bluuebunny/crossref_metadata_2025_split huggingface dataset:
FCP AND THE ED: SAVING LIVES THROUGH ORGANISING CARE.
Authors: McGowan H , Gopeesingh K , Gilligan P , O'Kelly P 
Published: November 2016

Objectives & BackgroundHospital overcrowding is a problem that manifests in the Emergency Department (ED) and causes poorer patient outcomes. In an effort to combat overcrowding full capacity protocols have been put in place to move patients from the ED to temporary extra beds placed in the inpatient wards. This improves patient flow in the ED allowing for better provision of care to patients. This study aims to gauge patient opinion on being placed in extra beds rather than staying in the emergency department.MethodsThrough a review of current literature the current full capacity protocol in Beaumont Hospital, Dublin was updated to reflect best practice and national guidelines. A structured questionnaire was employed to assess patient attitudes towards boarding in the ED and on the extra beds and to determine the preference patients had on where they would prefer to be boarded as an additional patient.Results75 patients took part in the study. 86.67% indicated a preference for being an additional patient on the ward, 10.67% had no preference and the remaining 2.67% preferred being boarded in the ED. This data agreed with similar studies from other centres internationally.ConclusionMoving patients from the ED into extra beds on the wards frees up space in the ED and enables staff to more effectively treat patients. The vast majority of patients are understanding of the issues facing modern healthcare providers and welcome the opportunity to be moved to quieter, more comfortable areas where they can have better access to the quality healthcare that hospitals exist to provide them with.Figure 1Figure 2
WHAT SHOULD BE DONE TO REDUCE EMERGENCY DEPARTMENT CROWDING? – A DELPHI STUDY
Authors: MacDonald-Nethercott E , Richter S , Boyle A , Higginson I 
Published: November 2016

Objectives & BackgroundEmergency department crowding is a serious public health problem throughout the developed world. In 2015 the UK Royal College of Emergency Medicine was charged by its executive with producing a toolkit to reduce crowding. This study was commissioned to inform said toolkit. The goal of the study was to develop a list of interventions to deal with crowding and exit block, based on consensus of a group of senior emergency physicians.MethodsThe Delphi technique was used to undertake a formal blinded consensus study. 33 experts were invited. These were committee members of the Royal College of Emergency Medicine who worked as emergency physicians in a diverse range of UK hospitals. Responses were collected using the web based survey tool SurveyMonkey over eight weeks in spring 2015. In round 1, experts suggested interventions to reduce crowding. In round 2, experts reviewed all proposals. Any proposal that was endorsed by at least 80% of experts (level chosen a priori) was included in the final recommendations. The authors then decided which professional role would be most able to deliver each intervention.ResultsOf 33 experts invited, 23 agreed to participate in round 1 and 18 in round 2. In round 1, respondents submitted 310 proposals which was reduced to 188 proposals when duplicates and irrelevant comments were removed. In round 1, 117 proposals reached the threshold of 80% agreement. These included 112 interventions recommended to reduce crowding (20 input, 40 throughput, 37 output and 15 multi-dimensional measures) as well as 5 interventions that should be avoided.ConclusionWe have developed a list of 117 expert-endorsed recommendations to deal with emergency department crowding. We not only identified which interventions to implement but also which to avoid. For each intervention we decided who should deliver it. Our findings provide useful advice to clinicians, commissioners, managers and policy makers.
PATIENTS ADMITTED FROM THE EMERGENCY DEPARTMENT INTO AN ACUTE MEDICINE BED FOR LESS THAN TWENTY FOUR HOURS–ARE THESE ADMISSIONS JUSTIFIED?
Authors: Clancy M , Gray H 
Published: November 2016

Objectives & BackgroundThe increase in emergency admissions over the past 15 years has come almost entirely from the EDs,for patients who spend two days or less in hospital. It has been suggested that these cases are of low severity and admitted because of a lack of alternative services, defensive medicine and the four hour target. We wished to develop means of classification as to whether the admission was jusitified or not using both explicit critiera and implicit expert approaches.MethodsExplicit approach: we wished to use the activities recorded in the patients medical and nursing notes covering their time in the AMU relating to observations (type, frequency and values), investigations (type and values), treatments (type and frequency), specialist review (specialty and grade) and post discharge care to generate a list of ‘candidate’ criteria. Candidate criteria were developed after review of 100 sets of notes.Three consultants in Acute Medicine were asked for each criterion –“would its presence justify admission?” and a majority verdict taken. The list of criteria was then that applied to 300 consecutie patients admitted to the Acute medical Unit. Unjustified cases would be those with the absence of any justifiable critieria.Implicit approach: three different consultants in Acute Medicine were given copies of 120 randomly chosen patients anonymised notes and independently asked to judge if the patients admission was jusitified or not and a majority decision was taken.ResultsBetween January and August 2014, 24% of patients attending the ED ( 13766), were admitted to the hospital. 5802 of these were admitted to AMU of which 1063(18%) stayed less than 24 hours ( approximately 150 /month).We studied 300 consecutive patients. Table 1 (screen shot) shows the criteria agreed by the expert panel,whose presence would justify admission together with their frequencies. Patients could meet more than one criteria. 275 met one or more of the AMU criteria (92%).Of the 120 cases reviewed by experts, 84 (70%) were considered justified and 36 unjustified.ConclusionUsing the explicit criteria 92% of cases were justified, and 70% by use of the expert panel note review. This does not suggest an excessive admission rate for the population that we have described, who can be both difficult to assess and to rapidly exclude serious pathology.
TRENDS IN VIOLENCE IN ENGLAND AND WALES 2010–2014
Authors: Sivarajasingam V , Page N , Shepherd J , Moore S 
Published: November 2016

Objectives & BackgroundThe National Violence Surveillance Network (NVSN) of emergency departments (ED), minor injuries units and walk-in-centres in England and Wales has brought clarity to contradictory violence trends derived from crime survey and police data. Gender, age specific and regional trends in violence-related injury in England and Wales since 2010 have not been studied.MethodsData on violence-related injury were collected from a structured sample of 151 EDs in England and Wales. ED attendance date and age and gender of patients who reported injury in violence from 1 January 2010 to 31 December 2014 were identified from attendance codes, specified at the local level. Time series statistical methods were used to detect both regional and national trends.ResultsIn total, 247 016 (178 709 males: 72.3%) violence-related attendances were identified. Estimated annual injury rate across England and Wales was 4.4/ 1000 population (95% CI 3.9 to 4.9); males 6.5/1000 (95% CI 5.6 to 7.2) and females 2.4/1000 (95% CI 2.1 to 2.6). On average, overall attendances decreased by 13.8% per year over the 5 years (95% CI −14.8 to −12.1). Attendances decreased significantly for both genders and all age groups (0–10, 11–17, 18–30, 31–50, 51+ years); declines were greatest among children and adolescents. Significant decreases in violence-related injury were found in all but two regions. Violence peaked in May and July.ConclusionFrom an ED perspective, violence in England and Wales decreased substantially between 2010 and 2014, especially among children and adolescents. Violence prevention efforts should focus on regions with the highest injury rates and during the period May–July.Figure 1Figure 2Figure 3Figure 4Figure 5
MORTALITY OF EMERGENCY PATIENTS IN A TERTIARY REFERRAL HOSPITAL IN SIERRA LEONE–BASELINE RATE AND CORRELATION WITH ADMISSION TRIAGE CATEGORY
Authors: Tolppa T , Lowsby R , Harrison H , Evans G , Kamara C 
Published: November 2016

Objectives & BackgroundDespite the increasing burden of trauma and acute illness in low and middle-income countries, emergency care in these countries remains immature and there is a lack of robust data regarding mortality. Emergency care at the main governmental referral hospital in Freetown, Sierra Leone has been redeveloped in the wake of the Ebola epidemic. Initiatives include twenty-four hour triage, a resuscitation bay and an acute medical unit. Mortality within the unit is noted down for emergency admissions, but to date, the information has not been collated or reviewed. This study aimed to determine the baseline mortality rate within the acute medical unit and to assess correlation with triage category on arrival.MethodsThe aims of this study were achieved by carrying out a retrospective review of emergency admissions at a tertiary referral hospital with 300 beds. The number of new admissions, deaths within the acute medical unit and the admission triage category of deceased patients were obtained from ledgers for a six-month period between January and June 2016. The triage categories are based on the South African Triage Scale (SATS) and include, in an order of increasing severity, green, yellow, orange and red. Patients that arrived dead to the department were excluded from the study. Pearson's correlation was used to test for an association between triage category and mortality.ResultsA total of 1657 acute medical unit admissions were recorded during the study period. The overall mortality was 10.5% (n=174). There was a strong positive correlation between triage category on arrival and mortality, which was statistically significant (r=.986, n=145, p=0.014). Only one deceased patient was assigned to the green category, which on review was found to belong to the orange category. Triage category was not recorded for 29 deceased patients (16.7%).ConclusionThe study represents the first effort in the acute medical unit to review emergency patient mortality and serves as a baseline for future data collection and comparison. This basic method of mortality data collection could be adopted in other units and local healthcare facilities in order to produce comparable data, which does not currently exist. The strong correlation between the assigned triage category and mortality highlights the value of triage in identifying the patients most at risk of dying.
USING A FINGERPRINT-ACCESS MEDICATION CABINET TO IMPROVE EFFICIENCY IN AN EMERGENCY DEPARTMENT.
Authors: Ragoo M 
Published: November 2016

Objectives & BackgroundCompliance with UK pharmacy standards requires medications to be stored in a locked cupboard. This creates inefficiency in a busy emergency department (ED) as there are delays locating the keys, then finding the medications in the cupboard. We report the efficiency gains of an Omnicell cabinet which is accessed by staff fingerprint and has a system of guiding lights to identify the requested medication within the cabinet. This is a prospective observational study comparing the time from prescription to administration of medications before and after the installation of an Omnicell.MethodsThe study setting was a tertiary academic centre in England with 130,000 attendances per annum. Prior to the installation of the Omnicell, we measured the time taken in minutes (min) for the nurse to locate the keys to the drug cupboard. We also measured the dispensing time. This was measured as the time from when the nurse reads the prescription of an oral medication to when the tablets were physically obtained by the nurse. A research nurse not involved in the care of the patient measured the dispensing time for a convenience sample of 100 patients over a four week period. A second convenience sample was collected 6 months after the installation of the cabinet. Participants were unaware of the study outcomes.ResultsThe mean time to locate the keys prior to the implementation of the Omnicell was 2.4 min (sd 2.7 min, n=110). The mean time taken to dispense medication prior to implementation was 7.5 min (sd 13 min, n=110) and after implementation was 1.1 min (sd 0.7 min, n=107). The mean time difference was 6.4 min (idependent t-test, 95% CI 3.9 to 8.9 min).ConclusionThis is the first study in a UK civilian ED to quantify the efficiency gains of the implementation of an Omnicell cabinet. We demonstrated that there was a time saving by removing the need to locate keys for the medication but this was only an average of 2.4 min. We underestimated the time saving that was made by having a system of guiding lights which directed the user to the correct medication within the cabinet. This contributed to the overall time saving of 6.4 min for every medication prescribed. This represents a significant improvement in efficiency in a large busy ED with more than three hundred attendences a day.
PROCEDURAL SEDATION IN THE EMERGENCY DEPARTMENT – HOW WELL TRAINED ARE OUR STAFF?
Authors: Currer M , Trudeau T , Laura H 
Published: November 2016

Objectives & BackgroundOver recent years,our middle grade cover has become more variable in terms of seniority and experience. In addition, we have undergone a rapid turnover of nursing staff, with more senior staff being replaced by highly motivated but less experienced nurses. Historically, there has been little formal teaching on procedural sedation, with most staff picking up skills “on the job”. However, with changing staffing profile coupled with recently published guidance, we felt a more structured approach was required.MethodsEmergency Department (ED) medical and nursing staff of all grades were asked to complete an on-line survey in order to determine levels of confidence, and aspects of sedation where they felt knowledge could be improved.ResultsWe received 38 responses, 17 from senior doctors (consultants, ST 4–6 and equivalent) 12 from junior doctors (all other grades) 9 from nursing staff. 31 of 38 (81%) felt that more teaching on sedation would be beneficial. All those answering “no” were senior doctors.Responders were asked to rate their confidence in pre procedural assessment, use and selection of medications, airway management, patient monitoring and safe discharge of patients. There was unsurprisingly considerable variation between groups. However, use and selection of medications was notably lower in all groups.In the free text options, topics commonly cited were pharmacology, identifying and managing complications and need for scenario/simulation sessions.ConclusionThe results of this survey were utilised to inform development of a teaching programme for all staff in the department, consisting of written material, case based tutorials and subsequent in-situ simulation sessions.Teaching packs are slightly different for nurses and medical staff but focus on patient selection; drug choice with notes on pharmacokinetics and pharmacodynamics, potential side effects and complications and important interactions; monitoring, and criteria for stopping close monitoring and for discharge.Case based tutorials are aimed at all staff, with scope for varying discussion topics according to the learners needs.The department already runs regular in – situ simulation sessions, and some standard sedation scenarios have been added to these sessions.In future, we plan to develop an on-line module for staff to undertake with a self assessment component.Table 1Confidence Levels for aspects of procedural sedationSenior DoctorJunior DoctorNurseOverallPre procedure assessment4.442.732.753.51Selection and use of medication4.192.002.883.20Airway management4.53.273.503.89Procedural monitoring4.693.093.884.00Safe discharge of patients4.632.453.883.77
ANALYSIS OF ACCIDENT AND EMERGENCY DEPARTMENT (A&E) WAITING TIMES FOR PATIENTS REFERRED TO AN OFFSITE SPECIALTY WITHIN A MULTISITE TRUST
Authors: Mohammad RK , Shetty R 
Published: November 2016

BackgroundLength of stay in A&E is inversely proportional to quality of care. Prolonged occupancy of A&E beds by patients that need care, more appropriately at a different facility causes exit block. This compromises care also to other patients waiting to be seen and further increases waiting times.ObjectiveThe primary aim was to determine the time of disposition in the patient group referred for further care to external sites and to compare it with the referring hospital A&E's waiting time in general.IntroductionThe present study was undertaken over 60 days, collecting data from a total of 10,603 patients who attended the A&E, amongst whom 117 patients were referred to an offsite specialty for further care.A retrospective observational study was undertaken to collect data from all patients referred to a specific specialty from a single A&E which is part of a multisite NHS trust with shared specialties at different hospitals. This data was collected for the period between 1/1/2016 and 29/02/2016. The waiting times for such patients was then compared with that of the average waiting time for this A&E.Materials and MethodsData was extracted from the symphony data analysis for the particular A&E over the mentioned time period. A list of patients referred offsite to a particular specialty was obtained. Waiting times for these patients were calculated as the time since registration till the time they left the department. The average waiting times for all patients who attended this A&E during the study interval was also obtained separately.Results: ObservationsDuring the study period a total of 10603 patients had attended this A&E of which 78.44% left the A&E within 4 hours. Of the remaining 21.56% who breached the 4 hour target time a disposition was achieved for a majority (12.37%) within 8 hours and only 4.32% stayed beyond 12 hours.A subset of 117 patients was identified during this same time period who were referred to another site for a specific specialty assessment. Of this group 96 patients (82.05%) occupied the A&E for more than 4 hours. Nearly one fourth (23.93%) of the referred patients remained in the A&E beyond 12 hours.ConclusionThe current study has found that the patient group that needs referral to external sites for specialty care has a markedly longer A&E waiting time compared to the A&E waiting times in general.Figure 1Waiting time comparison between all patients attending A&E and those referred offsite.Figure 2Percentage of patients plotted against their A&E waiting times, comparing total A&E attendances with a subset of patients referred offsite.Table 1Waiting times for patients attending A&E between 01/01/ 2016 and 29/02/2016Waiting times (hours)NumbersPercentage0–4831778.44%4–8131212.37%8–125164.87%>124584.32%Total10603100%Table 2Waiting time for patients referred offsite to a particular specialty between 01/01/ 2016 and 29/02/2016Waiting times (hours)NumbersPercentage0–42117.95%4–84538.46%8–122319.66%>122823.93%Total117100%
ACCIDENT & EMERGENCY PERFORMANCE AND SENIOR DOCTOR INITIAL ASSESSMENT MODEL; NATIONAL DATA ANALYSIS FOR ENGLISH NHS HOSPITAL TRUSTS
Authors: Abdulwahid MA , Turner J , Mason S 
Published: November 2016

Objectives & BackgroundA number of systematic reviews of triage related interventions showed that there is a growing interest senior doctors performing initial assessment on patients.This study aimed to answer the following question: How do NHS trusts (NHSTs) with senior doctor assessment compare on key performance metrics such the percentage of patients waiting for more than four hours with their counterparts with no senior doctor initial assessment at triage?MethodsThis was a retrospective study of English emergency departments (EDs) performance (routine A&E quality indicators analysis) from July 2014–June 2015 at NHST level. Trusts were divided into two main groups according to their triage practice.These were identified in a national survey of ED triage practices across England. The first model was a group of fifty NHSTs that operated senior doctor initial assessment of ambulance arrivals or walk-in patients. This was compared to fifty-seven NHSTs with EDs that did not operate senior doctor initial assessment including EDs that trialled this model in the past.Relevant statistical tests were undertaken to examine the possibility of a statistical significant difference amongst the A&E quality indicators across NHST groups.ResultsAnalysis of data showed that NHSTs with and the NHSTs without senior initial assessment in triage had similar performance with regard to all measured outcomes.It should be noted that the performance of NHSTs with senior doctor triage slightly improved on all measured outcomes after adjusting for confounding factors such as attendance rate. However, this was not statistically significant.ConclusionExamining the output of the analysis and relative statistical tests, there is insufficient evidence to suggest that senior initial assessment in triage improve ED performance.Hence, the study findings do not support the use of senior initial assessment in triage.Figure 1
CONSULTUS INTERRUPTUS: UNSCHEDULED INTERACTIONS WITHIN THE EMERGENCY DEPARTMENT
Authors: Gill SS , Paw R , Doyle P , Shah A , Al-Shakhshir S , Abukhder M 
Published: November 2016

IntroductionThe job of an EM consultant involves multitasking and dealing with multiple unscheduled interactions (UI). The fluid, unpredictable, time pressurised and multi-professional nature of EM makes it particularly susceptible to UI. An increasing number of UI can result in increased error. An Increasing number of decisions, irrespective of complexity can lead to error and decision fatigue. We aim to map the number of UI an EM consultant faces when on shift.ObjectivesThis study attempted to answer the following questions1. In a day how many unscheduled interactions does the senior EM physician deal with?2. How many of these are interactions are clinical interactions?3. What is the average length of time spent dealing with these unscheduled interactions?MethodsThis prospective observational study took place at a single centre urban ED in the West Midlands. The study period was from 1.12.15 to 23.12.15. An EM consultant was shadowed on shift by a medical student who recorded all non-patient interactions involving the consultant. The consultant had no input into data collection. The nature of the UI,, the time spent; and the outcome were recorded on a data collection form. This was then collated and analysed.ResultsA total of 23 shifts over 135 hours 34 minutes were observed.There was a mix of early (0800–1600), late (1600–2100) and weekend shifts.▸ All 10 members of the consultant body were observed.▸ Total Number of UI in study period: 2082▸ Average Number of UI per hour: 17.95 UI/hour.▸ UI rate (time per UI): 3 minutes 22 seconds▸ Average time per UI: 87.5 seconds (Range 10 seconds–34 minutes).▸ Clinical vs Non Clinical Interactions: 94% vs 6%.ConclusionIn this single centre study of an urban UK emergency department, 40% of shop floor consultant time is spent dealing with UI. The majority (94%) of these UI related to clinical interactions. In this study this equates to 17.95 UI per hour with an average time spent dealing with each interaction of 87.5 secondsDiscussionModern EM relise on a senior EM physician, running an organised shift, to cope with the vast number of UI that must be resolved. Combining the intensity of this role with an individual patient load is not feasible and departments should consider the initiation of a ‘captain of the ship,’ or ‘Fat Controller’ role along with a second senior EM physician to provide individual consultant level care to the sickest individuals who require senior input.