bluuebunny/crossref_metadata_2025_split huggingface dataset:
WHY DO ADULTS WITH PALLIATIVE CARE NEEDS PRESENT TO THE EMERGENCY DEPARTMENT?
Authors: Green E , Harris T , Tempest E , Brierley W , Riley B , Sattar H , Ward S 
Published: November 2015

Objectives & BackgroundPolicy in many countries focuses on preventing hospital admissions at the end of life. However, little attention has been paid to the role of the emergency department (ED) in this regard, despite the fact that a high proportion of hospital admissions among patients with palliative care needs originate in the ED. This paper aims to improve understanding of ED use within a palliative care context, which will subsequently facilitate decision-making around the constitution of an avoidable ED presentation.MethodsThe initial phase of this service evaluation comprised a literature review. Subsequently, the electronic records of all patients known to the specialist palliative care team at Whipps Cross hospital presenting to the ED over a three-month period were evaluated prospectively (n=112). These quantitative data were analysed using descriptive statistics. Finally, semi-structured interviews with seven patients from this sample were conducted and thematic analysis was applied.Results105 patients made 112 presentations to the ED. 53% were female; the mean age was 73. The two most common presenting complaints were shortness of breath (35%) and pain (28%). There is currently no internationally agreed definition of an appropriate ED presentation; therefore one was established for the purpose of this project. 76% of presentations were deemed to legitimately require ED management.Findings from the qualitative phase highlighted a significant lack of awareness of the availability of alternative services among patients. This often resulted in disjointed, inadequate care, and appeared to be complicated by the ‘postcode lottery’ phenomenon. Patients reported valuing continuity of care, which often resulted from being known to specialist services. Difficulties with data sharing between ED and specialty teams were observed, often delaying management, and communication between primary and secondary care was deemed problematic. Patients perceived the ED to be a safer environment than primary care, capable of providing a higher level of reassurance.ConclusionThis service evaluation explores the reasons for ED presentation among patients with palliative care needs from both the perspectives of healthcare professionals and service users. Findings challenge commonly held misconceptions regarding the presence of palliative patients in the ED, and direct potential changes in future service provision.
ROMANCING THE STONE: MORE DIAGNOSES OF RENAL COLIC DOES NOT EQUAL MORE CASES NEEDING INTERVENTION. A RETROSPECTIVE ANALYSIS
Authors: Sharpe D , Gidwani S , Clough R 
Published: November 2015

Objectives & BackgroundIn 2008 and 2009 the British Association of Urological Surgeons and the Royal College of Radiologists issued recommendations that non contrast CT scanning should be the first line imaging modality for the diagnosis of renal calculi in the acute setting. More than 6 years later we hypothesise that this has led to a large increase in CT scans and thus radiation exposure, without demonstrating and increased need for surgical intervention.MethodsAll CT scans of the abdomen or Kidneys, ureters and bladder ordered by the ED from 2008 to 2013 were collated via the Picture Archiving and Communication System. This data was analysed and all cases not relating to investigation of urolithiasis were disregarded. A final list was interrogated for gender, age and previous diagnosis of stones. Annual attendance rates to the ED and the number of litholopaxy procedures were also collected.Results1208 CT scans were performed to diagnose renal colic in this 6 year period. The number of scans performed annually rose from 51 in 2008 to 252 in 2013. 35% were women and of those women a median of 70% annually were under the age of 50. 23% of patients had previously confirmed urolithiasis. Of those a median of 64% annually were under the age of 50. Despite ED attendances rising in this period by 13.5%, the proportion of patients scanned for stones disease rose from 0.05% to 0.2%. The number of litholopaxy decreased from five to one.ConclusionThese results show that despite an increased proportion of patients receiving a CT scan since 2008, the number of patients requiring intervention has actually decreased. Additionally, repeated scanning of those under the age of may be causing significant cumulative radiation exposures. We propose a prospective trial is needed to use more appropriate imaging for this group of patients. In addition, refinement of the clinical question posed by patients with presumed urolithiasis might lead to the use of a different imaging modality such as ultrasound.
HOW DO OLDER PEOPLE WITH ACUTE CORONARY SYNDROMES PRESENT? THE EXPERIENCE OF A DEVELOPING COUNTRY
Authors: Hassanali Z , Sammy IA , Paul JF , Sinanan R 
Published: November 2015

Objectives & BackgroundAcute Coronary Syndrome (ACS) is a major cause of mortality in Trinidad and Tobago. Previous studies have demonstrated differences in the presenting symptoms between older and younger patients with ACS. However, to our knowledge, no such work has been done on older patients in the developing world.The aim of this study was to determine the differences in the reported symptoms of ACS between the older patients (age≥65) and younger adults (age 18–64) in the ED. A secondary objective was to determine if differences in reported symptoms also exist between men and women.MethodsA retrospective cross-sectional study of all adult patients admitted to the ED of the San Fernando General Hospital with a discharge diagnosis of ACS from August 1, 2012–May 31, 2013 was conducted. Elderly patient symptoms were compared with other adult patients using descriptive and analytic methods. Symptoms were similarly compared between males and females. Symptoms were compared using odds ratios. All results were presented with 95% confidence intervals and ‘p’ values.ResultsThe symptoms of 1148 adult patients with ACS were analyzed. The mean age of presentation was 61.6 years (SD12.2). 41.3% of patients were elderly and 47.0% were males. Syncope (OR 2.1; 95% CI 1.1, 3.7), Paroxysmal Nocturnal Dyspnea [PND] (OR 1.3; 95% CI 1.0, 1.7) and orthopnea (OR 1.3, 95% CI 1.0, 1.6) were more likely to be reported in the elderly while chest pain on exertion (OR 0.7; 95% CI 0.5, 0.9) and chest pain in the past 24 hours (OR 0.8; 95% CI 0.6, 1.0) were less likely to be reported in the elderly. Females were more likely to report shortness of breath (SOB) at rest (OR 1.4; 95% CI 1.1, 1.8), PND (OR 1.8; 95% CI 1.3, 2.4), orthopnea (OR 2.0; 95% CI 1.6, 2.7), palpitations (OR 1.7; 95% CI 1.3, 2.2), and nausea (OR 1.5; 95% CI 1.2, 1.9) than males. Chest pain at rest was still the most frequent symptom reported in all groups.ConclusionThis study demonstrates significant differences in symptoms between older and younger patients as well as between men and women. Clinical assessment of older patients with ACS should be tailored to their common presenting features. Further work is needed to develop a clinical assessment tool for older patients with ACS that accounts for differences in presentation.
VALIDATION OF RISK STRATIFICATION MODELS FOR LONE ACUTE SUDDEN HEADACHE (LASH)—HOW FAR HAVE WE TRAVELLED?
Authors: Binbay A , Chadwick A , Hassan T 
Published: November 2015

Objectives & BackgroundLone acute sudden headache (LASH) remains a challenging presentation for the emergency physician (EP). Maintaining safe practice and yet balancing the risks and benefits of potential over investigation have generated the development of risk stratification models to help identify patients with serious pathology such as subarachnoid haemorrhage SAH). The Ottawa SAH rule has potential to reduce the need for radiological intervention and lumbar puncture in certain groups of patients but has not been validated in a UK setting.To validate the Ottawa SAH rules in a UK emergency setting and assess its potential performance.MethodsA structured data retrieval tool was developed to perform a retrospective medical record review for all patients admitted to the Clinical Decision Units of two Emergency Departments (EDs) with severe headache, over a 12 month period. The Ottawa (OSAH) rules were then applied to this data set.ResultsOf the 1096 patients recruited to the study, 890(81.2%) had a CT scan performed due to a consideration of LASH to exclude SAH. Of patients with a normal CT, only 346 had a lumbar puncture (LP) performed due to patient choice or clinician decision making. A total of 15 patients had SAH confirmed (1.37%) – all on non contrast CT. Applying the OSAH rules would have identified all 15 patients with SAH (100% sensitivity). There was also the potential to decrease the number of LPs performed by 27%, 37% and 44% for each clinical risk tool.ConclusionThe OSAH rule is a useful adjunct to clinical decision making in patients presenting to ED with LASH in a UK population. The EP can also use data from studies like ours (the largest single centre study in the UK to date) to help in joint decision making with patients to help quantify risk and appropriateness of need for further investigation.
USING A CLINICAL PHARMACIST IN THE EMERGENCY DEPARTMENT
Authors: Henderson KI , Gotel U , Hill J 
Published: November 2015

Objectives & BackgroundUK urgent and emergency care (UEC) services are facing significant increased patient demand alongside a shortage of medical and nursing staff. From the early 2000's pharmacy services have been developing to support service provision in EDs with similar roles to in-patient clinical pharmacists but clinical pharmacists skills are still underutilised in UEC provision. To optimise ED skill mix and support medicines management a ED role was developed. Such a service would ensure medicines reconciliation for high risk ED patients, transcription of drug charts, increase use of patients own drugs (PODs) with potential cost savings, provide review for changes in medicines (including advice, patient information, antibiotic stewardship, high risk medicines) and direct support for transfer of changed medication and medicines information on discharge from ED (liaison with GP, community pharmacist, care homes) as well as reducing reattendance due to non-adherence.MethodsPharmacy secured funding for one whole time equivalent clinical pharmacist. The clinical pharmacy service (CPS) ran from 29.09.14–31.03.15, with hours 13–21.30 Fri/Sat/Sun, 12–18:00 Mon & 18–21:30 Mon-Fri.This review aims to demonstrate the impact of a clinical pharmacist in the ED.1. Quantify operational workload undertaken by the clinical pharmacist(s)2. Identify drugs staff request support/information for3. Identify main reason for drug support/information requestActivity and specific drug data were collected for every shift. A standard operational data collection proforma was piloted and amended for use.Results149 shifts (802hrs) were completed. 10 patients on average per shift, (five tasks completed in 32 mins). Staff requested support/information for 388 individual drugs. The most common reason - safety to prevent an ADR 60% followed by efficacy 32%, length of stay 10%, compliance/concordance 16%. Six percent (24/388) were for safety in relation to an ADR. Most requests where for medicines acting on the CNS 26%, CVS 23% or to treat infection 21%.ConclusionED Pharmacists ensured medicines quality and safety and released ED clinician time. This was achieved by Key pharmacist safety inputs1. allergy confirmation, providing a medicines safety barrier supporting safer prescribing in a high risk environment2. reduction in missed or delayed doses through early DH identification, MR and supply of non-stock medicines3. avoidance of ADRs4. provision of specific, timely drug advice
THROMBOPROPHYLAXIS FOR AMBULATORY PATIENTS WITH IMMOBILISED LOWER LIMB TRAUMA: A CLOSED AUDIT LOOP
Authors: Horner D , Ryan A , Bennett P , Gillet A 
Published: November 2015

Objectives & BackgroundPatients with acute lower limb injuries and temporary immobilisation are at risk of subsequent venous thromboembolic disease (VTE). Recent National Institute of Health and Care Excellence has recommended formal risk assessment in the emergency department and consideration of prophylaxis for those considered high risk. Subsequent RCEM guidance has been produced to support decision making in the form of the GEMNet guidelines. Despite these documents, practice remains inconsistent and patients continue to have adverse outcomes.We sought to evaluate local practice and implement change to improve standardisation.MethodsA prospective audit cycle over 2 discrete monthly episodes in 2015. Patient episodes coded as lower limb fractures were retrospectively assessed over a 4 week period to collect data on use of the local orthopaedic pathway and national GEMNet pathway. Adherence to local policy was assessed. Following the initial period of assessment, a series of interventions were agreed with local stakeholders in an attempt to standardise care and improve patient experience. The interventions included redesign of the pathway to adhere to GEMNet guidance, local education and launch, electronic patient record discharge prompt/block and orthopaedic engagement. After delivery of the interventions, patient episodes were re-evaluated to ascertain improvement in delivery of care and staff opinion.ResultsDuring the initial month of evaluation, only 32% (20/62) of applicable patients evaluated had a documented VTE risk assessment. Of these patients, none received thromboprophylaxis as per the local policy. A substantial proportion of these patients (40%) would have been considered eligible under GEMNet guidance. Following launch of the new pathway and delivery of the interventions, 93.1% (54/58) of applicable patients over the month had a documented risk assessment recorded in the medical notes. Of this cohort, 43% (25/58) were considered high risk by GEMNet guidelines and accordingly prescribed thromboprophylaxis. No clinical short term complications were encountered on chart review.ConclusionA series of interventions including simplification of risk assessment, stakeholder agreement, local education and electronic prompt led to a clear improvement in documented VTE risk assessment for ambulatory patients with temporary immobilisation secondary to lower limb injury.
ARE WE TALKING BUT NOT BEING HEARD?
Authors: Hardy J , Carrington S , Turner C 
Published: November 2015

Objectives & BackgroundPoor communication is at the heart of most complaints within the NHS. Failure to understand what a healthcare professional is saying can lead to confusion, fear, and complaints. We constructed a pilot study to understand the level of patients' comprehension of common statements heard in the emergency department setting.MethodsOver one week in 2015 we surveyed patients about their understanding of commonly heard medical expressions at a MTC in the W. Midlands. This was a convenience sample (due to team availability), but not restricted to any specific time of day/night.We identified five statements that represented procedures, processes within hospitals, and diagnosis. The questionnaire was given out after the medical consultation. Following completion an answer sheet was provided along with the opportunity to ask any further questions that there might be. Answers were written, with assistance where needed.The the data was collated using Excel. Answers to the common statements were divided into three categories; full understanding, partial understanding and no understanding. An a priori sample size of 30 was decided upon, largely because this is the number that our trust feels comfortable with when performing patient experience work. GAfREC approval was given.Results29 questionnaires were completed. Only one of our five statements (“you've got a fracture”) was understood by over 50% of the sample.Statements most poorly understood appear to involve hospital specific process involving acronyms such as ‘You're going to AMU’ (90% had no understanding) and ‘The ITU Reg is going to come and see you’ (76% had no understanding).Patients understand little of what we say to them and this gets worse the more acronyms we use.Despite this most patients felt the doctor and the nurse explained things well. This may reflect staff taking the time to explain medical terminology in the context of the patient's specific problem or pathology. Patients and relatives also reported that they were asked if they had any questions.ConclusionIt is unreasonable to assume patients understand commonly used medical terminology, Although medical terminology may be ubiquitous in a place of work it has the potential to be both profession and location specific. It is easy to forget this. As healthcare professionals we need to communicate using language the patient can understand and allow the patient an opportunity to ask for clarification.
FEASIBILITY AND COMPARISON OF NON-INVASIVE HEMODYNAMIC DEVICES IN THE EMERGENCY DEPARTMENT; USCOM VS NICCOMO
Authors: Green SJ , Hussain S , Hue J , Patel J , Coats T , Sims M 
Published: November 2015

Objectives & BackgroundWithin emergency medicine there is a demand for non-invasive techniques to measure patient observations. Within resuscitation of unwell patients, measuring Cardiac Output (CO) and Systemic Vascular Resistance (SVR) is carried out in intensive care environment using invasive techniques. In this study we trialled the use of two non-invasive Cardiac Output monitors to assess their feasibility and agreement. The USCOM (USCOM) is a suprasternal Doppler device that uses ultrasound technology and has been extensively researched within clinical medicine. The Niccomo (Medis) device is a novel biothoracic impedance monitor.MethodsPatients were recruited as part of the ‘multi-modality monitoring in the emergency department’ trial, University Hospital Leicester NHS trust (UHL). Adult patients with a wide range of clinical conditions presenting to the ED who were able to consent were recruited to the study. Devices were attached as per manufacturer instructions, with standard medical care ongoing throughout the study. Data was analysed using R statistical computation.Results215 patients were included in the study with an age range 18–95 years. 93 patients had readings for both modalities. Figure 1 represents a Bland-Altman comparing average CO readings of USCOM vs Niccomo with the global average USCOM reading was considerably lower than the Niccomo device. Figure 2, shows SVR of USCOM vs Niccomo, this again highlighted a large difference between measurements.ConclusionThis study revealed the Niccomo measured CO and SVR readings similar to the expected range of patients in this study. However, the USCOM revealed a significantly lower reading for CO and a higher SVR reading than the Niccomo. Further work needs to be undertaken to assess the clinical utility of the different methods to measure cardiac output. The study emphasises that different non-invasive methods of cardiac assessment are not interchangeable.
WRITTEN FIRST AID INFORMATION FOR PATIENTS IN THE EMERGENCY DEPARTMENT: A CLUSTER RANDOMISED CONTROLLED TRIAL
Authors: Pallot D , O'Keeffe C , Dawson J , Mason S , Oliver E , Mulligan J 
Published: November 2015

Objectives & BackgroundPatients with minor injuries create a significant workload for Emergency Departments. Each attendance is also an opportunity to deliver health education, and written information is established to be effective. Appropriate first aid may reduce the workload of the Emergency Department, and reduce injury morbidity. It was hypothesised that giving patients written first aid information during an attendance will improve confidence and knowledge of first aid.MethodsThe study was run at the Northern General Hospital, Sheffield, from 15th March to 4th April 2014. Consecutive adult patients attending the ED with eligible presenting complaints between 9am and 8pm were recruited. Patients were selected from those assigned to the minor injuries area of the ED.The eligible presenting complaints were:– Limb injuries– Wounds– Head injuriesAllocation to intervention and control groups was done by day of presentation based on a computer generated random sequence. Patients in the intervention arm were given written information about first aid produced by the British Red Cross. Both arms also received usual care inlcuding any normal verbal advice and other written information. The initial questionnaire was given to consenting patients in both groups before being seen by a doctor, and before the written information was given in the intervention group. The ED records were used to collect diagnosis and demographic data. Follow up questionnaire was performed at 4 weeks. Re-attendance data was collected from ED records at 3 months. Analysis of confidence was by repeated measures ANOVA and knowledge of individual treatments by binary logistic regression.Results293 patients completed the initial questionnaire and 194 (66%) were followed up. There was no effect on confidence in performing first aid on themselves (mean effect 0.321 on a scale of 0 to 10, 95% confidence −0.335 to 0.978). The intervention improved knowledge of limb injuries (p=0.006) and wounds (p=0.032) but not head injuries. The intervention also reduced suggestions to seek medical assistance in the intervention group (p<0.001).ConclusionWritten information improves knowledge, but does not affect confidence in first aid management of minor injuries. The follow up period was too short to show a change in attendance behaviour and further work should analyse the effect of first aid written information on patient behaviour.