a cannula inserted. Not knowing why the cannula was inserted was not associated with anxiety levels (p=0.415).Mean pain score (Likert 0–10 scale) was 1.66 (CI 1.21–2.12). Patients who underwent multiple attempts reported higher pain score, 3.45 vs 1.38 (p=0.020). Only 26.6% (CI 19%–35.4%) of patients were told the risks of cannulation but 88.8% (CI 82.5%–93.8%) of patients believed insertion of the cannula was important.ConclusionThe majority of patients have an understanding of the purpose of cannulation, with the majority of patients believing cannulation is important in emergency care. However patients are not frequently told the potential risks of cannulation and would like to be told these. Cannulae inserted in the emergency department are not frequently used and efforts should be made to reduce the number of cannulae inserted but then not used.
EVALUATING THE SAFETY AND COST EFFECTIVENESS OF MANAGING FAT PAD POSITIVE ELBOW INJURIES WITHIN THE EMERGENCY DEPARTMENT
Authors: Tricks R , Ilavala LN , Cumberland J 
Published: November 2016

Objectives & BackgroundElbow injuries associated with fat pads on X-ray are traditionally treated as fractures. Studies show fracture rates vary from 23%1to 90.2%2with follow up imaging. In 2006 Sheffield Children's Hospital (SCH) Emergency Department (ED) created a guideline advising isolated fat pad injuries do not need automatic referral to fracture clinic. Review is in ED Clinic at 7 days, unless x-ray is reported as a fracture. If concerns persist referral to fracture clinic should occur. This service evaluation assesses if the guideline is being followed, its safety, cost effectiveness and variation in diagnosis and management between professionals.MethodsWe retrospectively reviewed all elbow X-rays, with their ED and radiological reports, taken in the ED at SCH from June 2014 to May 2015. Those with an initial interpretation of fat pad only by the ED clinician were included. ED and hospital notes were reviewed for management and diagnoses.Results99 isolated fat pad injuries were identified– 5 discharged immediately. 64 were referred to ED clinic as per protocol and 30 referred directly to fracture clinic. Radiology identified 11/94 as fractures of which 4 had ED clinic follow up. 3/4 were flagged by radiology, 2 were redirected to fracture clinic. 1 went from ED clinic to fracture clinic; diagnosed as a soft tissue injury (STI). 1 was not flagged and reattended with a diagnosis of STI.Of the remaining 62, 43 attended. 7 were referred to fracture clinic. 2/7 were diagnosed as fractures.Of the 30 referred to fracture clinic directly, 7 had a fracture reported by radiology. 5/7 were diagnosed as a fracture. Of those reported as no fracture, 5 fractures were diagnosed clinically. 33% of all fracture clinic reviews were diagnosed as fractures compared to 1.6% of all those seen in ED clinic.Radiologists and Orthopods agreed in 71% of fractures.There were 5 unplanned re-attenders; 1(originally referred to fracture clinic directly) was diagnosed as a fracture.Taking into account clinic costs alone a saving of £9,965 was estimated in this population of 94 patients.ConclusionOur evaluation shows it is both safe and cost effective to treat simple, fat pad positive elbow injuries with collar and cuff and ED review at 7 days. There are significant cost benefits and with an appropriate safety net and radiology reporting system, no fractures requiring significant intervention were missed.
THE COST-EFFECTIVENESS OF PATIENT CONTROLLED ANALGESIA VERSUS ROUTINE CARE IN PATIENTS PRESENTING TO THE EMERGENCY DEPARTMENT IN PAIN, WHO ARE SUBSEQUENTLY ADMITTED TO HOSPITAL
Authors: Smith JE , Squire R , Pritchard C , Ewings P , Barton A , Rockett M , Creanor S , Hayward C , Eyre V , Cocking L , Benger J 
Published: November 2016

Objectives & BackgroundThe clinical effectiveness of patient controlled analgesia (PCA) has been demonstrated in a variety of settings. However, PCA is rarely utilized in the emergency department (ED). The aim of this study was to compare the cost effectiveness of PCA versus treatment as usual (TAU) in patients admitted to the ward from the ED with pain due to traumatic injury or non-traumatic abdominal pain. This is the cost-effectiveness analysis of the previously reported PAin SoluTions In the Emergency Setting (PASTIES) study.MethodsPain scores were measured hourly for 12 hours using a visual analogue scale from 0–100 mm. Scores of 45 mm or above reflected moderate or severe pain. Cost-effectiveness is reported as the additional cost per hour in moderate to severe pain avoided by using PCA rather than TAU, the incremental cost-effectiveness ratio (ICER). Sampling variation was estimated using bootstrap methods and the effects of parameter uncertainty explored in a sensitivity analysis.ResultsFor patients suffering pain from traumatic injuries, the cost per hour in moderate or severe pain averted (ICER) was estimated as £24.77 (bootstrap estimate 95% CI=£8.72 to £89.17). The ICER for patients with abdominal pain was estimated as £15.17 (bootstrap estimate 95% CI=£9.03 to £46.00). Overall costs were higher with PCA than TAU in both groups: for pain from traumatic injuries an additional £18.58 (95% CI 15.81 to 21.35) per 12 hours; for abdominal pain £20.18 (95% CI 19.45 to 20.84).ConclusionThe cost of PCA use in ED varies with the clinical scenario, but is in the region of £15–£25 per hour of moderate or severe pain averted. Overall additional costs are around £20 per 12-hour patient episode.Figure 1Sampling variation for traumatic pain trial: ICER estimates from 1,000 bootstrap samples shown on the cost-effectiveness planeFigure 2Sampling variation for abdominal pain trial: ICER estimates from 1,000 bootstrap samples shown on the cost-effectiveness plane
COMPARING THE ABILITIES OF TWO NOVEL TRIAGE TOOLS TO PREDICT HOSPITAL ADMISSION – THE GLASGOW ADMISSION PREDICTION SCORE AND THE AMBULATORY CARE SCORE
Authors: Jones D , Mason S , OKeeffe C 
Published: November 2016

Objectives & BackgroundPatient waiting times in Emergency Departments (ED) have risen in recent years, leading to increasing pressure on EDs to meet targets. As increased funding for EDs is an unlikely solution, better utilisation of current ED resources is required. An accurate method of predicting hospital admission at the point of triage could reduce wait times by facilitating patient streaming, bed planning and aiding staff decision making. Two tools that predict admission at triage have been created. They are the Glasgow admission prediction score (GAPS) and the ambulatory care score (AMBS). The primary aim of this study is to compare the the two tools' abilities to predict admission.MethodsSampling was performed over ten days at the Sheffield Teaching Hospitals NHS Trust ED. Data was collected prospectively at triage for all consecutive patients who presented to the ED during sampling periods. GAPS and AMBS were calculated independent of patient clinical management and their disposition recorded. The accuracy of each tool was assessed using receiver operating characteristic curve (ROC) analysis.ResultsData was collected for 645 patients. GAPS had a higher area under ROC (AUC) of 0.815 (95%CI 0.781 to 0.849), compared to AMBS at 0.763 (95%CI 0.727 to 0.800). The difference in AUC was 0.0518 (95%CI 0.0135 to 0.0900) P=0.0080. GAPS had a sensitivity and specificity of 81.4% (95%CI 75.8% to 86.1%) and 67.5% (95%CI 62.7% to 72.0%) respectively, a PPV of 59.1% (95%CI 53.5% to 64.5%) and a NPV of 86.2% (95%CI 82.0% to 89.8%). Finally, GAPS correctly predicted the outcome of 72.6% of patients. AMBS had a sensitivity of 49.2% (95%CI 42.6% to 55.72%), a specificity of 81.4% (95%CI 77.3% to 85.1%), a PPV of 60.4% (95%CI 53.1% to 67.4%) and a NPV of 73.5% (95%CI 69.2% to 77.5%). Lastly, AMBS correctly predicted the outcome of 69.6% of patients.ConclusionGAPS outperformed AMBS at predicting patient disposition. GAPS had a statistically significantly larger AUC than AMBS and as a result, better discriminative power. Additionally, GAPS had a more clinically favourable sensitivity, specificity, PPV, NPV and accuracy overall, when compared to AMBS. However, the results show that GAPS alone should not be used to determine patient outcomes, as it does not have sufficient accuracy, and may be best utilised alongside clinical judgment.
WE ALL LOVE A GOOD MEDICAL DRAMA – BUT ARE THEIR DEPICTIONS OF CPR BAD FOR THE PUBLIC?
Authors: Welman T , Welman T , Williams C , Bryan J , Colwill M , Lindberg E , Somerville C 
Published: November 2016

Objectives & BackgroundOut of hospital cardiac arrests (OHCS) are frequent worldwide but have disappointingly poor outcomes. Non medically trained individuals have been identified to perform substandard CPR by exerting less force than required to achieve adequate cardiac output. We have noticed that televised medical dramas often portray poor quality CPR. We set out to identify how well televised medical dramas depict cardiopulmonary resuscitation (CPR) and whether public knowledge of CPR technique is influenced by these programmes.MethodsWe performed a prospective observational study of three popular medical dramas: Grey's Anatomy, Casualty and Holby City. A short survey was distributed amongst non-medically trained personnel to investigate public knowledge of CPR technique. Rate and depth of chest compressions depicted on screen and selected as correct by survey participants were evaluated.Results90 episodes were reviewed over the study period with 39 resuscitation attempts shown. Rate of chest compressions varied from 60 to 204 compressions per minute with a median of 122 (95% confidence interval 113 to 132). Depth varied from one to six centimetres with a median of two (2.1 to 2.87). Both the rate and depth observed were found to be significantly different from the UK Resuscitation Council Guidelines (2010) (p<0.05, t-test). Survey participants (n=160, response rate of 80%) documented what they thought was the correct rate and depth of chest compressions and were scored accordingly. Those who documented watching medical dramas regularly, scored significantly worse than those who only tune in occasionally (p<0.05, Mann Whitney test).ConclusionTelevised medical dramas often depict an inaccurate portrayal of CPR and members of the public are significantly less well-informed about the technique the more they tune into these popular programmes. The authors recommend that television producers improve the depiction of CPR on television to mimic the national guidelines.
USE OF AN ANAPHYLAXIS CARE BUNDLE TO IMPROVE MANAGEMENT IN THE EMERGENCY DEPARTMENT
Authors: Adam E , Turnbull K 
Published: November 2016

Objectives & BackgroundNICE guidance on anaphylaxis (Dec 2011) focuses on initial emergency management and onward referral. The guideline emphasises 5 main domains; documentation, tryptase sampling, observation, safe discharge and speciality follow up. Poor guidance compliance was highlighted during a departmental audit in 2012. An anaphylaxis care bundle was developed and implemented in response. We aimed to evaluate the impact of this bundle on departmental management of anaphylaxis.MethodsA retrospective case note review of all adult patients diagnosed with anaphylactic shock, identified from electronic records between 8/7/15–13/12/15 (cycle 1) and 30/3/16–17/5/16 (cycle 2) was conducted. A departmental anaphylaxis care bundle was introduced on 14/12/15. The bundle included a diagnostic checklist, clinical pathway, patient information leaflet and covering fax letter for the newly arranged allergy clinic direct referral. Implementation was supported by posters, educational sessions and staff emails. Performance was evaluated against the 5 main domains of the NICE guidance with the required standard of 100% compliance.ResultsCycles 1 and 2 identified 29 and 10 patients respectively. Performance improved across all 5 domains following the care bundle implementation. Documentation of time of onset improved from 17/29 to 10/10. Tryptase sampling at presentation and after 1–2 hours improved 4/29 and 2/29 respectively during cycle 1 to 9/10 and 9/10 during cycle 2. None of the patients in cycle 1 received advice regarding baseline tryptase compared to 9/10 in cycle 2. All 10 patients in cycle 2 were observed for at least 6 hours compared to 24/29 in cycle 1. In cycle 2 safe discharge was achieved in 9/10 patients compared to cycle 1 where 20/29 received epipens and 12/29 received information leaflets. Referral to specialist allergy services improved from 3/29 to 9/10.ConclusionFollowing the introduction of the departmental anaphylaxis care bundle, more adult patients presenting with anaphylaxis are being managed, discharged and followed up in accordance with NICE guidelines. The concise algorithm could be an invaluable resource in other busy and high pressure departments. The importance of education, awareness, reinforcement and accessibility was important in achieving the improvements seen. Due to the rotational nature of junior staff on-going education is needed to ensure sustainability of the improved performance.Figure 1Figure 2Figure 3Figure 4Figure 5
DO ALL HEART SCORES BEAT THE SAME: EVALUATING THE INTER-OPERATOR VARIABILITY OF A CHEST PAIN RISK STRATIFICATION TOOL IN A UK EMERGENCY DEPARTMENT
Authors: Niven WG , Wilson D , Green S , Robertson A , Goodacre S 
Published: November 2016

Objectives & BackgroundPatients presenting with chest pain represent a significant proportion of attendances to the emergency department (ED). The HEART score derived by Backus et al is a validated tool for the risk stratification of suspected ischaemic chest pain within the ED – image 1 below.Little is known about whether HEART scores can be reproduced with reliable agreement irrespective of the grade of nurse or doctor. The goal of this research was to establish the inter-operator reliability of the HEART score as performed in the ED by different grades of doctor and nurse.MethodsThis was a prospective, cross-sectional study that was carried out at the Homerton Hospital – a district general hospital (DGH) with approximately 120 000 A+E attendances per year. Consented patients were interviewed separately by 4 clinicians of different grades. These were Senior doctor (ST4 and above), Junior doctor (FY2–ST3), Senior nurse (Band 6+), Junior nurse (band 5). Each clinician calculated the patient's HEART score independently. Data was entered electronically at the time of assessment. The intraclass correlation coefficient (ICC) was calculated using R statistical package as the primary measure of agreement. We calculated 86 comparisons would be needed to achieve a desired power of 80%.Results104 patients were consented for recruitment of which 88 complete comparisons were obtained. The mean HEART score was 3.7 with no significant difference between mean scores for each clinician group. The overall ICC was 0.9 (0.87, 0.93).The ICC was also calculated between each group of clinicians; junior nurse and senior nurse 0.88 (0.83, 0.92), junior nurse and junior doctor 0.92 (0.88, 0.94), junior nurse and senior doctor 0.91 (0.86, 0.94), senior doctor and senior nurse 0.9 (0.85, 0.93), junior doctor and senior doctor 0.89 (0.85,0.93) and senior nurse and junior doctor 0.93 (0.9,0.95).On analysis of subjective components of the HEART score, for history the ICC was 0.39 (0.27, 0.52), ECG interpretation 0.64 ( 0.54, 0.73), risk factor assessment 0.84 (0.79, 0.89).ConclusionThis study has demonstrated very strong overall inter-operator agreement between the 4 groups of clinicians studied. This suggests the HEART Score can be used reliably regardless of grade or role by both nurses and doctors as part of an early risk stratification process within the ED.Figure 1
IMPROVING QUALITY OF CARE IN THE MANAGEMENT OF PATIENTS WITH URINARY CATHETERS THAT ATTEND THE EMERGENCY DEPARTMENT
Authors: Yeung C , Krishnathasan K , Chan C , Blows S , Cheah K , Whitwell K 
Published: November 2016

Objectives & BackgroundPatients presenting with catheter problems are a significant burden on the Emergency Department (ED). An initial audit was performed in 2014/15 which showed that the majority of these patients were elderly, arrived in working hours, did not need to see a specialist and were discharged after simple interventions. A number were also repeat attenders.Following this audit, a number of interventions were introduced. The equipment was reviewed to ensure that the correct catheters were used. Troubleshooting protocols for common catheter problems were placed on the catheter trolleys. Education regarding catheter problems was incorporated into the induction program for junior doctors. Three urology ED nurse champions were appointed. A multidisciplinary team was formed comprising geriatric, urology & ED consultants, with the aim of formulating solutions to tackle the rising burden of catheter patients. The audit was then repeated in 2015/16.MethodsThis was a retrospective case note review of patients with a ‘catheter problem'. They were identified through a manual search on our ED coding database. Data (e.g. age, time of arrival, admission rate, etc.) was first collected from Nov 14 to Feb 15. This was repeated from Nov 15 to Feb 16 after our interventions listed above. 24 ‘catheter problem’ patients that presented in Oct 15 were also telephoned to evaluate patient satisfaction using a standardised questionnaire.ResultsThere were 5% fewer attendances and 28% fewer repeat attenders in 2015/16 despite a rise of 7% in the total no. of all ED attendances over the same time period. Again, majority of the patients were elderly, arrived in working hours (60%), and were discharged home from ED (83%). Only 13% needed a urological opinion.There were 18 phone responses out of 24 (75%). A going home catheter pack was given to all patients that needed them. The process of catherisation was explained to all patients. 100% of patients were satisfied with the ED service, with 67% awarding us a 6 (on a scale of 1 to 6, with 1 being not at all satisfied and 6 being very satisfied).ConclusionWe have improved the quality of care of patients with urinary catheters by ensuring correct initial management and good patient education. That has led to a subsequent reduction in patient attendances and re-attendances to the ED, as well as a high standard of care provided to those that did present in ED.Figure 1Attendances of 'catheter problem' patients in 2014/15 and 2015/16Figure 2Age distribution of 'catheter problem' patients in 2014/15 and 2015/16Figure 3Patient satisfaction survey scores
PELVIC FRACTURES IN TRAUMA PATIENTS ATTENDED TO BY THE EMERGENCY MEDICAL RETRIEVAL SERVICE
Authors: Browne H , Corfield AR 
Published: November 2016

Objectives & BackgroundPre-hospital application of pelvic binders is recommended by the 2016 NICE guidelines for Major Trauma in any patient with blunt high-energy trauma and suspected active bleeding from a pelvic fracture. The Emergency Medical Retrieval Service (EMRS) provide a pre-hospital critical care team by road and air to for the West of Scotland to a mixed rural and urban catchment area. The EMRS SOP mandates pelvic binder application to patients with suspected pelvic fractures including all polytrauma with significant mechanism of injury. We aimed to ascertain the incidence of pelvic fractures in this group of patients and whether this mechanism predicted significant pelvic injury.MethodsRetrospective analysis of all trauma patients attended by EMRS between 2011 and 2015 who had a pelvic binder applied and were not declared dead at scene. 140 patients were identified – of these, 11 were excluded due to lack of access to imaging. Data was obtained from the EMRS database and in-hospital systems including TrakCare, Portal and PACS. Information was collected and analysed using Microsoft Excel. Parametric data was analysed using Students T-test and non parametric data was analysed using Mann-Whitney test on Stata v12.ResultsOf the 129 trauma patients who had pelvic binders applied, 32 (25%) had evidence of active bleeding and 28 (22%) had a pelvic fracture identified on imaging. The ‘fracture present’ versus ‘fracture not present’ populations were compared. This data is summarised in Table 1. Most common mechanisms to cause pelvic fracture were being either the car occupant in an RTC (29% of fractures) or a pedestrian in an RTC (29%). Motorcyclists made up 19% of patients to whom a pelvic binder was applied, but they only represented 7% of the pelvic fracture population.ConclusionApplication of a pelvic binder to this group of patients seems an appropriate action as a significant proportion subsequently have a pelvic fracture identified on imaging. The population of pelvic fracture patients seen by EMRS are more commonly patients involved in road traffic collisions (as opposed to ‘falls from height’ seen more commonly in purely rural populations) with an ISS of more than 15 to constitute ‘major trauma’.Table 1Epidemiology of all trauma patients with a pelvic binder applied pre-hospitally by EMRSPelvic fracture presentPelvic fracture not presentp valueAge, years (mean)43440.760Gender (% male)46%72%0.010*Median ISS17130.211Suspicion of bleeding (%)39%21%0.0517 day mortality (%)4%10%0.317X-ray AND CT imaging of pelvis in hospital89%53%<0.001*Mechanism of InjuryLow Fall (<10 ft)4%3% High Fall (>10 ft)14%15% RTC – vehicle occupant32%40% RTC – pedestrian29%12% RTC – motorcyclist7%19% RTC – cyclist4%8% Other11%4%