bluuebunny/crossref_metadata_2025_split huggingface dataset:
LOWERING LEVELS OF BED OCCUPANCY IS ASSOCIATED WITH DECREASED INHOSPITAL MORTALITY AND IMPROVED PERFORMANCE ON THE 4 HOUR TARGET
Authors: Boden D 
Published: November 2015

ObjectivesThe aim of this study is to determine if there is a relationship between medical bed occupancy, performance against the 4 hour standard and hospital mortality rates.BackgroundThe problem of crowding in EDs is recognised by professional bodies around the world as a patient safety issue and, in 2014, this was the principle campaign of the UK Royal College of Emergency Medicine. Past research has focused on the outcome of ED patients, but less is known about the effect of access block, capacity and performance for the wider group of patients in a hospital.In June 2013, as a result of increasing workload pressures, Derby Hospitals NHS Foundation Trust introduced a 90% medicine bed occupancy target. A number of interventions were undertaken across the patient journey to facilitate this. These included daily Consultant ward rounds on medical wards, CCG-commissioning of additional community beds and planned utilisation of traditional surgical bed base for medical patients. This permitted a natural experiment to see the effect of this reduction in bed occupancy on 4HTP and mortality.MethodsThis before-and-after study was undertaken in a large UK District General Hospital over a 32 month period. A range of interventions were undertaken to reduce medical bed occupancy within the Trust. 4HTP and hospital mortality (HSMR, SHMI and Crude Mortality) were compared before, and after, intervention. Daily data on medical bed occupancy and 4HTP was collected from hospital records. Segmented regression analysis of interrupted time-series method was used to estimate the changes in levels and trends in average medical bed occupancy, monthly 95% 4HTP and monthly mortality measures (HSMR, SHMI and crude mortality) that followed the intervention.ResultsMean medical bed occupancy decreased significantly from 93.7% to 90.2% (p=0.02). The trend change in 4HTP, when comparing pre- and post-intervention, revealed a significant improvement in performance (p=0.019). The intervention resulted in a mean reduction in all markers of mortality (range 4.5%–4.8%). SHMI (p=0.02) and Crude Mortality (p=0.018) showed significant trend changes after intervention.ConclusionWhole system transformation can create lower average medical bed occupancy, reduce mortality and improve performance against the four hour target.
RAISING THE BAR FOR EXCLUSION OF ACUTE VENOUS THROMBOEMBOLISM IN THE EMERGENCY DEPARTMENT
Authors: Horner D , Wells S , Bonnici K , Reeves N , Parris RJ 
Published: November 2015

Objectives & BackgroundCurrent assessment protocols for suspected acute venous thromboembolism (VTE) have low specificity. As a result, many patients without disease receive high dose anticoagulation or undergo hospital admission for short periods pending definitive investigation. Elderly patients are particularly at risk. It has been suggested that increasing the threshold for a positive d-dimer test in patients over 50 years old may lead to significantly increased specificity of the test, without decreasing sensitivity. We sought to identify the clinical and cost impact of a variable ‘age adjusted' threshold in the Manchester area, to externally validate these findings.Table 1Test characteristics for use of an 'age adjusted d-dimer' assessment, during initial workup to exclude venous thromboembolic diseaseDisease PositiveDisease Negative Test Positive66253Positive Predictive Value 21%Test Negative2176Negative Predictive Value 98% Sensitivity 97%Specificity 41% Negative Likelihood Ratio – 0.07.MethodsA multicentre 6 month retrospective cohort study. Patients undergoing invasive investigation for exclusion of VTE were identified in several centres undertaking ambulatory management. All patients were identified as disease positive or negative via gold standard imaging. Serum d-dimer measurements collected on initial assessment were recorded. Age adjusted cut offs were calculated retrospectively by formula in line with recent evidence (age*10).Diagnostic test characteristics were calculated along with proportional reductions in imaging, therapeutic exposure and baseline estimates of cost.ResultsDuring the study period, 497 patients over 50 years of age were identified who were referred for definitive investigation to exclude VTE. Mean age was 74. Incidence of VTE was 16.3%. Use of an age adjusted cut point for d-dimer measurement would have resulted in withheld imaging/treatment in 138 patients (35.8%). Of these patients, 2 were false negative results – an 85 year old with a 5 week history of back pain eventually treated as a pulmonary embolus after high probability v/q scan, and an isolated distal deep vein thrombosis in a 72 year old. Test characteristics are displayed in Table 1. The strategy would have saved 128 doppler scans, 10 V/Q scans and 2 CTPA scans, in addition to 652 days of LMWH administration over the 6 month period, at a cost estimate of £11,620.56.ConclusionRetrospective application of an age adjusted d-dimer cut point for exclusion of VTE in ths cohort significantly increased specificity with limited impact on sensitivity. Caveats include those patients with longstanding symptoms and those with isolated distal deep vein thrombosis. UK centres should consider further local validation and trial adoption.
THE EFFECT OF FASCIA ILIACA COMPARTMENT BLOCK FOR HIP FRACTURES ON LENGTH OF HOSPITAL STAY AND DISCHARGE DESTINATION
Authors: Bray H , Collins N 
Published: November 2015

Objectives & BackgroundFascia iliaca compartment block (FICB) provides excellent pain relief for neck of femur fractures (NOFF). It can be given safely using an ultrasound guided technique in the Emergency Department (ED). At Salford Royal NHS Foundation Trust (SRFT) FICB was introduced to the analgesic pathway for hip fracture management in 2012, in combination with paracetamol and then opioids third line. The aim of this audit is to further investigate the effectiveness of FICB and determine whether the use of FICB can reduce hospital stay, discharge destination and in-hospital complication rates.MethodsData was collected retrospectively for all patients attending SRFT ED with a NOFF from 1 August 2011– 31 January 2012 and 1 August 2014–31 January 2015. 136 of 198 patients were included in the study. Patients were omitted if they were later found not to have NOFF, if they were treated non-surgically, or if any scanned notes from the ED or theatre were not available. Any patient receiving an alternative nerve block was also omitted from the study. Patient demographics and whether or not they received a FICB in the ED and in theatre were recorded. The length of stay in hospital, discharge destination, any in-hospital complications and 7 and 30 day mortality were also recorded for each patient.ResultsThe results showed that significantly more patients were unable to go immediately home after their acute hospital admission when they did not have a FICB in the ED or theatre, compared to when they did (Pearsons Chi square test, p=0.028). The biggest impact on patient destination was determined by receiving FICB in theatre (Pearsons Chi square test, p=0.006). Giving FICB during hospital stay had no significant influence on length of stay (Mann Whitney U test, p=0.507) or in-hospital complication rates (Pearson Chi square test, p=0.117).ConclusionGiving patients a FICB increases their chances of returning home at discharge. Without it patients are more likely to be discharged to intermediate care or residential and nursing homes. FICB had no effect on length of stay or in-hospital complications. We recommend that all patients be offered a FICB in the ED.
WHAT PROPORTION OF PATIENTS ARE ATTENDING THE ED AVOIDABLY? AN ANALYSIS OF THE ROYAL COLLEGE OF EMERGENCY MEDICINE'S SENTINEL SITE SURVEY
Authors: Morris T , Mason S , O'Keeffe C , Moulton C 
Published: November 2015

Objectives & BackgroundCrowding and exit block have been identified as major issues in emergency medicine, affecting patient safety, effectiveness of care and staff well being. Avoidable attendances (AAs – typically defined as non-urgent, self-referred patients who could be managed effectively and efficiently by other services) have been identified as a factor in the overall problem of crowding. The lack of a universal definition of an AA means these have been estimated to constitute between 10% and 90% of ED attendances.This study used data from the Royal College of Emergency Medicine's (RCEM) Sentinel Site Survey (SSS) to estimate the proportion of AAs in 12 Emergency Departments (EDs) across the country on a standard day.Methods12 EDs across England completed the SSS on 20.03.14, reflecting a standard day in the ED. All patients attending were recorded on the survey with details of investigations/treatments they received. The criteria used to define an appropriate attendance were developed using the questions from the survey, and the proportion of patients thought to be attending avoidably in each department was calculated.ResultsData analysis showed that a mean value of 22.4% (95% CI=20.9%–23.9%) of attendances could be deemed avoidable. Proportions of reported AAs ranged from 11.5% to 49.6%.With arrival by ambulance, the issue of prescriptions, or both these variables included in the criteria defining an appropriate attendance, this figure fell to 19.4%, 17.6% and 15.1% respectively.Younger age was shown to be a significant predictor of avoidable attendance, with 40.5% of under 16's attending avoidable, compared to 20.9% of adults aged 16–64 and 6.3% of over 65's.ConclusionThe proportion of potentially avoidable ED attendances shown by this study was lower than the percentages of patients reported to not need treatments in the ED by the Urgent and Emergency Care Review. This suggests that the ED is still the most appropriate healthcare setting for many patients due to the its comprehensive investigations, treatments and capability for urgent referrals. Younger patients were more likely to attend avoidably.The proportion of AAs is dependent on the defining criteria, highlighting the need for a standardised, universal definition of an appropriate/avoidable ED attendance. This is essential to understanding how AAs contribute to the overall issue of crowding.
ADMITTED AND IGNORED? WHAT HAPPENS WHEN ED PATIENTS ARRIVE ON WARDS?
Authors: Turner C , Hargreaves A , Nailor A 
Published: November 2015

Objectives & BackgroundThere is compelling evidence that way we treat fellow staff can reflect the way we treat patients. The greeting of staff/patients on wards is not something that is generally looked at and Emergency Medicine is in a unique position to measure this.When patients are moved to wards there is an expectation that their welcome will be professional and courteous. After the lead author received a clinical adverse event regarding the lack of welcome an HCA received on transferring a patient, he started a prospective collection of mixed data around the type of reception that patients and staff had when they arrived on the wards.MethodsOver 3 months in 2015 staff who were transferring patients were asked to fill in a standardised questionnaire regarding how they were received on the wards. The data was anonymised to person but not ward.The data collection tool was designed for ease of use by portering/HCA staff (as they do the majority of our transfers). Data collection involved both visual analogue scales (for warmth of reception), a Likert scale and boxes for free text (good and bad points).A data set of 150 reports was decided upon a priori as a pragmatic compromise, getting sufficient examples to have robust conclusions but also stopping and using the findings before the good will of the transfer staff was exhausted. Reporting was not mandated but the reasons for doing this were explained to the portering and HCA staff who usually were very willing to take part.There were no exclusion criteria.Results150 completed questionnaires were received, with a 65/35 split between those classified as good (warm) and those regarded as being poor (cold).Areas where there was a consistently positive or negative welcome were identified.Comments have been coded and classified and tabulated. Narratives have been used to describe the perceived experiences.ConclusionThere are areas of our hospital where patients consistently receive a warm and caring welcome. Unfortunately there are also areas where the culture permits a negative and cold welcome.Used sensitively, this information can help inform organisational/cultural change at a ward level to the benefit of both patients and staff.The information that we have gleaned is now being used to inform change and praise at a ward level within the trust. We have started a “Meet, Greet and Treat” programe with staff, aiming to improve the experience for all.
OBSERVATIONAL STUDY TO QUANTIFY THE CORRELATION OF DEPARTMENTAL EXIT BLOCK TO 4 HOUR STANDARD COMPLIANCE BREECHES
Authors: Moss P , Treanor D , Chan C 
Published: November 2015

Objectives & BackgroundThe Royal College of Emergency Medicine (RCEM) recent campaign, focusing on Emergency Department (ED) performance against the 4 hour standard, has highlighted exit block as a fundamental inhibitor of compliance with the standard. This leads to overcrowding, inefficiency processing patients, poor departmental flow and subsequent increased clinical risk. The study took place in the ED at St George's Hospital, London which is a major trauma centre seeing around 400 patients per day with the aim of quantifying the effect of exit block on the 4 hour standard.MethodsData was extracted from our patient tracking system (Cerner iCLIP) on a daily basis for a period of 9 months commencing September 2014. Exit block was defined as patients occupying cubicles whilst awaiting a bed allocation for 6 hours or more. We only included adult patients in this study. The data for a given day was extracted the following morning. The cumulative duration of stay of all the included patients was divided by 24 to calculate the number of cubicles “lost” to exit block in that 24 hour period.A scatter plot was then constructed of cubicles “lost” vs number of breeches of the 4 hour standard that day A correlation co-efficient was then derived. We also produce a similar graph for the same time frame correlating attendance number per day with number of breeches.ResultsThe data produced a correlation of 0.886 between cubicle loss and number of breeches per day. The correlation between attendance numbers and breeches was 0.208.ConclusionFrom this data we have been able to quantify the effect of exit block on departmental performance. The correlation is 0.883. This supports the previous published work on the subject of exit block and the Royal College of Emergency Medicine's “STEP” campaign; specifically the “E” for exit block as something that needs urgent attention to improve 4 hour standard compliance. This data could be used to derive a performance prediction model based not only exit block as we have defined it but other variables., at play in the ED such as ambulance arrivals, age profile of patients, absolute number of patients etc.Figure 1Figure 2
OUT OF HOSPITAL CARDIAC ARRESTS AND EMERGENCY CORONARY ANGIOGRAPHY
Authors: Slessor D , Ashton A 
Published: November 2015

Objectives & BackgroundThe rate of survival to discharge from an out-of-hospital cardiac arrest (OOHCA) is ∼10%. In patients with OOHCA improved survival rates have been reported in patients who have a ST-elevation myocardial infarction (STEMI) who undergo percutaneous coronary intervention (PCI). The evidence for patients without STEMI is unclear.The aim of this paper was to review our current management of patients following an OOHCA with ventricular fibrillation (VF); to determine how sensitive and specific our current practice is at ruling in and out stentable lesions, and to determine whether staff have a consistent approach.MethodsPatients were identified retrospectively, over a 6-month period, through the ICNARC database using diagnostic codes. All notes were reviewed to determine if the patient had an angiogram performed, whether this was an emergency procedure and if a PCI was performed. Sensitivity and specificity was determined for our current practice at ruling in and out stentable lesions. Survival was determined at six months.Cardiologists and Emergency Physicians were shown the ECG of each patient, blinded to the patient identification. They were given a short clinical history and asked to decide if the patient should have undergone an immediate angiography.Results27 patients were included. 12 patients had an immediate angiogram of whom eight had a PCI. A further four patients had a delayed angiogram, of whom three had PCI performed. The sensitivity and specificity of our current practice for ruling in and out stentable lesions was 73% and 75% respectively. Emergency physicians and Cardiologists were 91% and 78% sensitive respectively, and 54% and 78% specific. There was a wide variation in practice within each group of specialists.ConclusionLess than 50% of patients who had an OOHCA from VF underwent immediate coronary angiography. In those patients that did not undergo immediate coronary angiography, a delayed angiography was performed in 27%, of whom 75% had a PCI. Current practice resulted in a sensitivity and specificity that was too low to rule in or out stentable lesions.Emergency Physicians would arrange for more patients to have immediate angiography following cardiac arrest compared with Cardiologists. This would result in more patients with stentable lesions having PCI performed immediately, but would result in more cases of immediate angiography being performed in patients who do not have stentable lesions.
CAPS—A UKOSS STUDY OF CARDIAC ARREST IN PREGNANCY AND THE USE OF PERI-MORTEM CAESAREAN SECTION. IMPLICATIONS FOR THE EMERGENCY DEPARTMENT
Authors: Beckett VA , Sharpe P , Knight M 
Published: November 2015

Objectives & BackgroundThere is limited data regarding the nature and number of cardiac arrests in pregnancy (CAP). The Resuscitation Council and simulation courses such as MOET and ATLS, recommend that, in order to improve maternal outcome, perimortem caesarean section (PMCS) should be considered at 4 minutes post-arrest and completed at 5 minutes. There is no prospective data on the efficacy of this intervention or on how many women who arrest in pregnancy are managed in this way. Data from Holland suggests that, whilst more PMCS is being performed, there is significant delay in performing PMCS and low rates of maternal survival. We set out to determine the incidence of cardiac arrest in pregnancy as well as the use of PMCS. We also wanted to explore the outcomes, whether the cardiac arrest happened on the delivery suite, elsewhere in hospital or in the community.MethodsWe have carried out the first prospective study of cardiac arrest in pregnancy & perimortem caesarean section, using the well established UK Obstetric Surveillance System (UKOSS). Over a 3 year period, all cases of CAP in the UK were collected.ResultsBetween 2011 & 2014, 70 cases of CAP were reported. The UK incidence of CAP was 1:34 000 maternities. 16 women collapsed in the community, of which 87% (n=14) died. Of 47 women where the method of relieving aorto-caval compression was recorded, 21 had pelvic tilt & only 4 cases had the recommended manual uterine displacement. 7 women were avoidably moved to theatre for their PMCS. 47 women had a PMCS performed, 11 of which were performed in the Emergency Department (ED). In 43 of the cases, the decision to perform the PMCS was made by an Obstetrician, with 46 of the cases performed by an Obstetrician. Cardiac output was restored in 53 women. 60% (n=42) ultimately survived their arrest. In all women who survived, the median time from collapse to PMCS was significantly shorter than in those that died (p<0.001). There was no difference in time from collapse to ALS (p=0.098).ConclusionWe report a UK incidence of 1:34 000, with evidence of a readiness to perform PMCS. This intervention was usually carried out within the recommended time post arrest, with good maternal outcomes. Several cases were encountered in the ED. We recommend that the management of CAP should be embedded within resucitation training for ED staff to minimise delay in PMCS.
LAVAS: LACTATE—ARTERIAL AND VENOUS AGREEMENT IN SEPSIS
Authors: Datta D , Grahamslaw J , Gray AJ , Walker C , Graham C 
Published: November 2015

Objectives & BackgroundSepsis is a common condition with around 30% hospital mortality. Measurement of lactate levels is an important part of the sepsis bundle. Although peripheral venous lactate (PV-LACT) is widely measured, most research has used arterial lactate (A-LACT). The interchangeability between the measurements is debatable, with no research supporting the widespread use of PV-LACT instead of A-LACT. If we can demonstrate that PV-LACT has good agreement it would significantly reduce patient discomfort and the potential risks of arterial sampling for a large group of acutely unwell patients, whilst potentially reducing costs to the healthcare system.Table 1Analysis of PV-LACT cut-offs to predict A-LACT≥2PV-LACT cutpointNumber with arterial lactate ≥2 above PV-LACT cutpoint [n=49]SensitivityNumber with arterial lactate <2 below PV-LACT cutpoint [n=255]Specificity1.05491850.3331.554911710.6712.054912210.8672.55380.7762460.9653260.5312540.9963.5160.3272551PV-LACT=peripheral venous lactate A-LACT=arterial lactate.The aim of this study is to determine if peripheral venous lactate measurement gives the same results as arterial lactate measurement in septic patients attending the Emergency Department (ED).MethodsWe performed a prospective observational cohort study of 304 consecutive consented patients presenting with sepsis to a single UK NHS ED (110,000 adult attendances annually) between October 2013 and March 2014. Arterial and peripheral venous samples were taken within 20 minutes of each other, and measured in mmol/L. Bland-Altman analysis was used to compare the level of agreement between PV-LACT and A-LACT. Receiver operating characteristic (ROC) curves were created to delineate optimal cut-off points to predict arterial lactate ≥2 mmol/L.ResultsBland-Altman analysis noted a mean difference (PV-LACT-A-LACT) of 0.4 mmol/L, with 95% limits of agreement from −0.4 to 1.2 (figure 1). The majority of PV-LACT samples were higher than A-LACT samples, with a trend to a greater difference as lactate concentration increased. Only 7 A-LACT samples had a concentration ≥4 mmol/L. ROC analysis showed that we have a 100% ability to predict (i) A-LACT of <2 with a PV-LACT cut-off of 2.05, and (ii) A-LACT of ≥2 with a PV-LACT cut-off of 3.5 (table 1).ConclusionThis study shows good clinical agreement between PV-LACT and A-LACT. PV-LACT measurements <2 mmol/L predict A-LACT <2 mmol/L with 100% accuracy. We recommend the routine use of peripheral venous lactate in the management of septic patients presenting to the ED. This will allow faster screening of this important group of patients in EDs (as well as other healthcare settings) where arterial lactate analysis or appropriately trained staff are not available. We can also improve patient care by reducing patient risk and discomfort.Figure 1Bland–Altman plot of agreement between peripheral venous (PV-LACT) and arterial (A-LACT) lactate.