bluuebunny/crossref_metadata_2025_split huggingface dataset:
THE COMMUNITY FALLS PATHWAY—AN URGENT CARE INITIATIVE HELPING FALLEN OLDER PATIENTS TO STAY AT HOME
Authors: Hartley E , Holland J 
Published: November 2015

Objectives & BackgroundMany older patients present to ED after a fall. Older patients are more likely to get admitted to an acute bed when they present to the ED than younger patients. Admission is associated with loss of independence, acquired infections and delirium. Length of hospital stay is longer for older patients. Delayed discharge of medically well patients awaiting community care packages is associated with stagnant flow in the ED.We identified a population of older adults presenting via ambulance following a fall, who were being admitted for physio, OT and social worker assessment from the ED, but did not require inpatient treatment for a medical problem. We proposed that these admissions could be avoided.MethodsCross-sector admission avoidance initiative between primary and secondary care, ambulance services and social services in Coventry and Rugby area. Seamless 24/7 pathway developed to provide medical assessment, OT, physiotherapy, social support and emergency equipment to enable a patient to stay at home. We developed a traffic light based assessment system for ambulance crews, and resourced a 24 hour telephone line linked to an Advanced Nurse Practitioner and community care services. The ambulance crew refer to the ANP then get back on the road. The ANP can undertake a home visit to the patient, arrange a home visit from their GP or access an urgent GP appointment or appointments with the Falls clinic or Acute Medicine clinic. In addition to the medical assessment there is access to OT, physio and social care, including a fully stocked 24 hour equipment store.Results174 referrals were made in the first 26 weeks of the pathway. 154 patients were enabled to stay at home.The admission avoidance rate was 88.5%.6/154 patients self-presented to the local ED within 48 hours of their urgent care intervention.There were 2 recorded clinical incidents.Patient feedback has been positive.Cumulative cost-savings in the first 26 weeks is £248000.ConclusionThis cross-sector initiative has prevented admissions when the acute trust has been operating under significant bed pressure. This is an easy-to-use, patient centred, safe pathway giving comprehensive care to the fallen patient.For phase 2 we have developed an ED-based 'Pull-out Pathway' to enable the early discharge of fallen older patients following medical assessment in the ED. This will start in June 2015.Figure 1
INADVERTENT INTRA-ARTERIAL CANNULATION IN THE EMERGENCY DEPARTMENT: WHAT IS THE INCIDENCE AND HOW DO WE DETECT IT?
Authors: Edwards RG , Kehoe A , Graham B , Smith J 
Published: November 2015

Objectives & BackgroundInadvertent intra-arterial cannulation (IIAC) is a recognised complication of peripheral cannulation with the potential for severe consequences including limb ischaemia and amputation. Patients presenting to EDs are often complex, frail or obese (known risk factors for difficult cannulation) meaning the overall incidence may be much higher than that suggested by existing evidence.Objectives:▸ To report the rate of IIAC in our Emergency Department.▸ To assess whether blood gas analysis can be used to screen for IIAC.MethodsA prospective observational study was undertaken over a two week period. Every cannula inserted in the ED during hours of recruitment had blood drawn and blood gas analysis performed. The results were analysed by a senior ED clinician who assessed whether the blood gas values represented arterial or venous blood. Ultrasound assessment was performed on every cannula to confirm placement and, if there was any degree of uncertainty, transduced pressure readings were obtained.ResultsTwo IIACs were confirmed out of the 83 cannulae analysed, a rate of 2.4%. Both of these IIACs were detected by the senior clinician interpreting the blood gas. Two further cannulae were incorrectly identified as potentially arterial on the blood gas, but were proven to be venous using ultrasound. Both patients experiencing IIACs had multiple risk factors for difficult cannulation and 44% of all subjects had at least one risk factor.ConclusionIIAC occurs more frequently than previously reported in our ED. A high proportion of ED patients have risk factors that make IIAC more likely. Point of care blood gas analysis may be a useful screening tool for detecting IIAC, particularly when used in conjunction with ultrasound +/− transduction. The results of this study justify further research to confirm and extend these observations. Implications for everyday practice within the ED include increased awareness and recognition of IIAC.
THE IMPORTANCE OF UNDERSTANDING JUNIOR DOCTOR PERCEPTIONS OF CONFIDENCE AND COMPETENCE IN RELATION TO THE FEBRILE CHILD
Authors: Ronald D , Martin G , Coats T , Matheson D 
Published: November 2015

Objectives & BackgroundIt is important to determine whether trainees have gained a greater belief in their abilities at carrying out a particular skill or knowledge set (confidence), whether they are technically more proficient in putting them into practice (competence) or both. If confidence and competence are not clearly understood it cannot be assumed self-reported outcomes during training are valid. The aim of this work was to explore Junior Doctors' understanding of how they perceive their own performance in respect of managing feverish children.Table 1A proposed matrix of perceptions of competence, confidence and safetyReported CompetenceLowHighReported ConfidenceLowSelf-Perception: UnsafeSelf-Perception: Unsafe or SafeHighSelf-Perception: SafeSelf-Perception: SafeMethodsJunior doctors (postgraduate year 2) in a children's emergency department were consented to take part in the study following ethics committee approval. Two focus group sessions, utilising a novel focus group design (meta-planning) as a methodology to drive discussion, were undertaken one week apart (9 and 7 participants), to maximise attendance and allow unexplored themes to be discussed further if one session was inadequate. A repeat session for a new group (8 participants) was held one year later using the same methodology.ResultsThe focus groups demonstrated that although the junior doctors recognised a difference between confidence and competence they were not able to define it. Despite this difficulty there was general agreement of feeling ‘safe’ in the management of the febrile child at the end of the attachment. The groups also struggled to separate collectively themed categories of skills or constructs into distinct competence and confidence domains (figure one).ConclusionA perception of ‘safeness’ is as a concept that may aid self-evaluation and we present a matrix (table) that might be used to examine this and its relationship with confidence and competence. This will be useful for clinical supervisors and educators in Children's Emergency Departments as the concept is evolved from management of the febrile child but it is likely to have much wider use.Figure 1Response to question How can I become more confident in dealing with children〈Black Squares〉and How can I become more competent in dealing with children 〈White Squares〉.
A 10-YEAR DEMOGRAPHIC COMPARISON OF MAJOR TRAUMA AS A RESULT OF NON-ACCIDENTAL INJURY VERSUS ACCIDENTAL INJURY IN THE UK
Authors: Davies F , Coats T , Lecky FE 
Published: November 2015

Objectives & BackgroundNon-accidental injury in children is generally understood to have a different injury and age profile from accidental injury. The Trauma Audit Research Network (TARN) in the UK recently compared the demographics of paediatric versus adult trauma. This paper compares accidental with non-accidental major injury in children.MethodsThe national trauma registry of England and Wales – Trauma Audit and Research Network (TARN) database was interrogated for the classification of mechanism of injury in children by intent, from January 2004 to December 2013. Contributing hospitals' data was classified into accidental injury (AI), suspected child abuse (SCA) or alleged assault (AA) to enable demographic and injury comparisons.ResultsIn the study population of 14,821 children, 13,695 (92.4%) were classified as accidental injury, 368 as alleged assault (2.5%) and 758 as suspected child abuse (5.1%). Nearly all cases of severely injured children suffering trauma because of suspected child abuse occurred in the 0-5 year old age group (740 of 758, 97.6%). Of all suspected abuse cases, 584 of 758 (77%) occurred in babies under the age of one year. Compared with accidental injury, abused children have higher injury severity scores, particularly as a result of head injury and a three-fold higher mortality rate.ConclusionThis study highlights that major injury occurring as a result of child abuse has a typical demographic pattern. Abused children tend to be under 12 months of age, with more severe injury, especially head injury. Understanding the demographics of this patient group could help receiving hospitals identify children with major injuries resulting from abuse, and ensure swift transfer to specialist care.
S-KETAMINE SEDATION IN A TERTIARY PAEDIATRIC EMERGENCY DEPARTMENT
Authors: Byrne E , Mulvaney S , Abela N 
Published: November 2015

Objectives & BackgroundTo discuss the use of S-Ketamine for minor injuries in a tertiary Paediatric Emergency Department (PED), using a literature review of the topic and retrospective review of the department's first 200 patient's experience.MethodsA literature review of Ketamine was carried out on procedural sedation using Ketamine in children in the Emergency Department. This was combined with a retrospective audit of Alder Hey Hospital departmental practise of the first 200 patients undergoing this method of sedation. The first 200 patients were cumulatively recorded by the researchers and their case notes reviewed for indication for sedation, dose given, adjuntive medications used and adverse reactions.ResultsThere is ample literature data to support the use of ketamine for procedural sedation in the paediatric emergency department. In the audit, 200 patients were adequately sedated using IV ketamine with a mean dose of 1.1 mg/kg and a median dose of 1 mg/kg. The procedures carried out included laceration repair (46%), foreign body removal (17.5%), reduction of fracture or dislocation (29%) and other procedures (7.5%). 40 (19.8%) experienced an adverse reaction, the commonest of which was vomiting (7.9%), followed by airway problems (4.9%) and confusion (2%). 8 (3%) patients required adjunctive medication (ondansetron (6); midazolam (2)).ConclusionS-Ketamine is safe to use in the PED for sedation for minor injuries and procedures. However, further studies are needed to determine the correct dose regimen and to determine methods of decreasing adverse events.
THE USE (MISUSE?) OF MONTELUKAST IN WHEEZY PRE-SCHOOL CHILDREN
Authors: Abrahamson E , Abubakar-Waziri H , Wilson A 
Published: November 2015

Objectives & BackgroundThe role of montelukast in the rescue treatment of acute wheeze in pre-school children has come under increasing scrutiny. It has gradually entered clinical practice but without robust scientific data to support its use. Our department was an early adopter and we performed this review to compare clinical features and outcome between those treated and those not.MethodsWe performed a retrospective case note review of the management of all pre-school wheezers aged 0-5 years presenting to our Paediatric Emergency Department (PED) over a 12 month period. Cases were identified from the database using the Business Objects Tool©.Results391 cases were identified, of which 231 (59%) received montelukast (G1) and 160 (41%) did not (G2). The mean age (months) of cases was similar in G1 32.41 (7–60) versus G2 29.01 (4–59). 191 (82.7%) cases in G1 had at least one previous episode of wheeze vs 108 (67.5%) in G2, p=0.0005.G1 were more likely to have received montelukast previously 67 (29%) vs G2 22 (13.8%), p=0.0004. They were also more likely to show signs of respiratory distress G1 179 (77%) vs G2 100 (62.5%), p=0.0013. 40 (17%) cases in G1 had no prior history of wheeze. G2 were more likely to receive steroids 38 (23.8%) vs G1 29 (12.6%) p=0.0039.There was no difference in the number of cases with a history of atopy, G1 75 (32.5%) vs G2 58 (36.2%), or already on inhaled steroids G1 24 (10.4%) vs G2 18 (7.8%).Treatment with montelukast did not reduce overall admissions, G1 103 (45%) vs G2 65 (41%), nor did it reduce average length of stay (days) G1 1.52 vs G2 1.95. Further there was no significant difference in re-attendance rates to the ED within 7 days, G1 22 (9.95%) vs G2 21 (14.4%).ConclusionTreatment with montelukast had no significant impact on admission rates, length of stay or reattendance to hospital in children <5 yrs presenting with wheeze.Existing departmental guidelines were poorly adhered to, with some children receiving treatment despite no prior history of wheeze whilst many with previous wheeze did not receive it. Instead, we observed a tendency towards treating those who had previously received the drug and those with signs of respiratory distress.This study raises further questions regarding the use of montelukast in pre-school acute wheeze, and whilst limited as a retrospective study, it supports the doubts over its use as rescue therapy in these children.
SHOULD WE OFFER OPPORTUNISTIC VACCINATION IN THE PAEDIATRIC EMERGENCY DEPARTMENT?
Authors: Newell K , Rousseva C , Slade C , Isba R 
Published: November 2015

Objectives & BackgroundDespite the importance of children being up-to-date with routine childhood immunisations, uptake rates remain sub-optimal. Guidance from NICE and the WHO state that every contact a child has with healthcare services be thought of as an opportunity to provide catch-up immunisation. Paediatric emergency departments (PED) therefore have the potential to increase local vaccination rates.The overall aim of this work was to look at the viability of introducing opportunistic vaccination into the PED. The aim of these two audits was to look at potential barriers to such a programme.Audit 1: is vaccination status recorded in the notes of children presenting to the PED at North Manchester General Hospital (NMGH)?Audit 2: do PED staff currently deliver vaccinations in the department?MethodsAudit 1: a retrospective audit of the notes of 500 children who presented to the PED before their third birthday. Basic demographic data were recorded along with what vaccination history appeared in their notes.Audit 2: a retrospective audit of pharmacy orders for vaccines for the PED over a five and a half year period. These data were used as a proxy for how many vaccinations were administered in the PED the same time period.ResultsThe audit of vaccination status demonstrated that only 28% of attendees had their vaccination status recorded, but 93% of these were up-to-date with their vaccinations to an age-appropriate level.The audit of paediatric vaccinations demonstrated that across the 66 month period, 75 vaccinations were ordered.This work suggests vaccination status is not well recorded in the PED. In the absence of access to centrally-held vaccination records, this may prevent introduction of a successful programme. Additionally, it appears that only a small number of vaccinations are currently given in the department, suggesting that there may not be sufficient existing vaccination expertise.ConclusionWhilst these findings do not support the introduction of opportunistic vaccination to provide catch-up for routine childhood immunisations, this approach deserves further exploration and future work could look at signposting children back to primary care, rather than offering the vaccination in the department. However, it may be possible to offer other, non-routine vaccines in the PED as a way to increase local vaccination rates e.g. by offering intranasal seasonal influenza vaccination to children attending the PED.
MEDICAL EDUCATION VIA SKYPE BETWEEN A PAEDIATRIC EMERGENCY DEPARTMENT IN LONDON AND SOMALILAND AS A USEFUL ALTERNATIVE TO AN ALREADY EXISTING WEB-BASED PORTAL. A PILOT PROJECT
Authors: Son D , Ahmed H , Omar K , Wong A , Mahtani S , Burzic A 
Published: November 2015

Objectives & BackgroundTrying to establish an alternative e-learning tool to provide medical education to a country in need of support for the slowly growing medical community at undergraduate and postgraduate level. Following a devastating civil war in 1991, Somaliland is suffering a shortage of healthcare workers. King's College London has been working in partnership with educational institutions and healthcare providers in Somaliland since 2000.Methods6 sessions over a period of 8 weeks were arranged to deliver teaching on topics such as clinical examination or discussion of various clinical ETAT/APLS/NLS scenarios trying to focus on clinical reasoning and emergency management skills. The London based participants were a paediatric emergency department registrar, present in all sessions, and occasionally paediatric FY1 doctors and one medical student. The participants on the Somaliland side were paediatric lecturers and occasionally several final year medical students and intern doctors. It was decided to use Skype and compare whether its audiovisual and text functions would bring additional benefits compared with an already established instant messenger type web-based portal.ResultsThe initial feedback was positive and all participants agreed that Skype added a useful alternative to the still limited repertoire of distant learning opportunities. 100% of participants felt Skype with its audiovisual functions to be a very useful alternative to the existing teaching tool. 2 sessions had to be cancelled due to network problems. There were also connection issues in more than half of the other sessions. Over 80% of the participants would like more teaching in the form of Skype sessions. All participants identified network issues as a disadvantage and limiting factor.ConclusionDelivering distant online teaching sessions via Skype with its audiovisual functionality instead of purely text based online services clearly offers more advantages especially during clinical examination based or simulation sessions. It can currently only serve as an occasional teaching adjunct due to network instabilities and limited wifi availabilities in clinical areas mainly on the Somaliland teaching sites. Providing written and video materials in advance of Skype sessions will be tested in the future in order to use available time online more effectively.
WHAT IS THE RISK OF NEONATES PRESENTING TO EMERGENCY DEPARTMENTS WITH NO PHYSIOLOGICAL OR OBSERVATIONAL DERANGEMENT HAVING SEPSIS?
Authors: Roland D , Alifieraki S , Anzar S , Davies F 
Published: November 2015

Objectives & BackgroundInfants, especially those in the first month of life, are a very high risk group of attendees to Emergency Departments. Despite immunistaion programmes the incidence of serious bacterial illness in this group remains around 10%. Although in some cases the protocolised nature of fever management according to NICE guidance makes a physiological assessment less relevant (all children under 3 months with a fever>38.5 tend to get a full septic screen) increasing attendances to emergency and urgent care settings make early and correct decision making vitally important.Table 1POPS versus bloods results and postive culturesPOPSPatients (total =104)Positive Bloods (Raised WCC or CRP)Positive Cultures0310012500217Patient A (CRP 25) Patient B (CRP 7)Patient A (Mixed Flora in Urine)3100049Patient C (CRP 9)Patient D (Mixed flora in urine)55Patient E (CRP 17) Patient F (CRP 8) Patient G (CRP 26)Patient E (Enterovirus in CSF* and Coliform in urine) Patient F (Enterovirus in CSF* and PCR)65Patient I (CRP 137*)Patient H (Enterovirus in CSF*)7200Values with * represent those meeting RCPCH recognising acute illness in children working group criteriaMethodsNearly all patients attending our Children's Emergency Department have their vital signs assessed at triage or expediently with the Paediatric Observation Priority Score (POPS). POPS aggregates a combination of physiological characteristics, with observational components and specific domains of nurse gut feeling and past medical history (Figure 1). All infants less than 4 weeks old who presented over a two month period were included as part of a service evaluation of POPS. Data was recorded on POPS, disposition and outcome of any investigations pertaining to the diagnosis of a serious bacterial illness. The criteria for a serious bacterial illness was that defined by the RCPCH recognising acute illness in children working group.Results104 patients (less than 4 weeks) presenting to the Emergency Department had POPS scores, disposition and any investigations recorded. There were 3 patients with enterovirus meningitis (of which 1 had a coliform UTI) but no positive blood cultures. Results by POPS are in table 1. With a prevalance of serious bacterial illness at 3.8% the negative predictive value of POPS<4 was 100%.ConclusionThe POPS system applied at initial assessment maybe useful in recognising children who are not at risk of serious bacterial illness. However the lack of positive blood cultures in this sample means it is not definitively possible to demonstrate the utility of physiological and observational signs alone in assisting with decision making in neonates presenting to the ED i.e does a POPS 0 exclude serious bacterial illness? A national study evaluating the exclusion of sepsis in neonates would be a beneficial health service research project.Figure 1