bluuebunny/crossref_metadata_2025_split huggingface dataset:
THE IMPACT OF BYPASS OF NON-SPECIALIST ACUTE HOSPITALS IN FAVOUR OF SPECIALIST NEUROSCIENCE CENTRES AS THE PRIMARY HOSPITAL DESTINATION FOR TRAUMATIC BRAIN INJURY PATIENTS
Authors: Edwards DT , Lecky F , Fragoso-Iniguez M 
Published: November 2016

Objectives & BackgroundSince the introduction of the regional trauma networks in the UK, the practice of transporting traumatic brain injury (TBI) patients past the nearest non-specialist acute hospital (NSAH) in order to reach the closest specialist neuroscience centre (SNC) has been implemented. However, it has not yet been established whether this practice of ‘bypass’ improves survival in TBI patients, and there are concerns that it may cause delays in the stabilisation of the airway, breathing and circulation (ABC) leading to worse survival. This study sought to address this uncertainty in survival benefit.MethodsA comparative cohort study method was used to observe the differences in risk-adjusted survival in TBI patients who either bypassed the nearest NSAH to attend a SNC, or underwent selective secondary transfer from a NSAH to a SNC. The data of 400 patients with significant TBI (abbreviated injury scale score ≥3 in the head region) from two Trauma Networks in the North of England was retrospectively extracted from the Trauma Audit and Research Network (TARN) database, and cases of bypass (n=112) or secondary transfer (n=96) were identified. Using direct standardisation to adjust for casemix variation, and logistic regression to control prognostic variables, the differences between the expected and observed rates of survival in each group were compared.ResultsBypass of TBI patients did not significantly increase the observed minus expected survival rate (+4.4, 95% CI –1.6 to 10.5). However, selective secondary transfer of TBI patients was associated with more survivors than expected (+11.3, 95% CI 3.4 to 19.3), although the difference between groups was not statistically significant.ConclusionBypass of NSAHs in favour of SNCs, does not appear to significantly improve survival in TBI patients; and selective secondary transfer to a SNC, following stabilisation of ABCs at a nearer NSAH, may be a more appropriate strategy.Figure 1
A COMPARISON OF THE HEART, TIMI AND GRACE SCORES IN THE PREDICTION OF A MAJOR ADVERSE CARDIAC EVENT (MACE) IN PATIENTS PRESENTING WITH UNDIFFERENTIATED CARDIAC CHEST PAIN: A PROSPECTIVE COHORT STUDY IN A UK POPULATION.
Authors: Reaney PD , Elliott H , Cooper J 
Published: November 2016

Objectives & BackgroundCardiac sounding chest pain is one of the commonest reasons for presentation to the Emergency Department (ED) or acute medical receiving. An electrocardiogram (ECG) can rapidly identify those patients suffering from an ST elevation acute coronary syndrome (ACS) but the differentiation of patients with non ST elevation ACS from those with non cardiac chest pain or stable cardiac disease is often not straightforward and encompasses historical, clinical and biochemical factors. Effective early risk stratification of this group of non ST elevated ACS patients may streamline care pathways for those at high risk and lead to effective use of resources and early discharge in those in whom ACS is unlikely.MethodsA prospective cohort study of adult patients presenting to the ED or acute medical receiving unit of Aberdeen Royal Infirmary with cardiac sounding chest pain and an a non-diagnostic ECG. A necessary sample size of 1000 patients was calculated and recruitment began in December 2014. HEART, GRACE and TIMI scores were calculated from data obtained on patient attendance, with subjective aspects entered by the attending medical practitioner in real time. Patients were followed up to 30 days for the development of a MACE. Receiver Operated Characteristic (ROC) curves were plotted to determine discriminative power of each of the three scores to detect MACE. Sensitivities and specificities (with 95% CIs) for each score (at different cut-offs) were calculated.ResultsPreliminary results are available on 605 patients. Ages ranged from 20–95 years (mean 61.8 years), 360 (59.5%) were male and 108 patients (17.9%) patients suffered a MACE at 30 days.Area under the ROC curves demonstrated that HEART (0.86) had a greater ability to discriminate patients going on to develop a MACE than TIMI (0.71) and GRACE (0.76) scores.Within the HEART low risk group 1.2% of patients developed a MACE and within the high risk group over 60% developed a MACE.ConclusionThe HEART score out performs GRACE and TIMI in predicting MACE in patients presenting to the ED with cardiac sounding chest pain. It rapidly identifies a low-risk population that may be suitable for early discharge or ambulatory management from the ED and higher risk patients may be promptly prioritised for invasive management.Figure 1Table 1Preliminary HEART Score DataRisk GroupHEART ScorePatients30 Day MACE (%)Low0–31672 (1.2)Intermediate4–632538 (11.7)High7–1011368 (60.2)
COMPARISON OF STANDARD CPR AND CPR FEEDBACK METHODS IN TERMS OF THE EFFECTIVENESS OF CHEST COMPRESSIONS DURING CARDIOPULMONARY RESUSCITATION: A RANDOMIZED CONTROLLED STUDY
Authors: Akbuga Ozel B , Ozel G , Mamak Ekinci EB , Goger B , Delikanli C , Ersoy EC , Karademir LN , Gursoy M , Kocalar UG 
Published: November 2016

Objectives & BackgroundThe primary purpose of the study was to compare the metrics on the effectiveness of chest compressions obtained through an advanced CPR (cardiopulmonary resuscitation) manikin and a real-time CPR feedback device during simulated CPR.MethodsThis was a prospective, randomized controlled study. The study group consisted of 21 medical school and 62 paramedic students who were already trained in BLS skills. A five-question pretest on high-quality CPR was administered to all participants and they all performed a two-minute chest compression on an advanced CPR manikin. No statistically significant relationship was found in terms of pretest results, basal compression rates and depths between the two groups (p>0.05). The population was then randomly divided into two groups. The control group, consisting of 43 students, performed two-minute CPR on an advanced CPR manikin, followed by a two-minute CPR session with a simple metronome feedback. The study group performed two-minute CPR on an advanced CPR manikin, followed by a two-minute CPR using a TrueCPR real-time feedback device. We analyzed the compression rate and depth of both techniques.ResultsThe compression rate during CPR with a simple metronome feedback was significantly higher compared to that obtained during standard CPR (108±6.2 vs 119.0±18.2/min;p<0.05). However there was no significant difference in compression depth between the techniques (p>0.05). Use of the TrueCPR feedback device resulted in significant improvement in both the compression rate (106.2±4.8 vs 121.6±13.1/min;p<0.05) and the compression depth (56.5±5.8 mm vs 53.6±7.0 mm; p<0.05) compared to standard CPR without feedback. When CPR performance obtained by using both feedback methods was compared, there was no statistical difference between compression rates (p>0.05), whereas the TrueCPR device yielded significantly deeper compression depth compared to the simple metronome (56.5±5.8 vs 53.3±6.5 mm; p<0.05).ConclusionFeedback with a device during CPR is an effective method to achieve adequate compression rate and depth. The real-time feedback device can be particularly effective and offer advantages during the actual CPR procedure based on the more effective CPR metric achieved by its use. However, further studies to show the clinical effectiveness of the real-time CPR feedback devices are needed.
PALLIATIVE CARE IN THE EMERGENCY DEPARTMENT: A SYSTEMATIC REVIEW
Authors: Cooper E , Sheikh Z , Townend W , Johnson M , Hutchinson A 
Published: November 2016

Objectives & BackgroundEmergency departments (EDs) receive a variety of patients: those with unexpected injuries or trauma, chronic disease exacerbation or progression and existing advanced disease or terminal illness. Thus expectations of attendees can vary greatly. However the primary focus of EDs is acute management.The provision of tailored palliative care (PC), that meets the unique needs of people with advanced disease, is often difficult in the ED. The main objective of this qualitative synthesis was to increase understanding of the ED experience of people with advanced disease, their relatives and healthcare professionals.MethodsMedline, Embase, CINAHL and PsychInfo were searched for articles published prior to 2016. All titles and abstracts were reviewed by two independent reviewers according to predefined eligibility criteria. Differences were resolved by discussion and recourse to a third independent reviewer. The subsequently identified full texts then underwent the same process. Included papers were appraised for quality. A thematic synthesis of these qualitative data was then conducted using the techniques described by Thomas and Harden.ResultsThe search identified 19 studies which fulfilled the inclusion criteria. All passed the quality appraisal stage. Coding of the articles revealed 31 free text codes which were divided into nine key themes: environmental factors, provision of care, communication, interdisciplinary working, decision making, accessing care, education, legal concerns and preparation for death. These were condensed further into three analytical themes that described the most prominent aspects of the experience of PC patients, relatives and healthcare providers in the ED: environment and purpose; systems of care and interdisciplinary working; education and training.ConclusionThis synthesis has provided a greater breadth of insight to enable recurring themes regarding the potential conflicts between emergency care and PC to be identified with a view to overcoming the challenges faced. Significantly recognising the need for educating ED physicians in the scope and components of PC, improving interdisciplinary working and enabling better understanding of patients and carers about their likely disease progression and the opportunities open to them. Further research should focus on the best ways to provide such education, the specific reasons for shortfalls in communication and how these could be overcome.
ULTRASONOGRAPHY OF THE INTERNAL JUGULAR VEIN TO ASSESS INTRAVASCULAR STATUS IN THE ED
Authors: Anwer S , Majeed A , Naveed A , Rehman S 
Published: November 2016

ObjectivesTo assess the intravascular volume status using bedside ultrasonography of the internal jugular vein in the ED & to compare the results of two different methods, one qualitative and the other quantitative.BackgroundEstimation of intravascular volume status is an important parameter both for initial assessment and to evaluate the response to treatment in critically ill undifferentiated patients especially in an ED setting.Point of care ultrasound has been gaining popularity in the practice of EM. Ultrasound of the inferior vena cava (IVC) is used in estimating the Intra vascular volume, and is part of the RCEM's level 2 ultrasound training. IVC can be difficult to visualise in some patients. Internal Jugular Vein (IJV) is more easily accessible. Ultrasonography of the IJV has been described in the literature both as a qualitative and a quantitative tool to predict intravascular volume status.MethodsA prospective feasibility study at the ED of a tertiary hospital. We used a convenience sample. In phase-1 we scanned 15 healthy volunteers and in phase-2 we scanned 21 acutely unwell adult patients from Oct to Nov 2015. The appearance of the IJV was noted in first 45 degrees and than in supine position as described by Lipton, 2008. Than the aspect ratio (height/width) of the IJV was measured in supine position as described by Kelleret al,2009. We used a high frequency linear probe at a depth of 3.5–4 cm. The EP performing the ultrasound was blinded to the clinical information. The findings of the ultrasound were kept blinded from the attending EP. Results of the ultrasound were retrospectively compared with the final clinical judgment of the attending EP using clinical data to assess the fluid status of the patient as recommended by NICE Guidelines on intrvenous fluid therapy, 2013.ResultsThe results showed that for assessing the intravascular volume status bedside ultrasonography of the IJV byaspect ratio technique has a Sensitivity of 83.33%.▸ Specificity of 73.33▸ PPV of 55.56▸ NPV of 91.67▸ LR+of 3.12▸ LR– of 0.23▸ Whereas by appearance technique▸ sensitivity of 85.71%▸ Specificity of 88.71▸ PPV of 75.0▸ NPV of 92.31▸ LR+of 6▸ LR– of 0.17ConclusionThe results of this feasibility study demonstrated that point-of-care ultrasonography of the IJV in the ED can aid in the assessment of intravascular volume status. Both techniques showed moderate sensitivities and specificities which were comparable.Figure 1Figure 2Figure 3Figure 4
HOW TO DEVELOP AN EMERGENCY DEPARTMENTIN-SITUSIMULATION PROGRAM
Authors: Trippick S , Buckley A 
Published: November 2016

Objectives & BackgroundThe Department of Health recommends innovative, evidence-based, high quality simulation for learning.1The focus in recent years has shifted toin-situsimulation (ISS) which is physically integrated into the clinical environment.The development of ISS remains in its infancy with national variation in quality.2Limited evidence-based standards along with powerful cultural and logistic challenges often impede implementation of this practice.3We will describe the process in developing an ISS program in the ED and discuss the challenges. It is hoped this will be useful for other departments wishing to develop simulation.MethodsA multi disciplinary faculty was established. Faculty training needs were identified and local training supported. Quarterly faculty meetings were founded.A training needs assessment survey with a safety and teamwork questionnaire was emailed to all ED staff. A program of fortnightly sessions was designed in line with this, alternating adults and paediatrics. Scenario development was based on the RCEM curriculum, problematic events in the ED and observed learning needs.Simulations varied in level of fidelity, timing and location within the ED. Scenarios progressed to involve cross-specialty.Simulations commenced with a pre-briefing and lasted around 20 minutes followed by a 20 minute debrief. Debriefs were structured around a standard format incorporating clinical and non technical elements. Following each session participants completed an evaluation questionnaire (figure 1). During the scenario faculty noted observed latent safety threats on a template adapted from the NPSA contributory factors framework (figure 2). Identified latent threats were reviewed and escalated, including incident reporting.ResultsThe ISS program over the first year delivered 22 sessions to 86 participants with a good spread of participation across the team (figure 3).Participant feedback demonstrated the positive impact of ISS on team working, communication, technical skills and overall practice (figure 4).The identified latent threats covered a variety of contributory factors (figure 5).The main obstacle encountered relates to cancelling sessions due to service delivery needs.ConclusionThrough developing an ISS program in the ED our key learnings include:▸involving relevant stakeholders▸regular multi-professional faculty meetings▸minimising effects on service delivery▸tailoring simulations for the local team▸recording outcomesFigure 1Figure 2Figure 3Figure 4Figure 5
KEEPING THE DREAM ALIVE. A RAPID REMOTE PEER CPD TOOL FOR SENIOR EMERGENCY PHYSICIANS
Authors: Rowlinson J 
Published: November 2016

Objectives & BackgroundDuring times of ED pressures training & CPD opportunities are often sacrificed, with conversations & emails focused on operational issues. Senior EM physicians continue to experience an interesting breadth of patients which was the foundation of their career choice. Senior EM physicians face clinical dilemmas and may not have ready opportunities to discuss, reflect and review their practice amongst peers. In Jan 2016 a remote senior EM peer CPD tool was introduced to allow impartial team review and reflection on a colleague's difficult clinical encounter. The tool has been welcomed and may be of interest to other EDs as an addition to their CPDMethodsThe senior ED team submitted dilemmas to the project coordinator. A SurveyMonkey link, containing a description of two local ED dilemma with management option choices listed, was emailed to the senior ED team, with a request to vote for which one action they would have decided upon in that situation. A separate but identical survey was sent to senior trainees (ST3–6 ACP) and to ED consultants, to see any differences in responses. All responses were unidentifiable. A succinct analysis of results with graphs was emailed after 10 days, together with a brief summary of the realtime decision made and patient outcomeResultsTypically surveys received responses from 9 consultants and 9 trainees. The remote online survey enabled flexible and more ready participation. Dilemma topics submitted were varied and included decisions around ceilings of care (ITU/palliation, CPR duration, elderly trauma), care without onsite specialist services (HI & raised ICP, acute aortic dissection & pericardial effusion), ECG interpretation, interactions with police. No scenario resulted in a unanimous vote of one most appropriate management choice, with splits of opinions ranging from 50:50 to 25:75. Trainee and consultant group responses were usually, but not always mirrored. The ability to compare practice against respected colleagues was assuring for the team, though the variety in responses also thought provokingConclusionED physicians encounter situations without concrete guidance to fall upon and a best intention decision must be made. This tool is useful for reflection with colleagues, personal debrief and team's CPD. In addition, the survey results initiated enthusiastic discussions around the practice of emergency medicine which at times of ED pressures can be diluted.
DOES ADDING LACTATE TO THE NEWS SCORE IMPROVE IDENTIFICATION OF SEPTIC PATIENTS?
Authors: Gunn N , Haigh C , Thomson JR 
Published: November 2016

Objectives & BackgroundA previous audit has shown that in general with each rise in NEWS group there is an increase in serum lactate measured. However, it was noted that in the lowest NEWS Group 0–4 the average lactate was 2.5. A lactate level of >2 has been used as an initial marker of severity of illness yet these patients would be missed at triage.We decided to look at whether adding the lactate to the NEWS group would improve the early identification of septic patients at triage.A recent paper has used this in the context of patients with pneumonia.MethodsWe retrospectively reviewed 200 cases of adult patients who presented to the ED who had been identified as septic and had a sepsis 6 form completed. Initial NEWS scores and serum lactate levels were noted.Results200 cases were identified over a 6 month period–109 male; 91 female; age range 18–95 yrs, average 66.7 yrs. 3 notes were excluded as a serum lactate was not taken.4 patients were admitted to ICU; 17 admitted to HDU and 22 patients died.NEWS scores ranged from 1–19, average 7.4; IQR 1–NEWS 5; IQR 3–NEWS 9.Initial serum lactate levels ranged from 0.6–15.4, average 2.7; IQR1–1.4; IQR 3– 3.NEWSL scores ranged from 2.5–27.4, average 10.2; IQR1 –7.4; IQR 3– 12.3.The paper by S Jo et al combined lactate with NEWS scores and used ranges –<3; 3.1–5.2; 5.3–8; and 8.1+. We have adopted the same ranges.Numbers of patients are shown in table 1.Table 2 shows the number of patients in each NEWS group who required critical care input or died. With each rise in NEWS group, critical care patients are identified. However, 1 patient died in the NEWS 0–4 group which would not be deemed high risk at triage.Table 3 shows the number of patients in each NEWSL group who required critical care input or died. When adding the lactate to the NEWS score all patients were identified that required critical care or died in the highest NEWSL 8.1+ group. This group takes into account the patient in the NEWS 0–4 group who died.The ROC curve for NEWS vs NEWSL is shown in figure1. The AUC is 0.7187 with an accuracy of 0.6617 which is deemed fair discriminatory ability for the NEWSL score.ConclusionThe addition of lactate to the NEWS score identified all patients requiring critical care input or who died in the highest group –8.1+. This is a simpla calculation that can be performed at triage using point of care testing.Larger studies are required to confirm its validity.Figure 1Table 1Number of patients in each groupNEWS GroupsNEWSL Groups0–429<325–6483.1–5.2107–8535.3–8539+708.1+132N/A3Table 2Number of patients in each group requiring critical care or diedNEWS GroupITU AdmissionHDU AdmissionDied0–40015–61217–81639+2917Table 3Number of patients in each NEWSL group requiring critical care input or died.NEWSL GroupITU AdmissionHDU AdmissionDied<30003.1–5.20005.3–80208.1+41522
TICKED OFF ABOUT SAFE SEDATION: A CHECKLIST IMPROVES COMPLIANCE WITH SEDATION GUIDELINES IN AN EMERGENCY DEPARTMENT
Authors: Butterfield E , SIAH J , Napier J 
Published: November 2016

Objectives & BackgroundEmergency department (ED) procedural sedation is becoming more common, but associated adverse events have been reported. The Royal Colleges of Anaesthetists and of Emergency Medicine (RCoA and RCEM) have produced guidelines on the sedation of adults in the ED (RCoA and RCEM, 2012).In other environments checklists have been shown to improve patient safety (WHO, 2016).We hypothesised that introduction of a checklist would increase compliance with sedation guidelinesMethodsIn an East London ED, compliance with the RCoA/RCEM sedation guidelines was audited retrospectively from January to December 2015. On 1st June 2015 a sedation checklist was introduced.98 patients were identified from electronic patient records and data was compared between 3 groups:▸Patients sedated before 1st June 2015 (PreCheck): n=44▸Patients sedated after 1st June 2015, on whom the checklist was used (PosCheckPos): n=28▸Patients sedated after 1st June 2015, on whom the checklist was not used (PosCheckNeg): n=26ResultsDemographic data was similar between all the groups with no significant differences in age distribution, procedure, sedating agent, number of drugs used, the grade of the sedationist, discharge destination, or the proportion of sedations done out of hours.No significant adverse events occurred in any of the groups.When the checklist was used, 61% of sedations met all of the criteria for a safe sedation (ASA grading; airway assessment; fasting status and consent documented; two doctors and full monitoring). Prior to the checklist, 18% of sedations met all of the criteria.When the checklist was used (figure 1) there was a significant improvement in the number of cases meeting the audit standard for documentation of: consent, location, staffing, fasting status, ASA grade and airway assessment.When the checklist was not used despite being available, performance was no better than before the checklist was introduced (figure 2).ConclusionThe sedation checklist improved standards when used, but did not improve the performance of the ED overall because those who forget the existence of the checklist seem prone to forget to document the key steps in safe sedation.To increase compliance with RCoA and RCEM sedation guidelines the checklist needs to be a compulsory part of the set up for sedation, linked with the dispensing of sedation drugs.Figure 1There are significant improvements in the proportion of sedations meeting the audit standards when a checklist is usedFigure 2When the checklist is not used, performance is no better than before it was introduced