bluuebunny/crossref_metadata_2025_split huggingface dataset:
44 Quantifying the 5 year mortality of frequent attenders to the emergency department
Authors: Davison Alexander , Boyle Adrian , Hayhurst Catherine 
Published: November 2017

IntroductionFrequent Attenders (FA) to Emergency Departments (ED) are a vulnerable population which we perceive to have a high morbidity and mortality. ED clinicians find this population challenging and they are at risk of being stigmatised. There has been little published work in the UK quantifying the risk of death in this population. Here we aim to quantify the 5 year mortality of this population and identify key risk factors.MethodsWe identified a cohort of frequent attenders, defined as attending the ED 5 times or more between 1/4/2010 and 31/3/2011. We followed these patients via their electronic patient record from Cambridge University Hospital which is linked to the NHS spine.Overall mortality for the population has been calculated and we will produce a censored Kaplan-Meier survival estimate to account for patients we have been unable to follow up. Using a cox regression model we will analyse the impact of the chosen variables (age, sex, continued number of attendances to ED, and presence of a major physical or psychological illness or alcohol abuse) on mortality.Initial results(pending full statistical analysis)5 year mortality for the entire cohort was 24% and when limited to 16–65 year olds 5 year mortality was 11%. There will be a full risk factor analysis of this data available.ConclusionFrequent Attenders to Addenbrooke’s ED have a risk of death much greater than the normal population. A large proportion of the patients who died were very elderly and so 5 year mortality is less surprising but may suggest a need for further community care involvement to reduce ED attendance.The crucial finding is that the risk of death for adult FAs between the age of 16–65 is much higher than would be expected of the normal population. This indicates a need to treat this population with increased care.
45 Patient evaluation of trauma service
Authors: Jagdev Balraj , Gardiner Hannah , Turner Chris 
Published: November 2017

Patient Experience of the Trauma System (PETS)Trauma care is highly organised, time critical medicine. Changes to patient management in trauma care are often the result of Random Control Trials, and expert opinion following rigorous evaluation of the evidence. Highly efficient, injury focused care is required to achieve the best outcomes for patients. One area that has not been researched so thoroughly however, is the patient experience of trauma care. As evidence already suggests that patients with high stress levels have poorer outcomes, we wanted to investigate the patient perception of the trauma system. We were particularly interested to find out if there were any areas where patient anxieties could be reduced or eliminated.MethodologyA ten-person qualitative study was initially conducted to test for feasibility and reproducibility. The methodology involved semi-structured interviews investigating outcome measures such as the patient’s perception of being looked after, biggest concerns and understanding of care, among others. Interviews were undertaken by a medical student and a Foundation Year 2 doctor (at the end of the Emergency Medicine block, post sign-off) trained in the methodology.The initial study was carried out over one month in early 2017 and involved adult patients (>18 years) admitted via the trauma care pathway who were Glasgow Coma Score 15/15. Interviews took place within 48 hours of admission in the Emergency Department (prior to transfer), the observation ward or the extended care trauma unit. Barriers to patient interviews included: severity of injuries; patient refusal; language proficiency and patient recollection (some had no recollection of being in resus). Despite this we managed an initial sample of 10 patients, with rich data.Following on from the pilot study we have made some amendments to our questions and have conducted a further set of 20 interviews.ConclusionsA significant proportion of patients have concerns during trauma care that they feel unable to voice. This has the potential to increase their stress levels and have an adverse impact on their recovery. The concerns are varied and not always predictable, often unrelated to the injury. Thus we feel there may be patient benefit from the use of a single open question towards the end of the primary survey. We suggest AMPLE-AE for ‘is there Anything Else you would like to tell me or ask about?’
46 Testing of the ‘always events’ approach to improve the patient experience in the emergency department
Authors: Kay Cameron , Lowe David 
Published: November 2017

AimsThis project aimed to identify issues patients would like to see improved when interacting with the Minor Injuries Unit (MIU) and as a result generate measurable and feasible Always Events (AEs) based on patient feedback that can be implemented via a Quality Improvement (QI) process. We then looked to assess and improve on the delivery of the agreed AEs to enhance MIU patient experience.MethodsAEs were identified by using a short semi-structured survey questionnaire with a free text response section from 45 patients. Patients were asked what should always happen in the ED. Iterative thematic analysis identified information provision and explaining how the department worked as key themes. Two interventions, an educational poster and a video campaign, were designed and implemented to address this issue. Improvement was assessed via convenience sampling of patient questionnaires using a five-point bipolar Likert scale and free text responses which were compared to a set of baseline results via run charts to examine impact of each intervention. A total of 300 patients completed questionnaires throughout the baseline and intervention periods.ResultsBaseline results stood at 80% for patient satisfaction regarding information provision, rising to 88% by the end of the poster intervention and 92% by the end of the video intervention. Understanding of how the ED functions stood at 83% in the baseline sample before rising to 86% throughout the poster and video intervention. Composite survey results rose from a baseline level of 82.2% to 86.3% for the poster intervention and 88.8% by the end of the video intervention stage. Patient questionnaires indicated that information provision directly from staff was variable throughout the study period.Figure 1Figure 2DiscussionImplementing the AE approach in the MIU has had a positive effect on patient experience. The poster intervention had the greatest impact on enhancing patient understanding. Our study indicated that direct information provision from staff was sufficient for patients and improvements in responses were due to the project interventions. Next steps should be to further implement the video in the department via inclusion on the patient Wi-Fi homepage and waiting room television to maximise the impact of the video. The patient–staff co-design nature of this study shows the AE methods strength in improving patient-centred care. In summary, this project emphasises that the AE method is an effective, valid and beneficial form of Quality Improvement to be used within EDs which has the potential for widespread future use.
47 Systematic review and meta-analysis of analgesic efficacy and safety profile of single injection fascia iliaca compartment blocks in the acute pre-operative pain management of hip fractures
Authors: Fadhlillah Fiqry , Chan David 
Published: November 2017

BackgroundIt is hypothesised that a single injection fascia iliaca compartment block (FICB) administered in the pre-operative setting provides better analgesic control for traumatic hip fractures and is not associated with major adverse effects. Systemic analgesics, whilst effective, could lead to cardiovascular, respiratory and cognitive impairment. As a consequence, undertreatment of acute pain remains prevalent in adult patients with hip fractures, with a consistent decline seen in analgesic administration with age.ObjectivesDetermine the analgesic efficacy and safety profile of single injection FICB performed in the pre-operative period for acute pain management in adult patients with traumatic hip fractures compared to other forms of analgesia.MethodsMEDLINE, EMBASE, Cochrane and CINAHL were independently searched to identify randomised controlled trials (RCTs) in English. Patients aged >18 years old who have suffered an isolated traumatic hip fracture (proximal femoral fracture) and received single injection FICB pre-operatively were included. No date restriction was applied and key journals and articles were scrutinised to include studies not identified by the primary search.ResultsOut of 3757 citations, eight RCTs were included in the final quantitative analysis, comprising of 645 participants. Acute pain was significantly reduced in FICB during positioning and movement, standardised mean difference (SMD)=−1.82 (95% CI:−2.26 to −1.38, p<0.00001) but was variable at rest (p=0.20). There was a reduced incidence of analgesia breakthrough (n=57 versus n=73), drowsiness/sedation (n=1 versus n=22), desaturation (n=0 versus n=4) and nausea and vomiting (n=3 versus n=7) in the FICB arm. There were similar numbers of patients across both arms that reported localised bruising (n=3). Only one study was at low risk of bias.Figure 1Figure 2ConclusionsFICB is superior in controlling acute pre-operative pain in adult patients with traumatic hip fractures. The benefit is more evident during positioning and mobilisation of the limb. FICB has a better safety profile and reduces dependency on systemic analgesia.
48 Calpol: are we overdosing on blood tests?
Authors: Patel Brijesh 
Published: November 2017

BackgroundIn February 2012, the Commission on Human Medicines recommended lowering the paracetamol toxicity treatment threshold for all patients. Children between one month and six years of age are physiologically distinct and metabolise paracetamol differently, making them less prone to toxicity. Furthermore, overdose in early childhood is almost exclusively accidental, as opposed to predominately deliberate self harm seen in adults and adolescents. As a result, the use of the new 75 mg/kg ingestion threshold for young children would appear to be of unproven benefit, and is substantially lower than the threshold used in other countries.AimTo establish the sensitivity and negative predictive value of using a 150 mg/kg ingestion threshold to identify hepatotoxicity in children one month to six year old group with paracetamol overdoses.MethodRetrospective case review. Potential cases were identified by filtering an electronic Patient Management System for a discharge diagnosis of ‘accidental ingestions and poisonings’ over the period 1 st January 2012 to 19th October 2016 (57 months). ED documentation was reviewed to identify cases of paracetamol ingestions by children under the age of 6 years. Those with intentional harm, known staggered ingestions over 1 hour or under one month age (corrected for gestation) were excluded.Clinical notes and laboratory data were reviewed and, data parameters collated using a standardised proforma. Ingested doses were estimated, where possible, by subtraction methods. In some cases, the ingestion time was revised according to the time that the child was previously seen prior to the ingestion. A composite outcome for hepatotoxicity was used consisting firstly of the current UK standard treatment threshold (100 mg/L line on paracetamol toxicity nomogram) together with any evidence of biochemical hepatoxicity or clinical features of potential hepatotoxicity at any subsequent ED attendances over the next 7 days.ResultsThe final cohort consisted of 165 individual patient ingestions. A 150 mg/kg ingestion threshold had a sensitivity of 100.0% (95% CI:47.5 to 100.0) for hepatotoxicity, with a negative predictive value of 100% (95% CI:97.5 to 100.0).ConclusionThis retrospective study supports the hypothesis that accidental paracetamol ingestions less than 150 mg/kg, in children one month to six years of age, can be safely managed without investigation or treatment, in accordance with other international guidance. The use of 150 mg/kg threshold would reduce testing in over a third of attendances in our cohort. Study limitations include retrospective bias and the predominate use of serum paracetamol levels to determine toxicity.
49 Paediatric traumatic cardiac arrest – the development of a treatment algorithm
Authors: Vassallo James , Nutbeam Tim , Rickard Annette , Lyttle Mark , Smith Jason 
Published: November 2017

IntroductionPaediatric Traumatic Cardiac Arrest (TCA) is a high acuity, low frequency event with fewer than 15 cases reported per year to the Trauma Audit Research Network (TARN). Traditionally survival from TCA has been reported as low, with some believing resuscitation is futile. Within the adult population there is growing evidence to suggest that with early and aggressive correction of reversible causes, survival from TCA may be comparable to that seen from medical out-of-hospital cardiac arrests. Key to this survival has been the adoption of a standardised approach to resuscitation.The aim of this study was, by a process of consensus, to develop a national, standardised algorithm for the management of paediatric TCA.MethodsA modified consensus development meeting was held. Statements discussed in the meeting were drawn from those that did not reach consensus (positive/negative) from a linked three round online Delphi study. Those participants completing the first round of the Delphi study were invited to attend.19 statements relating to the diagnosis, management and futility of paediatric TCA were discussed in small groups. After five minutes the key points from the small groups were presented to the whole audience. Subsequently, using electronic voting devices, each participant anonymously recorded their agreement with the statement using ‘yes’, ‘no’ or ‘don’t know’. In keeping with our Delphi study, consensus was seta prioriat 70%. Statements reaching consensus were included in the proposed algorithm.Results41 participants attended the consensus development meeting. Of the 19 statements discussed, 13 reached positive consensus and were included in the algorithm. A single statement regarding initial rescue breaths reached negative consensus and was excluded. Consensus was not reached for five statements, including the use of vasopressors and thoracotomy for haemorrhage control in blunt trauma. The proposed algorithm for the management of paediatric TCA is shown as Figures 1 and 2 for blunt and penetrating trauma respectively.Figure 1Figure 2ConclusionIn attempt to standardise our approach to the management of paediatric TCA and to improve outcomes, we present the first algorithm specific to the paediatric population.
51 Paediatric emergency clinicians are rarely exposed to non-airway critical procedures: a predict/PERN study
Authors: Garrahan Juan P , Lyttle Mark , Oakley Ed , Dalziel Stuart , Nguyen Lucia , Rao Arjun , Mintegi Santiago , Babl Franz 
Published: November 2017

BackgroundRecent studies suggest that approximately one per thousand paediatric ED attendances may require some sort of critical procedure, with intubation being by far the most common. It is unknown how often critical non-airway procedures such as chest decompression, CPR, ED thoracotomy, defibrillation, pacing, and advanced vascular access techniques are performed by paediatric emergency clinicians.ObjectiveTo determine the recent performance or supervision, and confidence for various paediatric critical non-airway procedures by senior paediatric emergency clinicians.Design/methodsWeb based survey of senior paediatric emergency clinicians regarding performance, supervision, and confidence relating to critical non-airway procedures in children aged 0–18 years. The survey was distributed through Paediatric Emergency Research Networks (PERN) in the UK and Ireland, USA, Canada, Europe, South America, Australia and New Zealand.Results1602 clinicians responded to the survey, with an overall response rate of 65%. 1508 (94%) respondents reported their most recent non-airway procedural experience. In the last 12 months, 979 (64%) had personally inserted an intraosseous line, 283 (19%) a central venous line, and 265 (18%) an arterial line. In the same time period, 962 (64%) had performed CPR, 190 (13%) had performed needle thoracostomy, 245 (16%) had performed tube thoracostomy, 380 (25%) had performed DC cardioversion or defibrillation, and 57 (4%) had performed transcutaneous pacing. 18 (1%) had performed pericardiocentesis, 19 (1%) a venous cutdown, and 21 (1%) ED thoracotomy. More than 70% of respondents had never supervised or performed pacing, pericardiocentesis, venous cutdown or ED thoracotomy. 332 (22%) and 348 (23%) had never performed or supervised insertion of a central venous line or arterial line respectively.Procedural confidence for intraosseous lines and CPR was high, while confidence increased with increasing patient age for central venous access and arterial lines. ED thoracotomy, pericardiocentesis and venous cutdown had the lowest frequency of respondents reporting confidence in performing the procedure.ConclusionsMore than half of the paediatric emergency clinicians surveyed had performed CPR and inserted an intraosseous needle within the last 12 months. Performance of other non-airway critical procedures was less common, and associated with less procedural confidence.
52 Loop-mediated isothermal amplification PCR (LAMP) for the rapid identification of invasive meningococcal disease in the emergency department
Authors: Waterfield Thomas , Patenall Bethany , McKenna James , Fairley Derek 
Published: November 2017

BackgroundDespite successful vaccination programmes meningococcal disease (MD) remains the leading infectious cause of septicaemia and death in children in the UK and Ireland.1,2The early diagnosis of MD significantly improves outcomes with reduced morbidity and mortality.1,2The early stages of MD are often indistinguishable from a simple viral illness making an early positive diagnosis of MD difficult.1Hibergene have developed a commercially available bedside Loop-mediated isothermal AMPlification PCR (LAMP-MD) test that is a highly sensitive 0.89 (95%CI 0.72–0.96) and specific 1.0 (95%CI 0.97–1.0) for identifying children with invasive MD (4) (figure 1).Figure 1AimsThe aims of this RCEM funded study were:Assess the ease of use and suitability for the EDDetermine the time taken to perform the testIndependently verify LAMP-MD performance against TaqMan quantitative PCR.MethodThe LAMP-MD was assessed for practicality and ease of use within the ED including an assessment of training needs, footprint and health and safety requirements.For verification of the Hibergene LAMP-MD analyser and assay we used dry nasopharyngeal swabs sent for viral screening. Additional verification was undertaken using N. meningitidis genomic DNA spiked over a range of concentrations. This included serotypes A, B, C, W, X and Y and a dilution series to determine the limit of detection. All samples were then analysed using real time TaqMan qPCR.ResultsThe LAMP-MD analyser was easy to use and could be accommodated in the EDThe mean time for detection of Meningococcal DNA was 14.01 minDetection of meningococcal serogroups A, B, C, W, X and Z was confirmedThe detection limit for dry nasopharyngeal swabs was below 2 genomic copies per µlNo non-specific amplification was observed in 17 randomly selected negative clinical swabsThe LAMP-MD assay was 100% sensitive and specific relative to real-time TaqMAN PCR.ConclusionLAMP-MD is a practical, rapid point of care test that can reliably detect all Meningococcal serotypes in less than 15 min.Funding has been secured to perform a PERUKI supported study to investigate the potential for LAMP-MD in the diagnosis of meningococcal disease in children.ReferencesMeningitis Research Foundation.Meningococcal Meningitis and Septicaemia Guidance Notes2014.Ó Maoldomhnaigh, et al.Invasive meningococcal diseasein children in Ireland. PMID: 27566800.NICE.Management of petechial rash.Bourke TW, et al.Diagnostic accuracy of loop-mediated isothermal amplification as a near-patient test for meningococcal diseasein children. PMID: 25728843.
53 Piloting patch – providing assessment and treatment for children at home – and piecing together what works
Authors: Ward Caroline , Knight Katie , Ballard Mary-Rose , Keogh Georgina , Samuel Miriam , Buttle Sara , Robb Claire , Cleugh Francesca 
Published: November 2017

AimsPATCH is a pilot acute community children’s nurse led service delivering assessment and treatment for children at home who are moderately unwell and might otherwise be admitted to hospital or attend Paediatric Emergency Department (PED). Children are referred by PED or GP and followed up via telephone support and home visits depending on clinical need for duration of acute illness.MethodsPilot year funded by Imperial Charity. Using evaluation to build business case for sustained commissioned service.Phase 1 Sept 2016– May 2017:reduced short stay admissions and re-attendances to PED for common mild-moderate respiratory conditions e.g., viral wheeze, bronchiolitis.Phase 2from May 2017:piloting direct GP referrals to PATCH team to evaluate impact in reducing attendances to PED for children needing further assessment or support beyond GP consultation, and enabling families to manage common acute conditions at home.Using QI methodology, Model for Improvement we developed a driver diagram and used real-time PDSA cycles to capture our learning and inform small iterative changes of service development. Process mapping and world cafe style events were held with local community nurses, health visitor leads, GPs and commissioners to co-design referral pathways and explore more widely how PATCH fits into the whole urgent care system.Figure 1Parental feedback evaluated via semi structured interviews.ResultsActivity – Appendix 1Phase 1 – Concentrated on respiratory conditions from PED.Total 188 referrals in first 7 months. Bronchiolitis 45%; viral wheeze 37.5%; asthma 7%; lower respiratory tract infections 5.4%.Figure 250% of patients received home visits and telephone consultations; 50% only telephone support.Successes: Cost effective – Appendix 273 acute admissions avoided, costing c£400 per/night97 PED re-attendances prevented at £117 per attendance.Projected cost avoidance within acute care provider £3 27 640 pa.Estimated cost of service £2 84 000 pa.Positive feedback and reported health seeking behaviour change – Appendix 3ChallengesInformation governance, cross organisational working, complex commissioning arrangements.Figure 3DiscussionWithin first 7 months PATCH has had a significant impact on avoiding admissions and re-attendances, thus improving flow and performance in PED. The projected financial impact is that it is cost effective.We are using this data to pursue a business case internally and with local CCGs. We are optimistic of succeeding and using phase 2 to build on partnerships garnered across the whole system to expand PATCH’s impact further by reducing PED attendances and continuing to improve our local urgent care pathway for children.