bluuebunny/crossref_metadata_2025_split huggingface dataset:
WHAT DO THEY DO OUT THERE?
Authors: Turner C , Turner J 
Published: November 2015

Objectives & BackgroundIt is a frequent source of frustration to many clinicians (and others) that they do not understand what each other do all day. This can result in unnecessary antagonism and frustration. As a relatively new (and evolving) specialty EM has the potential to be poorly understood by other clinicians and groups.We aimed to break down the activities of consultants on shop floor shifts so that they might be better understood both internally and externally to our department.MethodsThis is a single site, convenience sample (all consultant shifts covered), 2 month study in a MTC. GAfREC approval was given. A group of 6 medical students were identified and trained in methodology for using our locally derived consultant activity tool.We decided upon an iterative method of recording consultant activity. Consultant activity was recorded in 4 hour blocks, with minute by minute subdivision.A recording tool revision occurred after 12 hours, with minor changes. Results were entered into Excel and are shown below.Results48 hours of shop floor consultant time have been observed. The most common task was discussing or reviewing patients- 26% 15% of the shift is spent dealing with operational issues in the department.Consultants are interrupted approx 17 times per hour. 14% of the shift is spent actively (explicitly) teaching Both running trauma and performing procedures take about 4% of the time each.ConclusionShop floor shifts require consultants to be performing a myriad of different tasks. Task saturation is clearly a risk and interruptions are frequent.Operational issues take up a significant amount of time but reassuingly the single most time consuming activity is direct patient care (through discussion or actually seeing the patient).Further work around the psychological toll and techniques used to promote resilience in the consultant body would be valuable.
SEEING IS BELIEVING: THE LIVECITY AMBULANCE E-HEALTH TELEMEDICINE PROJECT
Authors: Gilligan P , Amadi-Obi A , Sheung P , Alrmawi A , Gasem J , Tynan C , Khashab A , Gannon S , Mutawa A , Eswararaj M , Little R , Padki A , Houlihan A , Owens N , Morris D , Merriman W , O'Donnell C 
Published: November 2015

Objectives & BackgroundThe European Commission funded LiveCity Project e-health research involved a multidisciplinary team including telecommunication engineers, network engineers, hardware and software engineers, paramedics, nurses, doctors and research scientists. The intention had been to use off the shelf hardware and open access software to establish an internet based audiovisual communication over a 3 G network between the communication hub in the Emergency Department and the site of the emergency. It was intended to assess the feasibility of providing pre-hospital telemedicine and to assess it's clinical impact.MethodsThe 289 control patients were recruited in the Emergency Department by a member of the research team whilst the 34 patients in the intervention arm who underwent a telemedicine consultation were recruited by a researcher who accompanied the ambulance to the site of the emergency. The quality of audio-visual communication was monitored throughout each of the 34 patient's pre-hospital telecommunication consultations. The impact of the telemedical interaction on patient care was assessed.ResultsThe deployment of the wearable device in the field was associated with a number of significant challenges Including server and network issues associated with a failure to establish a link or loss of signal. The hardware evidenced issues with battery failure in the camera or hard drive, over heating of the hard drive, damage to the dongle, tearing of the back packs, breaks at connection points to the hard drive. There was an issue of delay between the audio feed and the video feed and a delay created by the encryption of both. There was freezing of images, pixilation of images, degradation of sound quality, loss of signal with movement. There was looping of the audio signal. In 33 of 34 patients the telemedical consultation was compromised by technological challenges but it was possible to obtain clinically useful information.ConclusionBespoke wearable hardware and software need to be developed for telemedicine in the pre-hospital environment.A 3 G network does not reliably support continuous uninterrupted audio-visual telemedicine in the pre-hospital setting. Paramedics infrequently require medical oversight but when they do it needs to work first time every time.
IDENTIFYING WORKPLACE STRESSORS IN THE EMERGENCY DEPARTMENT—AN EXPLORATORY STUDY
Authors: Basu S , Yap C , mason S 
Published: November 2015

Objectives & BackgroundStress amongst ED staff has been studied previously with observational research conducted since the 1980s. Many have measured outcomes of exposure to stress such as mental ill-health and more recently burnout. The factors which underlie workplace stress in the ED however are not well understood. This study aims to explore these issues in more detail.MethodsThe HSE stress indicator tool was administered to all staff working in the ED at the Northern General Hospital in Sheffield in November 2014 (Doctors, Nurses, Support Workers, Admin, Orderlies and Domestics). Results were analysed using the HSE analysis tool which compared our results against 136 other surveyed organisations in the UK. Following the survey, six focus groups containing a mixture of professional groups were held in which results were presented, factors underpinning observed results were discussed and issues that were not identified in the questionnaire highlighted. A more detailed questionnaire was developed.ResultsOverall response rate was 66%. All six staff groups identified high levels of demand and low levels of control over their work. Nursing staff displayed the highest levels of stress across the seven domains of the tool with little difference with respect to seniority of grade. Junior doctors displayed the lowest levels of stress of all professional groups. Higher levels of stress were seen in consultants than other medical grades. Orderlies and domestics whilst scoring higher on the demand/control domains, scored similarly to other groups with respect to support and relationships with colleagues (Table 1). Focus groups with staff identified issues relating to effort-reward imbalance and organisational justice which were not covered by the HSE tool. A more detailed questionnaire including these models of stress will be administered in July 2015 and to a control group from another hospital department which will be presented at the conference if the abstract is accepted.ConclusionThis exploratory study has identified differences in the origins and nature of workplace stressors affecting professional groups in our ED. If they are to be successful, interventions aimed at tackling workplace stress in the ED should take account of these differences. Further work should explore whether our results reflect those of other EDs and develop appropriately tailored intervention to address this issue on a wider scale.Figure 1
THE DOCTOR WILL SEE YOU NOW: A STUDY OF PERSPECTIVES ON TELEMEDICINE IN THE PRE-HOSPITAL ENVIRONMENT
Authors: Gilligan P , Houlihan A , Padki A , Amadi-Obi A , Owens N , Khashab A , Mutawa A , Eswararaj M , Gannon S , Alrmawi A , Gasem J , Sheung P , Tynan C , Little R , Merriman W , O'Donnell C , Morris D , Chochliouros I 
Published: November 2015

Objectives & BackgroundThe LiveCity Project funded by the European Commission included the development of hardware and software and the provision of a telecommunication infrastructure with high-speed internet to allow for an encrypted audio-visual video communication from the site of an emergency to the Emergency Department. Having previously performed a questionnaire based study on telemedicine amongst paramedics we extended our research to examine if Doctors, nurses and patients in the Emergency Department felt it would be beneficial and would want and accept telemedicine in pre-hospital emergency care.MethodsTwo separate seventeen item questionnaires were developed by the research team in consultation with the key stakeholders for patients and staff. Two members of the research team approached doctors, nurses and patients in the Emergency Department to consent them to enrolment in the study. Statistical analysis was performed using SPSS software. The comments and statements from the qualitative data were analysed using simple thematic analysis.Results100% (56) of patients said they would like the technology used if they were in an ambulance and possibly suffering a stroke or a major injury, and 96.3% (54) said they would like it used if they were possibly suffering a heart attack. 83.3% (n=10) of doctors and 89% (n=16) of nurses were in favour of using pre-hospital video platform technology in stroke, Myocardial infarction and major trauma. The potential benefits were felt to be in diagnosis of time-dependent illnesses, time management in the ED, increased hospital preparedness for incoming patients and increased triage efficiency. Nurses and Doctors expressed concern that there may be difficulty operating the technology in situations such as adverse weather conditions, low light levels and in remote areas without network coverage. Concerns regarding potential breaches in patient confidentiality were noted.Conclusion99% of patients, 92% of Doctors and 94% of nurses saw the potential of an audio-visual link from the pre-hospital environment to the Emergency Department. Stakeholder enthusiasm for pre-hospital telemedicine must be met with the technological requirements to provide such a service. As noted by one patient a pre-hospital audio-visual link to the Emergency Department could be a “potentially a life saving service”.
AUDIT STANDARDS IN PAEDIATRIC SEVERE SEPSIS
Authors: Mackenhauer J , Cantle F 
Published: November 2015

Objectives & BackgroundSevere sepsis in the paediatric population is a rare, but serious condition that requires prompt recognition and management in the Emergency Department. Whereas severe sepsis in the adult population is being continuously monitored using standardized quality measures, data on performance in the paediatric population is sparse in our institution. We hypothesized that performance can be measured using available data sources. The aim of this study was to measure baseline performance using the RCEM adult-sepsis audit standards in the paediatric population with severe sepsis.Audit result: Paediatric severe sepsisAudit standardRCEM adult standardAudit result paediatrics (n= 19)Missing data (n) Vital signs recorded fully within 15 mins100%47%0Capillary glucose recorded in ED (anytime) 100%84%1Intravensous fluid bolus given within 1 hour75%42%1Serum lactate measured in ED (anytime)100%89%1Antibiotics within 1 hour of arrival50%42%1Blood cultures obtained prior to antibioticsStandard (%) not defined by RCEM37%0Urine dip obtained in EDNot part of RCEM standard21%1Assessment by doctors within 30 minsNot part of RCEM standard84%1MethodsThis is a single-centre descriptive study from a university hospital with 30,000 A&E-paediatric attendances per year. Data were collected from January 2012 through April 2015. Inclusion criteria were children (<16y) admitted through the A&E with direct transfer to paediatric ITU with evidence of sepsis in the A&E. Cases were identified by ICD diagnosis of sepsis upon discharge from PICU. We did not include transfers from other hospitals.Baseline data was collected from the electronic patient system: Age, gender, pre-morbid conditions, as well as in-hospital mortality and length of stay (LOS). The RCEM standards for adult sepsis, as well as adapted measures, were extracted from the scanned hand written ED charts: Timing of bedside assessment by doctor, blood cultures, antibiotics, and fluids. Measurements of lactate and blood glucose.Monitoring of vital signs upon arrival, and documentation of urine dip and presumed focus of infection.ResultsWe identified 19 cases of paediatric sepsis admitted through the A&E. 13 of 19 cases (68%) were male, median age was 70 days and 8 of 19 (42%) were born at term with no significant past medical history. Median LOS in hospital was 5 days, and all patients (100%) survived to discharge. Please see table for audit results.ConclusionAvailable data sources can be used to measure baseline performance in the paediatric population with severe sepsis. We did not fulfil any of the RCEM adult-sepsis audit standards. Timeliness of vital signs and administration of first fluid bolus seem to be amongst the biggest challenges in our institution. Further research is needed to investigate if continuous monitoring on these measures will improve performance.
DELAYED PRESENTATION HEAD INJURIES: WHICH PATIENTS PRESENTING AFTER 24 HOURS NEED A SCAN?
Authors: Marincowitz C , Townend W 
Published: November 2015

Objectives & BackgroundNICE guidelines are used to triage the 1.4 million patients attending the ED with head injury in England and Wales annually for CT imaging. These guidelines are based on research conducted in populations presenting within 24 hours of injury. We therefore postulated that they might not apply to those presenting later in the same way.Objectives:1) Estimate the proportion of CT head scans requested for patients presenting more than 24 hours after injury.2) Compare the CT abnormality rate within and after 24 hours of injury.3) Compare the use of the NICE guidelines and their sensitivity for intracranial injury within and after 24 hours.MethodsWe reviewed ED trauma CT head requests from Hull Royal Infirmary for 6 months from Nov 2011. Requests were matched to ED records where possible. Correlation between the presence of a NICE indication and traumatic intra-cranial injuries was assessed (Pearson Chi-square test- SPSS 22).Results676 scans were performed for adult head trauma. 8.6% showed a traumatic abnormality; 1.2% required neurosurgery and 0.3% died. 650 records were available. The proportion of CT head scans completed for head injury patients presenting after 24 hours of injury was 15.5% (12.7–18.3% (95% CI). The CT abnormality rate was 8.4% (6.1–10.7% 95 CI) within and 9.9% (4.1–15.7% 95% CI) after 24 hours. 13.7% of CT scans within 24 hours and 38.6% of CT scans after were completed in patients with no NICE indication. Within 24 hours, NICE guidelines predicted 45/46 intracranial injuries (97.8% sensitivity [87–99.9% 95% CI]) and 7/10 injuries after (Sensitivity 70% [35.4–91.9% 95% CI]). The correlation between NICE indication and CT head abnormality for patients presenting within 24 hours (Chi-Square P=0.018) was not found in those presenting later (Chi-Square P=0.556).Conclusion15.5% (12.7–18.3% (95% CI) of scanned patients presented after 24 hours. The abnormality rate was similar to that found in those presenting earlier. NICE guidelines were less predictive in this group. A different approach for such patients may be required.
AGE-ADJUSTED D-DIMER THRESHOLD: RAISING THE BAR ON VTE DIAGNOSIS
Authors: Jaconelli T , Eragat M , Crane S 
Published: November 2015

Objectives & BackgroundThe standard work-up for patients suspected of having venous thromboembolism (VTE)-specifically deep vein thrombosis (DVT) and pulmonary embolism (PE) involves risk stratification, usually with the Wells score. This method of risk stratification dictates that patients who are deemed to have a low pre-test probability of VTE should have a serum D-dimer level taken. D-dimer values correlate positively with increasing age, this work looks at whether an age adjusted value can be used to safely exclude VTE.Table 12x2 Table for Standard D-dimer ValueVTE PositiveVTE Negative Old D-dimer Positive25157182Old D-dimer Negative0377377255345592x2 Table for Age-adjusted D-dimer ValueVTE PositiveVTE Negative New D-dimer Positive25112107New D-dimer Negative0422422 25534559MethodsWe designed a study protocol which aimed to identify the clinical outcomes of all patients at York Hospital who had a D-Dimer level measured in ED. Using retrospective data we estimated the proportion of patients who had investigations for suspected VTE, and the results of these investigations. The primary outcome was the diagnosis of VTE. We derived data for the sensitivity and specificity D-Dimer tests (in the diagnosis of VTE) using the current cut-off (230 ng/ml) and also for a proposed new cut-off 5× the age in those over 50 and 250 ng/ml up to the age of 50.ResultsFrom 01/11/13 to 21/03/14, 682 patients underwent D-dimer testing for suspected VTE (256 DVT and 426 PE). Those with a high wells score were excluded from analysis leaving 559 patients (156 DVT and 403 PE). Of this group 12 were diagnosed with DVT on ultrasound and 13 diagnosed with PE on CTPA; the rest had alternate diagnoses. 25 patients had positive D-dimers with the age adjusted value i.e. there were no false positives. With the age adjusted value 17 ultrasound scans would have been avoided and 28 patients would have PE safely ruled out.For the standard D-dimer the sensitivity was 100% (86.28–100 95% CI), specificity was 70.60% (66.53–74.43 95% CI) and the NPV was 100% (99.03–100). For the age adjusted value the sensitivity was 100% (86.28–100 95% CI), specificity was 79.03% (75.32&–82.40% 95% CI) and the NPV was 100% (99.13%–100% 95% CI).ConclusionThe data shows that in patients suspected of having a VTE with a low pretest possibility, an age adjusted D-dimer increases the specificity of the test with no effect of the sensitivity when compared to the conventional D-dimer threshold. In practice this means that more patients can be safely discharged from the emergency department without further, unnecessary investigations. This may result in reduced hospital admissions, radiology time and iatrogenic harm from CTPA.
THE IMPLEMENTATION OF MASSIVE HAEMORRHAGE PROTOCOL (MHP) FOR THE MANAGEMENT OF MAJOR TRAUMA:A TEN YEAR,SINGLE CENTRE STUDY OF PATIENT OUTCOMES
Authors: Mothukuri R , Battle C , Guy K , Mills G , Evans PA 
Published: November 2015

Objectives & BackgroundMassive haemorrhage in major trauma is one of the leading causes of death. Haemostatic failure leads to uncontrolled blood loss and reduced tissue perfusion resulting in coagulopathy. Recent studies support the use of early component replacement. In the UK, trauma centres have adopted the use fresh frozen plasma, platelets and packed red cells in the ratio of 1:1:1 to improve and maintain normal haemostatic function. In 2011, MHP was introduced to improve links between the trauma team and transfusion team and accelerate the issue of blood products.Our aim is to evaluate and compare the outcomes before and after implementation of MHP.MethodsAll trauma patients admitted to the Emergency Department (ED) of a large teaching hospital in South Wales between 2005 and 2015 were studied, using the data collated for submission to the Trauma Audit and Research Network (TARN). Demographic variables included sex, age, Injury Severity score (ISS) code, PS14 and injury mechanism; management variables included whether the trauma team was activated, whether Tranexamic acid (TXA) was given and whether the MHP was instigated. Outcome variables included hospital and critical care length of stay and mortality. Patients were divided into two groups; those admitted before the introduction of MHP(pre-MHP) and those admitted after its introduction (post-MHP). Differences in the data were analysed using the Fisher Exact test (categorical variables) and student's t-test (continuous variables).ResultsA total of 832 patients were included in the analysis,446 in the pre-MHP and 386 in the post-MHP group.There were no significant differences in patient age, sex, PS14 or injury mechanism. The pre-MHP group had a significantly higher ISS (p=0.02). There was no difference in the activation of the trauma team between the two groups. There was no difference in the mortality between the two groups. Tranexamic acid and the MHP were used in a significantly greater number of cases in the post-MHP group. Hospital length of stay and the critical care length of stay were significantly reduced following the introduction of the MHP (both p<0.001).ConclusionWe demonstrate,a well-defined MHP and the use of TXA contributed to reducing patient length of stay both in critical care and in hospital.Further data analysis is needed to show correlation between use of component replacement and improved outcome.Figure 1Results.
AGE IS ONLY A NUMBER?—TIME IN THE EMERGENCY DEPARTMENT (ED)
Authors: Liston P , Conyngham G , Brady M , Byrne P , Gilligan P 
Published: November 2015

Objectives & BackgroundThe average age of patients occupying the ED in Beaumont ED is seen to be rising and this fact coupled with an aging population points to potential future demand pressures on ED departments. This research looks at the changing age profile of patients that attend the ED and the relationship between age and waiting time or Patient Experience Time (PET) in the ED. This research is part of a wider research project looking to simulate patient flows through the ED.MethodsWe analysed a 10 year dataset from the ED at Beaumont Hospital to study trends in average patient age and PETs. We then applied linear regression to the 2013 data, (60,000 patient visits to the ED), to examine the relationship between age and PET. Three separate models were developed with PET, time from admission to first medical and time from bed request to being admitted to hospital as the respective dependent variables. These models also controlled for triage type, patient admitted (Yes/No), number in ED and other factors.ResultsThe average age of ED patients has risen from 43.8 years in 2005 to 48.2 years in 2014 (Figure 1). These older patients have a greater likelihood of admission and in addition experience longer waiting times in ED (See Figures 2 and 3). Using a regression analysis, age was seen to contribute an extra half an hour in PET per 10 year increase. Age had, in contrast, a negative effect on time to first medical with lower waiting times for older age groups. In the final model, predicting the patient time from bed request to being admitted to hospital, age emerged as the most significant factor, with older patients experiencing significantly longer waits. Figure 4 demonstrates these findings, in particular the significant proportion of PET for older patients due to bed requests.ConclusionAge has a significant effect on patient experience time in the ED. The time to first medical care is mainly driven by triage category, but even controlling for this, older people receive care faster. However, subsequently older patients spend longer in the ED and this is due to longer waits for older patients for a hospital bed. The result is an ED populated with elderly boarders. With an ageing national population in Ireland this research emphasises a need to plan for the future healthcare of elderly patients within and beyond acute hospitals.Figure 1Average Age of Beaumont ED Attendees.Figure 2Age profile of Beaumont ED Patients (Admitted and Discharged).Figure 3Average Patient Experience Time per Age Band for Admitted and Discharged Patients.Figure 4Waiting Times by Age Band (2014).