bluuebunny/crossref_metadata_2025_split huggingface dataset:
19 Accuracy of biomarkers for venous thromboembolism in pregnancy: the diagnosis of pulmonary embolism in pregnancy (DiPEP) biomarker study
Authors: Goodacre Steve , Hunt Beverley , Parmar Kiran , Shephard Neil , Horspool Kimberley 
Published: November 2017

ObjectiveTo estimate the accuracy of biomarkers for venous thromboembolism (VTE) in pregnant and postpartum women with suspected pulmonary embolism (PE).DesignObservational cohort study augmented with additional cases with VTE.SettingEmergency departments and maternity units at eleven prospectively recruiting sites.ParticipantsPregnant or postpartum women presenting with suspected PE or diagnosed DVT.InterventionsResearch nurses/midwives collected a blood sample from women with suspected PE or diagnosed DVT and data relating to diagnostic imaging, treatment and adverse outcomes. Blood samples were centrifuged, stored and then transported to Guy’s St Thomas Trust for analysis.Main outcome measuresWomen were classified as having or not having VTE on the basis of diagnostic imaging, treatment and subsequent adverse outcomes. Primary analysis was limited to women with conclusive diagnostic imaging. Secondary analyses included women with clinically diagnosed or ruled out PE.ResultsUsable blood samples were taken from 18 women with diagnosed DVT and 310 women with suspected PE, of whom 18 had PE confirmed by imaging and 247 had PE ruled out after imaging and were included in the primary analysis. Mean biomarker levels only significantly differed between women with and without PE for Clauss Fibrinogen (p=0.007), ELISA D-Dimer (p=0.001), Innovance D-Dimer (p=0.004), Thrombin Generation Lag Time (p<0.001), Thrombin Generation Time to Peak (p=0.001) and Plasmin Antiplasmin (p=0.004). The AUC (95% CI) for each biomarker was APTT 0.669 (0.570 to 0.768), BNP 0.549 (0.453 to 0.645), C-Reactive Protein 0.542 (0.445 to 0.639), Clauss Fibrinogen 0.589 (0.476 to 0.701), ELISA D-Dimer 0.668 (0.561 to 0.776), Innovance D-Dimer 0.651 (0.545 to 0.758), MRproANP 0.524 (0.418 to 0.630), PF1 +2 00.562 (0.462 to 0.661), Plasmin-antiplasmin 0.639 (0.536 to 0.742), Prothombin Time 0.613 (0.508 to 0.718), Thrombin Generation Lag Time 0.702 (0.598 to 0.806), Thrombin Generation Endogenous Potential 0.559 (0.437 to 0.681), Thrombin Generation Peak 0.596 (0.478 to 0.715), Thrombin Generation Time to Peak 0.655 (0.541 to 0.769), Tissue Factor 0.531 (0.424 to 0.638) and Troponin 0.597 (0.499 to 0.695). ROC analysis showed that only thrombin generation lag time had any potential to rule out PE with sufficient sensitivity while achieving meaningful specificity, with sensitivity of 97% and specificity of 25% at the threshold that optimised sensitivity. Repeat analysis excluding women who had received anticoagulation was limited by the small number (n=4) who had PE.ConclusionCurrently available biomarkers show little potential for aiding the diagnosis of suspected PE in pregnancy and postpartum.Figure 1Figure 2Figure 3
22 Emergency department litigation and coroner’s inquests: a ten year analysis
Authors: Tilbury Nicholas , Tabner Andrew , Johnson Graham 
Published: November 2017

IntroductionThe burden of litigation within the NHS should not be underestimated. Indemnity costs rise in response to the rising frequency and costs of claims, with recent changes to the discount rate projected to increase NHS Litigation Authority (NHSLA) costs by £1 Billion per year. Litigation also has a significant psychological impact on staff. This study represents the first examination of litigation and Coroner’s ‘Prevention of Future Deaths’ reports relating to emergency department care in the UK.MethodUsing the Freedom of Information (FOI) Act (2000) we submitted data requests to both the NHSLA and the Ministry of Justice (MoJ).The NHSLA provided data concerning ED litigation claims between 2006 and 2015 including:Number of claims by yearNumber of successful and unsuccessful claims by yearNumber of settled claimsCost of claims (including defence costs, claimant costs and damages awarded)The MoJ provided data concerning PFD reports issued to EDs between 2006 and 2016. Data concerning PFD reports issued between 2012 and 2015 were extracted from the MoJ website. Data included:Report dateAge and gender of the deceasedReport summaryResultsThe total number of ED litigation claims made between 2006 and 2015 was 10,040; 5745 (57.2%) resulted in a financial settlement. The number of claims successfully settled ranged from 382 in 2005/06 to 830 in 2014/15 with an upward trend throughout the decade. The mean cost of a successful claim was £114,029; increasing from £66 754 in 2005/06 to £1 41 027 in 2014/15, a 111% increase. Delay/failure in diagnosis was the most common cause for litigation (4318 [44.5%]) and PFD reports (15 [21%]).A total of 70 PFD reports were issued within the study period; there was no trend in the number of reports issued per year. The greatest number of reports were issued in 2014 (18), far exceeding any other year.DiscussionAnnual claim numbers have increased by 117% over the study period and mean claim cost has increased by 111% (far in excess of any rise expected due to inflation). Causation cannot be determined by this observational study, but potentially contributory factors include: the increasingly litigious nature of society in general; rising patient expectations and the worsening crisis in staff retention, recruitment and morale.This analysis of litigation patterns and PFD reports provides an insight that enables further focus on the underlying causes, subsequent improvement in patient care and a reversal of current litigation trends.
23 Patient and staff perspectives on the reasons for increasing emergency department attendances
Authors: Ablard Suzanne , Rimmer Melanie , O’Keeffe Colin , Mason Suzanne 
Published: November 2017

Background/objectivesAn NHS England review recognised that demand for Urgent and Emergency Care is unsustainable. Health practitioners and policy makers are interested in understanding the reasons why patients with low acuity problems attend the Emergency Department (ED). This should, in turn, assist the development of interventions to reduce demand.We aimed to gain an understanding about the reasons for rising ED demand and to identify possible solutions.MethodsA self-report patient survey was administered to non-ambulance patients at 9 EDs across Yorkshire and Humber (Y and H) asking participants: reasons for attending the ED; awareness of alternative services; and perceptions of the suitability of other services to manage their health problem. Survey data was analysed descriptively and compared with two similar studies conducted in 1997 and 2006.Semi-structured interviews were conducted with ED and Urgent Care staff (Consultants, Doctors, Nurses, Managers, General Practitioner) working in 9 EDs across Y and H. The interview topic guide was structured around: description of patients attending EDs and impact on demand; and current/future initiatives to deal with rising demand. The interviews were transcribed verbatim and analysed thematically using Framework Analysis.Results481 surveys were completed. Increasing numbers of patients reported that a health professional advised them to attend the ED (31% in 1997 vs 50% in 2016). Awareness of alternative urgent care services had increased since 2006 but the perceived appropriateness of these services had decreased or stayed the same.Interviews were carried out with 25 ED and urgent care staff. Reasons for attendance at the ED were divided into patient-level reasons (e.g., people are more demanding of the healthcare system; poor health literacy) and structural-level reasons (e.g., difficulties accessing primary care; alternative healthcare services directing patients to the ED inappropriately). Our participants described a wide range of interventions divided into patient-level interventions (e.g., increasing patient education) and system-level interventions (e.g., streaming patients into appropriate services), but there was no clear consensus with regards to which interventions had had the greatest impact.ConclusionWe found evidence of a rise in patients being referred to the ED by other healthcare services. This may be a reflection of the wider healthcare system under strain, thereby causing overspill into EDs. Future research is needed to design and test interventions that can lead to improvements in the system that are acceptable to patients, do not lead to increased demand, are cost-effective and lead to more sustainable working environments.
24 An audit into the number of patients suffering out-of-hospital cardiac arrest that are resuscitated despite a high likelihood of futility
Authors: Cokljat Mia , Clegg Gareth , Clarke Scott 
Published: November 2017

BackgroundFor a significant number of patients suffering out-of-hospital cardiac arrest (OHCA) cardiopulmonary resuscitation (CPR) is likely to be futile and attempting it may be the wrong thing to do. Anticipatory care plans with do-not-attempt cardiopulmonary resuscitation (DNACPR) instructions exist to prevent this. Anecdotally we felt that many patients present to our Emergency Department (ED) with ongoing resuscitation which was not in their best interests. The aim of this study was to establish the proportion of patients arriving in our ED with ongoing CPR who had low, intermediate or high risk of futility.MethodsThe survival outcome and past medical history of patients with OHCA brought into the ED of the Royal Infirmary of Edinburgh in 2015 were extracted from hospital records. Indicators of general deteriorating health and clinical indicators of underlying life limiting conditions were used to populate the Supportive and Palliative Care Tool (SPICT). The SPICT score was used as a measure of likely CPR futility. A SPICT score of 0–2 meant low risk of futility, 3–4 intermediate risk and >5 a high risk.ResultsOf the 283 cases, 202 (71.4%) had a low risk of CPR futility; 46 (16.3%) an intermediate risk; and 35 (12.4%) were considered to be at high risk of CPR futility. In all low, intermediate and high risk categories, the commonest outcome was to be pronounced dead in A and E (55.4%, 73.9% and 71.4% respectively). For the low risk of futility group, a significant proportion (27.7%) survived to hospital discharge, whereas patients in the intermediate and high risk groups rarely survived with only 2.17% and 2.86% respectively discharged from hospital. Of the low, intermediate and high risk patients, 11.4%, 91.3% and 100% respectively had one or more significant underlying comorbidities.ConclusionsOur results suggest that community DNACPR implementation in Edinburgh is suboptimal, with many patients resuscitated and transported to the ED with ongoing resuscitation despite a high likelihood of futility. It is unclear what is required to improve this situation. Possible avenues for improvement may be more anticipatory care planning in the community, better recording of the outcomes of key conversations with patients and carers, or more consistent implementation of these plans by Ambulance Service responders. We plan further work to establish how this system can be changed to serve patients and their families better.
26 Protocol for the upcoming study: patient input monitoring of pain in the emergency room: novel electronic log (PIMPERNEL): a randomised controlled trial of an electronic pain score display in adults in the emergency department
Authors: Thornton Hilary , Coats Timothy 
Published: November 2017

BackgroundPatient surveys and research have shown that Emergency Department attendees do not receive adequate analgesia. Pain monitoring has not been automated and usually involves a member of staff asking the patient to rate their score with no continuous record, often no specific place to record it and no automated alarm system for scores outside accepted parameters. Few patients have regular monitoring of their pain and our own preliminary research showed that over one week only 58% of patients with moderate to severe pain had a second or subsequent score recorded.EquipmentA small pain monitoring display has been developed at the University of Leicester and acts as an electronic version of the 11 point numerical rating scale. Data are transmitted to a tablet through a wireless connexion. PIMPERNEL (Patient Input Monitoring of Pain in the Emergency Room: Novel Electronic Log) is a feasibility study testing this for the first time.ObjectivesThe primary objective is to determine the feasibility of studying the effect of an electronic pain monitoring display on the pain experienced by emergency care patients. Secondary objectives include determining whether patients use the display, whether pain ratings correlate with routine records, how pain changes over time, whether patients use the display for reasons other than pain, which potential stratification factors may be useful for a subsequent multi-centre study and whether analgesia prescription changes. We will also obtain patient and staff feedback.Inclusion criteriaAdults, initial pain score 5 or more, likely to be staying for at least 2 hours, able to consent and understand English.Study procedureWe aim to recruit 200 patients (100 per arm) from the emergency department at Leicester Royal Infirmary. All patients will use the display. This is a parallel group, two arm superiority trial with a 1:1 allocation ratio. Patients will be randomised to have their pain score on display (intervention) or hidden (control). Blinding is not possible. The display beeps every 15 min to remind patients to enter their pain score. Treatment will not be constrained by study protocol and will depend on the judgment of the treating clinician. The study will continue for up to 6 hours to allow time for the first dose of analgesia to wear off. Data collection will cease when the patient leaves the department. Questionnaires will be given to participants and the staff nursing them.
27 The DiPEP (Diagnosis of PE in Pregnancy) study: can clinical assessment, d-dimer or chest x-ray be used to select pregnant or postpartum women with suspected PE for diagnostic imaging?
Authors: Goodacre Steve , Horspool Kimberley , Nelson-piercy Catherine , Knight Marian , Shephard Neil , Lecky Fiona , Thomas Steven , Hunt Beverley , Fuller Gordon 
Published: November 2017

ObjectiveTo determine whether clinical features (in the form of a clinical decision rule) or d-dimer can be used to select pregnant or postpartum women with suspected PE for diagnostic imaging.DesignObservational cohort study augmented with additional cases.SettingConsultant-led maternity units participating in the UK Obstetric Surveillance System (UKOSS) and emergency departments and maternity units at eleven prospectively recruiting sites.Participants198 pregnant or postpartum women with diagnosed PE identified through UKOSS and 324 pregnant or postpartum women with suspected PE from prospectively recruiting sites.InterventionsData were collected relating to clinical features, elements of clinical decision rules, d-dimer measurements, diagnostic imaging, treatment for PE and adverse outcomes.Main outcome measuresWomen were classified as having or not having PE on the basis of diagnostic imaging, treatment and subsequent adverse outcomes. Primary analysis was limited to women with conclusive diagnostic imaging. Secondary analyses included women with clinically diagnosed or ruled out PE.ResultsThe primary analysis included 181 women with PE and 259 without. Most clinical features showed no association with PE. The only exceptions were number of previous pregnancies over 24 weeks (p=0.017), no varicose veins (p=0.045), no recent long haul travel (p=0.006), recent surgery including caesarean section (p=0.001), increased temperature (p=0.003), low oxygen saturation (p<0.001), PE-related chest x-ray abnormality (p=0.01) and other chest x-ray abnormality (p=0.001).Clinical decision rules had areas under the receiver-operator characteristic curve ranging from 0.577 to 0.732. No clinically useful threshold for decision-making was identified for any rule. The sensitivities and specificities of d-dimer were 88.4% and 8.8% using the standard laboratory threshold and 69.8% and 32.8% using a pregnancy-specific threshold.ConclusionsClinical decision rules, d-dimer and chest x-ray should not be used to select pregnant or postpartum women with suspected PE for diagnostic imaging.
3 Derivation and internal validation of a clinical decision rule to guide whole body computed tomography scanning in trauma
Authors: Chatha Hridesh , Sammy Ian , Body Rick , Sattout Abdo , Hollingsworth John 
Published: November 2017

BackgroundThere are no widely accepted validated clinical decision rules for the use of WBCT in trauma. Given the potential risks and costs, there is a clear need for a clinical decision rule (CDR) to safely guide targeted use of WBCT. We aimed to derive a CDR to guide clinical decisions on WBCT utilisation by detecting patients at high and low risk of multi-region trauma.MethodsWe retrospectively identified consecutive patients who had presented to a major trauma centre with suspected major trauma. Study took place at Aintree University Hospital, Merseyside. After extracting data, we derived a clinical decision rule for detection of multi-region trauma by logistic regression and recursive partitioning. The primary outcome was defined as injuries of AIS≥2 in two or more body regions, while the secondary outcome was the presence of two injuries of AIS≥3 in two or more body regions. This rule was cross-validated on the original sample using bootstrapping.Results1608 patients were included in the study. The derived model combined a bespoke physiological score with mechanistic and anatomical factors. The physiological score identified the risk of multi-region injury at various cut-offs of age, systolic blood pressure, GCS, heart rate and respiratory rate. Patients were further categorised according to mechanism of injury and clinical findings, and specific physiological scores were applied to each category to determine which patients in these categories required WBCT. ‘High risk’ injury mechanisms included high falls and unprotected road traffic collisions. Clinical signs of injury were categorised by body region, including the head, chest, abdomen and pelvis (figure 1). The overall sensitivity of the clinical decision rule for the primary objective was 96.0% (95% CI:94.8 to 97.2) while the specificity was36.1% (95% CI:33.3 to 39.0). The negative likelihood ratio was 0.11. For the secondary objective the sensitivity was 98.5%, the negative likelihood ratio 0.04.Figure 1ConclusionThis study derived a two stage CDR which was highly sensitive for identifying patients at high risk of multiregion injury. A prospective external validation study is now required to further refine and improve this model. This could provide a useful screening tool in the future.
30 Do nice guys finish last?
Authors: Turner Chris , Turner Jake 
Published: November 2017

Emergency medicine is widely recognised as an intense specialty. Interruptions are known to derail thoughts, increasing cognitive load and result in longer periods before deep thought is re-established. Although approachability and warmth are regarded as important factors in clinicians we wondered what impact these characteristics had on the number of interruptions.MethodologyA team of 6 medical students were trained in the use of abespoke tool to record shop floor activities. Over 4 months we conducted 100 hours of minute by minute time and motion study of emergency medicine consultants during their clinical shifts, and noted how often they were interrupted. At the end of shifts the assessors were asked a set of qualitative questions on the behaviour and attitudes of the consultants. These questions were completed in seclusion and in an anonymous format, to minimise the chance of bias/influence.Questions included‘How friendly was the consultant with other staff?’ ‘How friendly was this consultant with patients?’ And, ‘How would you rate this consultant’s ‘general positivity’?’We then assessed whether consultants that scored ‘higher’ inthese areas were more likely to be interrupted. Our hypothesis was that consultants who were more friendly were less intimidating for juniors and nurses to approach with questions, and so may suffer from an increase in cognitive load due to being interrupted and questioned more frequently than consultants who were felt to be less approachable.We found that consultants who scored 1(highest) in friendliness had an average of 7.38 interruptions per hour, compared to consultants who scored 3 or greater, who had an average of 3.59.ConclusionsOur average interruptions were close to those found in previous publications (between 6 and 9 interruptions per hour), however there was a large amount of inter-consultant variability, with one consultant during one shift being interrupted over 12 times per hour on average. If the results of this study are replicable, then it may raise questions about how best to manage this extra cognitive load. Although some may argue that being seen as slightly less friendly has an advantage in the reduction of interruptions, this may come at a cost to patient safety. There is clearly a fine balance to be made.Figure 1Average interruptions per hour by friendliness score
31 The quality improvement QIP – improving multidisciplinary staff engagement with quality improvement in the RVH emergency department
Authors: Bannon Olly , Greenwood Emma 
Published: November 2017

In recent years the RVH Emergency Department (ED) had been under intense pressure and public scrutiny. This led to a demoralised workforce who had become disengaged with quality improvement (QI). QI projects had become an exercise in data collection with little focus on improving care for patients.Two consultants undertook training in QI and then decided to develop a QI project aiming to empower staff and embed QI as daily practice. An ED QI steering group of interested multidisciplinary members was formed and devised an improvement plan to increase staff engagement with QI.The steering group secured funding for a subscription to the Institute of Healthcare Improvement (IHI) online open school. This was made available to 50 staff and was used to increase knowledge of QI methodology. An aim of 250 open school modules completed by August 2017 was set. This total was surpassed in June 2017, amounting to over 330 hours of QI training undertaken in staff’s own time. To date 13 staff members have achieved IHI Certificates in Quality and Safety.We designed a series of projects which were linked with the Trust Improvement plan. The QI teams are all multidisciplinary with medical and nursing staff from different grades involved in each as well as input from other professionals such as pharmacy, physio and clerical/admin staff.Figure 1Through the delivery of this project the ED team’s enthusiasm for QI has been reinvigorated. We have demonstrated improvements in clinical standards such as pain management where a project was undertaken, which has seen a 4 fold increase in the number of patient’s who sustain a fractured hip receiving the gold standard treatment of fascia iliaca nerve block.We have shown improvements in communication with the ‘Unfinished Symphony’ project demonstrating significantly better ED/GP written handover correspondance and the ‘What’s in a name’ project decreasing inter-specialty conflict during the referral process. We have also increased efficiency with senior review for Ambulance patients and subsequent significant decrease in waiting times. A recent project targeting the waste associated with unnessecary triage blood tests is showing promising early results.Figure 2The ED improvement team have endeavoured to improve the environment for staff by developing a ‘Grrr to Great’ board, through which staff are empowered to highlight problems but are also tasked with developing solutions. We have also increased accessibility of QI data by producing a QI update board and displaying data openly and transparently in the department.Figure 3