bluuebunny/crossref_metadata_2025_split huggingface dataset:
Palliative care coding practices in Canada since the introduction of guidelines and the HSMR indicator
Authors: Fekri Omid , Amuah Joseph Emmanuel , Herasimovich Viachaslau , Chaudhary Zeerak , Leeb Kira , Gurevich Yana 
Published: November 2015

ObjectivesThis study examines palliative care (PC) coding practices since the introduction of a national coding standard and assesses a potential association with hospital standardised mortality ratio (HSMR) results.SettingAcute-care hospitals in Canada.Participants∼16 million hospital discharges recorded in Canadian Institute for Health Information (CIHI)'s Discharge Abstract Database from April 2006 to March 2013.Primary and secondary outcome measuresIn-hospital mortality, patient characteristics and service utilisation among all hospitalisations, HSMR cases and palliative patients.MethodsWe assessed all separations in the Discharge Abstract Database between fiscal years 2006–2007 and 2012–2013 for PC cases at national, provincial and facility levels. In-hospital mortality was measured among all hospitalisations (including HSMR cases) and palliative patients. We calculated a variant HSMR-PC that included PC cases.ResultsThere was an increase in the frequency of PC coding over the study period (from 0.78% to 1.12% of all separations), and year-over-year improvement in adherence to PC coding guidelines. Characteristics and resource utilisation of PC patients remained stable within provinces. Crude mortality among HSMR cases declined from 8.7% to 7.3%. National HSMR declined by 22% during the study period, compared with a 17% decline in HSMR-PC. Provincial results for HSMR-PC are not significantly different from regular HSMR calculation.ConclusionsThe introduction of a national coding standard resulted in increased identification of palliative patients and services. Aside from PC coding practices, we note numerous independent drivers of improving HSMR results, notably, a significant reduction of in-hospital mortality, and increase in admissions accompanied by a greater number of coded comorbidities. While PC impacts the HSMR indicator, its influence remains modest.
Prediction modelling for trauma using comorbidity and ‘true’ 30-day outcome
Authors: Bouamra Omar , Jacques Richard , Edwards Antoinette , Yates David W , Lawrence Thomas , Jenks Tom , Woodford Maralyn , Lecky Fiona 
Published: November 2015

BackgroundPrediction models for trauma outcome routinely control for age but there is uncertainty about the need to control for comorbidity and whether the two interact. This paper describes recent revisions to the Trauma Audit and Research Network (TARN) risk adjustment model designed to take account of age and comorbidities. In addition linkage between TARN and the Office of National Statistics (ONS) database allows patient's outcome to be accurately identified up to 30 days after injury. Outcome at discharge within 30 days was previously used.MethodsProspectively collected data between 2010 and 2013 from the TARN database were analysed. The data for modelling consisted of 129 786 hospital trauma admissions. Three models were compared using the area under the receiver operating curve (AuROC) for assessing the ability of the models to predict outcome, the Akaike information criteria to measure the quality between models and test for goodness-of-fit and calibration. Model 1 is the current TARN model, Model 2 is Model 1 augmented by a modified Charlson comorbidity index and Model 3 is Model 2 with ONS data on 30 day outcome.ResultsThe values of the AuROC curve for Model 1 were 0.896 (95% CI 0.893 to 0.899), for Model 2 were 0.904 (0.900 to 0.907) and for Model 3 0.897 (0.896 to 0.902). No significant interaction was found between age and comorbidity in Model 2 or in Model 3.ConclusionsThe new model includes comorbidity and this has improved outcome prediction. There was no interaction between age and comorbidity, suggesting that both independently increase vulnerability to mortality after injury.
CVLA STUDY: CAPILLARY AND VENOUS LACTATE AGREEMENT—A PILOT OBSERVATIONAL STUDY
Authors: Datta D , Grahamslaw J , Gray AJ , Graham C 
Published: November 2015

Objectives & BackgroundBlood lactate measurement is used as a marker of the severity of illness in patients presenting to the Emergency Department (ED): higher lactate levels are associated with increased mortality. Arterial lactate is the gold standard of measurement, however is increasingly being substituted by peripheral venous lactate (PV-LACT) measurement.Capillary lactate (CAP-LACT) measurement has been used in the paediatric ED and in sports science; however it has not been thoroughly tested in the adult ED. Until recently there has not been a medically certified point-of-care meter to use in clinical settings. The Nova Biomedical StatStrip Lactate meter can measure CAP-LACT with a disposable strip system similar to the routine measurement of capillary glucose in the ED. CAP-LACT has the potential to allow quick lactate recording by all triage staff with minimal equipment, whilst being more acceptable to the patient as an investigation.We aim to collect pilot data investigating the agreement between CAP-LACT and PV-LACT in the ED. This will allow us to determine feasibility and statistical power for the design of a definitive study.MethodsWe performed a prospective observational cohort study of 99 consented patients between October and December 2014 requiring PV-LACT measurement as part of their routine clinical care to a single UK NHS ED (110,000 adult attendances annually). Paired CAP-LACT and PV-LACT (in mmol/L) was recorded, and level of agreement determined by Bland-Altman analysis.ResultsThe median lactate measurements were 1.3 for PV-LACT and 1.6 for CAP-LACT (table 1). Bland-Altman analysis noted a mean difference (CAP-LACT-PV-LACT) of 0.23 mmol/L, with 95% limits of agreement from −1.86 to 2.33 (figure 1). Median PV-LACT tourniquet time was 1 minute, with median time between samples being 4 minutes (interquartile range 2–4 minutes) (table 2). Only 4 samples had a lactate greater than 4 mmol/L.ConclusionThe results show that there is potential for CAP-LACT to replace other methods of lactate measurement. However the wide 95% limits of agreement and lack of high lactate values means further definitive studies need to be conducted before we can use CAP-LACT in routine practice. The pilot data will allow the design of this definitive study. Capillary lactate could potentially revolutionise triage by allowing wider minimally invasive screening of patients presenting to the ED.Figure 1Bland–Altman plot of agreement between capillary and peripheral venous lactate.Table 1Descriptive statistics for lactate measurements1st quartileMedian3rd quartileVenous0.91.32.2Capillary11.62.4Table 2Patient characteristicsDemographicsNumber of patients99Age in years: mean (sd)57.4 (18.7)Gender=Male (n)5630 day outcome (number of patients)Dead4 Alive95Venous sample tourniquet time (number of patients)<1 minute3 1 minute71 2 minutes15 ≥3 minutes10
EXCELLENCE THROUGH DESIGN—IMPROVING THE MASSIVE HAEMORRHAGE PROTOCOL
Authors: Carrington S , Turner C , Burton J , Woolrich-Burt L 
Published: November 2015

Objectives & BackgroundThere has been an increasing use of massive haemorrhage protocols (MHP) within our trust. A number of clinical incidents were noted around roles/responsibilities when MHPs were run. Design failures (latent errors) were felt to contribute to these. Most MHPs are untested and are reliant on clear protocols, good communication and efficient team work. We proposed that running drills of our MHP in the ED setting would allow us to identify the latent errors and human factors that exist in our MHP then addressing these.MethodsWe proposed a 2 stage process where initially we tested functionality then identified and changed aspects of the system.FunctionalityWe ran 5 in-situ, real time MHP simulations involving the relevant members of the MDT in the ED. The 20 minute scenarios were followed by a structured human factors debrief. This allowed us to establish latent errors that were affecting the MHP. Results were then collated and codified from the sessions to allow planning of teaching for ED and non-ED staff.RedesignFollowing this a card redesign was identified as being necessary. We used the principles of negative space, contrast, proximity and the pictorial superiority effect. A cluster randomised recall trial was then conducted at an F2 teaching session (66 participants), with participants blinded to the other version of the cards. A trauma video was shown (thoracotomy) and recall measured after this. Data analysed by an author blinded to both the study design and the data collection. GAfREC permission given by R+D.ResultsHF/Ergonomics phase1. Difficulty identifying team members/roles2. Communication difficulties-same task being undertaken by multiple staff members3. Notes/ID labels not given to trauma team leader (TTL). TTL felt to be unapproachable4. Porters not feeling able to identify themselves5. Action cards and protocol not used-text heavy6. Staff not realising action cards were double sided7. Blood forms unavailable8. Poor prioritisation/labelling of the crossmatch sample9. Pre-arrival preparation steps being omittedCard redesign phase18 people recalled all the important information – all used the new cards. 0 people in the old card group recalled all the information. 66 of the f2s (100%) preferred new design of card.ConclusionHF principles helped identify areas for improvement. Utilising design principles appears to have had significant impact on the effectiveness of the cards.
TIME TRENDS IN INTRACRANIAL BLEEDING AND NEW ORAL ANTICOAGULANT PRESCRIPTION
Authors: Hogg K , Stiell I , Bahl B 
Published: November 2015

Objectives & BackgroundDabigatran, rivaroxaban and apixaban were approved for stroke prevention in the past 4 years. Phase 3 studies reported a lower risk of intracranial bleeding compared to warfarin however there is little real-life data to validate this. We assessed time trends in oral anticoagulant (OAC) associated intracranial bleeding between 2009 and 2013. We compared bleeding rates to provincial OAC prescription trends.MethodsICD-10 codes were used to identify all atraumatic intracranial bleeds presenting to our neurosurgical centre (covering a population of 1.3 million). Trained researchers extracted data on anticoagulant medication in the week prior to diagnosis of intracranial bleed. Provincial prescription data for OACs were obtained from IMS Brogan CompuScript Market Dynamics. The primary outcome was the incident OAC-associated intracranial bleed time trend between 2009 and 2013. The secondary outcomes were the non-OAC associated intracranial bleed time trend, and the provincial OAC prescription trends.Results2050 patients presented with atraumatic intracranial bleeds. 371 (18%) patients were prescribed an anticoagulant, of which 335 were OACs. There was an increasing trend over time in the rate of anticoagulant associated bleeding (p=0.009) and non-anticoagulant associated bleeding (p=0.063). Warfarin accounted for a disproportionately large number of all OAC-associated bleeds compared to prescription prevalence. Dabigatran, rivaroxaban and apixaban accounted for a smaller proportion of OAC bleeds when compared to prescription prevalence.ConclusionWe found an increasing number of patients treated for intracranial bleeding over time. Warfarin accounted for a disproportionate number of intracranial bleeds and the new oral anticoagulants, fewer than expected.
A COMPARISON OF TIDAL AND INCENTIVE BREATH COLLECTION METHODS FOR THE DETERMINATION OF BREATH VOLATILES CONCENTRATION
Authors: Anderson K , Coats T , Monks P , White I , Pandya H , Beardsmore C , Skinner J 
Published: November 2015

Objectives & BackgroundExhaled Volatile Organic Compounds (eVOCs) have been used to identify patients with many diseases including pseudomonas infection and lung cancer. Breath for eVOC analysis is conventionally collected from one or more deep exhalations. The long controlled exhalation of the American Thoracic Association nitric oxide protocol has been the commonest method used in breath research. However, some patients may be unable or unwilling to perform deep exhalations. Movement of breath analysis from the laboratory to the bedside requires a patient-friendly method for collecting breath samples, especially if breath analysis is to be tested in the relatively uncontrolled environment of an Emergency Department. Continuous monitoring of VOC spectra throughout the breath cycle during tidal breathing has the potential to provide an easier method of sample collection in the clinical situation. This study was designed to compare single controlled exhalation with tidal breathing.MethodsExhaled breath volatile organic compounds were measured to compare two methods of breath collection in emergency care; the standard single prolonged exhalation (incentive test) and relaxed breathing (tidal test). 125 patients with minor conditions were recruited from the Emergency Department and samples were collected in real-time using an on-line PTR-ToF-MS coupled to Loccioni breath collection apparatus. A Matlab program was used to extract the spectra of the alveolar portion of breath and measure the abundance of each eVOC.ResultsThe total amount of eVOCs detected by the two methods was highly correlated (R2=0.91), with the incentive method giving slightly higher overall eVOC levels than the tidal breath method (mean of differences=98,749 NCPS, P<0.0001). Although the total VOCs were highly correlated, there was a large amount of unexplained variation in the spectra. The tidal breath test had a much higher completion (99% compared with 75% for the incentive test), which was due to the greater reliability (less complex sampling equipment) and greater ease of use by patients.ConclusionFollowing this study we recommend the use of a tidal breath sampling method in future studies of emergency care patients to prevent selection bias.
ARE TRAUMA TEAM LEADERS ANY GOOD AT PREDICTING NEED FOR WHOLE BODY SCANS?
Authors: Bowman R , Turner C 
Published: November 2015

Objectives & BackgroundWith increasing demands on the NHS and also radiology time, we wondered if the EM trauma team leaders were able to accurately assess whether patients required a whole body scan (and thus if we could reduce the health burden of numbers of scans done).MethodsOver a 3 month period from February to May 2015 a simple questionnaire was completed as part of the trauma chart documentation at a major trauma centre in the West Midlands. This was filled in by the trauma team leader (TTL). The TTL was asked to predict if the scan was going to be significantly abnormal and also the main reasons for the scan being done (mechanism/abnormal physiology etc).Data was collected and collated at the end of the study and tables produced to show High/Low Gestalt and actual outcome.Significance of injury was decided on the basis of change of treatment or requiring admission under a specialty team other than EM. All trauma scans were eligible and no exclusion criteria were specified.Results98 completed forms were able to be used, (of a potential 180).For the 98 cases where the forms were filled and the patient met our trigger for a trauma team, TTL sensitivity and specificity were calculated.Sensitivity was 77.42% (58.9% to 90.41%), Specificity was 86.67% (69.28% to 96.24%).Likelihood RatioLR (positive test)=5.80 (2.52 to 14.80)LR (negative test)=0.26 (0.12 to 0.47)The primary reasons for exclusion were incomplete documentation and trauma scans not being done (patients for whom trauma chart documentation was used but who did not meet the preset criteria).ConclusionAlthough TTLs are reasonably accurate when it comes to deciding who should have a full trauma scan we are not sufficiently good (as a group) to determine whether a scan should go ahead on clinical acumen alone. Although disappointing in some ways this should give us further evidence in our discussions with radiology colleagues about the need for a major trauma CT scan.We are good, but not quite good enough to avoid the scan.
ANALYSING VARIATION IN STAFFING LEVELS, ATTENDANCES AND PERFORMANCE AGAINST THE 4-HOUR TARGET USING DATA FROM THE ROYAL COLLEGE OF EMERGENCY MEDICINE'S SENTINEL SITE SURVEY
Authors: Morris T , Mason S , O'Keeffe C 
Published: November 2015

Objectives & BackgroundThe achievement of safe and sustainable staffing levels has been highlighted as a major priority by the Royal College of Emergency Medicine's (RCEM) STEP campaign in the interests of reducing exit block and its associated problems. This study used data from the RCEM Sentinel Site Survey (SSS) to analyse variation and associations between staffing, numbers of attendees and performance against the 4-hour target in 12 emergency departments (EDs) in England.MethodsA convenience sample of 12 EDs recorded the number of hours worked by all grades of staff on 20.03.14. The number attendances in each department was used to adjust for department size, and to calculate how long each staff grade could be expected to spend with the average patient in each department. SitRep data from NHS England was used to measure departmental performance against the 4-hour target in the week 17–23 March 2014.ResultsHaving adjusted for attendances, variation was seen in all staffing grades between departments. The least variation between departments was observed in consultant hours per patient (mean=8.4 minutes, range=8.4 minutes). The most variation was observed in nurse hours per patient (mean=75 minutes, range=63 minutes). For doctors, core trainees (CT1-3) showed the most variation in hours per patient (mean=14.4 minutes, range=31.2 minutes).A significant association was observed between numbers of attendances and the number of hours worked by doctors (Spearman's Rank=0.643, P=0.024). This association was not seen between nursing hours and attendances (Spearman's Rank=0.071, P=0.077). No significant association was observed between staffing levels per patient and performance against the 4-hour target (P=0.829, P=0.186 for doctors and nurses respectively).ConclusionAfter adjusting for attendances variation in staffing hours can be seen in all EDs. Hours worked by doctors were seen to be associated with attendances, however hours worked by nurses were not. The number of staff hours recorded in departments was not significantly associated with departmental performance against the 4-hour target. Further analysis in a greater number of EDs across the UK would provide greater insight into variability in numbers of staff, and how this impacts patients attending the department.
HIV TESTING IN A DISTRICT GENERAL HOSPITAL'S EMERGENCY DEPARTMENT
Authors: Smith C , Kendall R 
Published: November 2015

Objectives & BackgroundPrincess Royal University Hospital (PRUH) is in Bromley, where local HIV prevalence is 2.5 in 1000.1National guidelines recommend considering HIV screening in certain hospital settings, where prevalence is greater than 2 in 1000.2It is estimated that 24% of people with HIV remain undiagnosed,3with clear benefits of early diagnosis including decreased morbidity, mortality, and healthcare cost. Screening programmes in emergency departments (EDs) may be useful but present challenges,4and pilots have run in large EDs5 but we are unaware of similar schemes in smaller EDs.MethodsFor five days in November 2014 between 8 am and 8 pm, we offered an HIV blood test to all patients aged 18–75 attending PRUH ED's walk-in triage. Participants were informed of the result two to three weeks later, and asked for feedback about the study. Any positive results would be followed up by HIV specialist services.Questionnaires regarding perceived acceptability and relevance of testing were distributed to staff working in the department.Results112 patients were eligible for the test; of these, 88 (78.6%) accepted and 24 (21.4%) declined. Of the 88 tests performed, we established an accurate result in 76. All 76 (100%) patients tested negative for HIV. We were able to inform 68 patients of their negative result; of the other 8 patients, 2 had died and 6 were not contactable.Results from patient questionnaires showed patients most commonly declined due to recent testing, or perceived low risk status.The majority of staff questionnaire respondents felt routine HIV testing in the ED was beneficial and acceptable.ConclusionOur results confirm patient acceptability of routine HIV testing in EDs, demonstrated by the high uptake of testing. We did not establish any HIV positive results, which was expected given the sample size and local prevalence. We showed routine HIV testing in EDs is feasible and has a high level of staff acceptability, both of which are promising for continuing routine HIV screening in PRUH. We hope to extend the screening to all medical admissions to the hospital, as recommended by current national guidelines.
CORRELATION BETWEEN TRANSCUTANEOUS AND ARTERIAL CO2 PARTIAL PRESSURES IN ACUTE CARE
Authors: Ward E , Hussain S , Coats T 
Published: November 2015

Objectives & BackgroundPartial pressures of carbon dioxide (pCO2) and oxygen (pO2) in arterial blood are used in emergency department (ED) settings to assess disease severity and guide management. Measurement is usually performed via arterial blood gas (ABG) analysis which is painful and invasive. Transcutaneous monitoring (TCM) of blood gases has been used extensively in neonates as an alternate means of measuring pCO2 and pO2 though its use in adults is not well researched. A good correlation is seen between TCM and ABG analysis of pCO2 in ideal conditions in highly selected patients. This study evaluated the relationship between TCM and ABG analysis in a “real world” emergency care situation.MethodsBreathless patients presenting to the ED at the Leicester Royal Infirmary requiring ABG analysis were considered for inclusion to the study. In suitable patients the TCM4 monitor (Radiometer) was attached as per manufacturer's instructions to measure tcpCO2 and tcpO2 at the time of ABG analysis. Patient demographics and clinical observations were noted. Data was initially analysed using Microsoft Excel, and Bland Altman analysis was performed using GraphPad Prism.ResultsPaired measurements were recorded from 21 patients. The relationship between tcpCO2 and PaCO2 (see Figure) showed a strong correlation (R2=0.9), with a weaker correlation for O2 (R2=0.5). Bland Altman analysis showed a mean difference for pCO2 of −0.82kPa, with 95% limits of agreement from −2.49 to +0.84 kPa. For O2 the mean difference was 0.46 kPa (95% limits −5.72 to +6.64). Skin perfusion and BMI had no effect on the accuracy of TCM. TCM tracings must be evaluated for signal quality before a reading can be interpreted (in the same way that pulse oximetry readings are only valid if there is a ‘good’ trace). Electrode failure due to non-adherence of the fixation ring was common, often requiring re-application. In contrast to ABG sampling, TCM was very acceptable to patients with no reports of discomfort.ConclusionPragmatic ‘real world’ use of TCM in unselected emergency care patients does not show as close a relationship as previous studies however limits of agreement indicate that tcpCO2 is likely to be clinically useful in an ED setting. For pO2 the agreement was weaker however in clinical care pCO2 is often a larger determinant of treatment. A clinical trial is needed to compare standard care (current BTS COPD guideline) against treatment directed by TCM.Figure 2The relationship between tcpCO2 and PaCO2 (n=21).