bluuebunny/crossref_metadata_2025_split huggingface dataset:
TROPONIN USE IN EMERGENCY DEPARTMENT SYNCOPE
Authors: Reed M.J. , O'Neill A 
Published: November 2015

Objectives & BackgroundThere is evidence to suggest that contemporary troponin assays predict serious outcome in syncope, however recent data from newer high sensitive assays show less predictive accuracy. It is still unclear where troponin fits into Emergency Department (ED) syncope decision-making, and also where current practice lies.The aims of this study were:(1) to assess current use of troponin by clinicians in ED syncope patients, and(2) to assess whether a high sensitive troponin assay is better able to predict outcome in ED patients presenting with syncope than a contemporary assay.Table 1Area under the Receiver Operating Characteristic curves for contemporary and sensitive troponin and serious outcome at one month and one yearArea under Receiver Operating Characteristic curve (95% CI)Contemporary Troponin assay and 1 month serious outcome0.587 (0.254-0.919)Contemporary Troponin assay and 1 year serious outcome0.631 (0.438-0.823)Sensitive troponin assay and 1 month serious outcome0.766 (0.539-0.993)Sensitive troponin assay and 1 year serious outcome0.741 (0.581-0.902)MethodsSingle centre retrospective ED cohort study. Eligible patients were identified by way of an electronic patient record keyword search, then individually searched.Patient's contemporary troponin (Abbott Architect troponin I; Abbott Laboratories, Abbott Park, Illinois) and high sensitive troponin assays (Abbott Architect STAT high sensitivity troponin I) were recorded. Both were being measured in our ED during this period, only the contemporary being released to clinicians.Serious outcome at one month and one year was recorded.ResultsBetween 1st November 2012 and 31st January 2013, there were 27,878 presentations to the ED. 27,128 patients were non syncopal, and 497 had an exclusion criteria. 253 patients were enrolled in study. Mean age was 59.0 (SD 24.7). 19 (8%) patients were reported to have chest pain and 36 (14%) patients had ECG changes suggestive of ACS, 5 had both. 100 (40%) patients were admitted to hospital. 15 (6%) patients had a serious outcome at one month and 43 (17%) patients at one year. At one year, 26 (10%) patients had died.Troponin was measured in 43 patients (17%). 29 (67%) had chest pain and/or ECG changes. Troponin was more likely to be measured in a patient with chest pain (p <0.001; Chi-squared 15.86, df=1) or ECG changes (p <0.001; Chi-squared 54.31, df=1).5 of 43 patients had a raised initial contemporary troponin (≥0.05 ng/ml). 7 of 43 patients had a raised initial sensitive troponin (men ≥34 ng/L, women ≥16 ng/L). ROC analysis is detailed in the table.ConclusionED clinicians are more likely to order troponin in syncope patients that present with chest pain or ECG changes, symptoms characteristic of ACS in line with current NICE guidelines.A high sensitivity troponin is able to predict serious outcomes at one month and one year much better that the contemporary troponin assay.
IT'S NOT ALL ABOUT NUMBERS: IS THE SUPPLY OF LEARNING ENCOUNTERS SUFFICIENT TO GENERATE COMPETENCE IN TRAUMA TEAM LEADERSHIP DURING HIGHER SPECIALITY TRAINING?
Authors: Graham B , Nutbeam T , Smith J 
Published: November 2015

Objectives & BackgroundHigher Speciality Trainees (HSTs) are expected to gain competence required for autonomous practice as a consultant. Whether EM HSTs have adequate exposure to achieve competence in the trauma team leader (TTL) role is unclear.Our primary aim was to investigate whether the supply of learning encounters is sufficient to generate competence in the TTL role during HST. Secondary aims were to explore HSTs' participation in trauma calls, roles undertaken, confidence and competence within the TTL role, supervision, opinions on training and the number of TTL encounters required to attain competence.MethodsHSTs in the West Midlands completed a survey exploring the study objectives including confidence in the TTL role. Consultants completed a separate survey assessing HST competence in the TTL role, reasons for lack of competence, and the desired number of supervised encounters required for HSTs to attain competence.To estimate the supply of TTL encounters available, the number of trauma calls was derived from regional and TARN data. This number was proportionally reduced to represent a 48 hour week, divided by the number of HSTs. To assess demand, the supply estimate was compared to the mean number of supervised TTL encounters specified by consultants.Results27/27 eligible HSTs responded. HSTs reported attending 67% of activations during working hours, frequently in the TTL (67%) or Primary Survey roles (29%) but rarely in the airway role (3.2%). 39% of TTL encounters were supervised. 70% reported being confident in the TTL role.35/37 eligible consultants responded. 42% felt that their HSTs were competent in the TTL role. Common deficiencies were lack of exposure and leadership ability.100% of HSTs and 88.5% of consultants reported that a dedicated trauma placement would be desirable (median duration=6 months).Analysis estimates that the number of actual supervised TTL encounters during HST (n=33) is in keeping with the number desired by consultants (n=36) (figure 1).ConclusionThe quantity of TTL encounters during HST broadly matches the demand for exposure specified by consultants. Despite this, there is a disparity between trainee confidence and consultant assessment of competence. Exploration of reasons underlying this difference and the desire for dedicated training may identify areas where HSTs development can be enhanced.Figure 1Flow diagram demonstrating methodology to estimate supply of supervised TTL encounters and average number of supervised TTL encounters desired by consultants.
INADVERTENT INTRA-ARTERIAL CANNULATION IN THE EMERGENCY DEPARTMENT: FEASIBILITY OUTCOMES FROM A PILOT STUDY
Authors: Edwards RG , Kehoe A , Graham B , Smith J 
Published: November 2015

Objectives & BackgroundInadvertent intra-arterial cannulation (IIAC) occurs in some Emergency Department (ED) patients. Interpretation of point of care blood gas analysis (BGA) by a senior emergency physician (EP) may be used to screen for this. We conducted a prospective observational pilot study to investigate the rate of IIAC in the ED setting and to explore feasibility questions to inform a future larger study.Objectives:▸ To assess the performance of medical students and foundation year one doctors in ultrasound (US) assessment of cannula location.▸ To determine the time taken to complete US assessment of one cannula.▸ To assess EP confidence in BGA interpretation.▸ To explore whether or not venous BGA values varied by site of cannula.MethodsFive medical students and FY1 doctors received a two-hour training session from an EP in US assessment of peripheral cannula location. Competence was confirmed by five observed US assessments. Data collectors performed US assessment of cannulas inserted in a convenience sample of ED patients over a two week period (83 patients). Their confidence and time taken to complete US assessment were recorded. Routine BGA obtained during cannula insertion were shown to an EP whose confidence in interpretation was recorded. Data collectors completed a survey to record their experience of various aspects of the study.Results100% of data collectors found using ultrasound to determine the location of a cannula to be 'very easy' or 'quite easy'. Adequate US views were obtained in 94% of examinations. Mean duration of US assessment was 11 minutes 25 seconds. 87% of cannulae had a routine BGA taken and EPs were 'quite confident' or 'very confident' in their interpretation in 97% of BGAs. There was no difference in blood gas values between different insertion sites.ConclusionJunior doctors and medical students can be trained in US assessment of cannula placement. BGA is frequently performed during cannula insertion. EPs interpret BGA confidently. Insertion site does not complicate interpretation. It is feasible to use this methodology for larger studies.Figure 1Figure 2
END-TIDAL CO2 DETECTION DURING CADAVERIC VENTILATION
Authors: Coats T , Biggs M , Robinson C , Rutty G , Adnan A , Morgan B 
Published: November 2015

Objectives & Background“Life like” end-tidal CO2 production has been reported in frozen cadaver during intubation training. There is currently no human model of CPR, however the new technique of post-mortem CT (PMCT) uses CPR to circulate injected contrast for an enhanced CT scan to aid the diagnosis of the cause of death. This might give the potential to compare different methods of CPR. This procedure also allowed us to examine ETCO2 production, to see if the previous single observation could be reproduced.MethodsThe patient was an elderly female without known abnormality of the airway, who had been in a temperature-controlled environment at 4 degrees centigrade for 32 hours after death with no other preservation. She was intubated and approximately 60 minutes later ventilation was commenced. End-tidal CO2 was measured from the start of ventilation using continuous waveform capnography (Propaq CS Monitor, Model 246, Software version 3.7X, Welch Allyn). After eight minutes of ventilation a right ante-cubital venous injection of contrast was given and two minutes of chest compressions performed using a Lucas device. Ventilation was then stopped on an inspiratory hold and a whole body CT was undertaken. The project had Research Ethics Committee approval and was supported by a Resuscitation Council (UK) grant. Consent was obtained from relatives.ResultsThe initial ETCO2 levels were high (6kPa), then decreased rapidly confirming previous findings. A novel observation was that the level of CO2 rose again (albeit at low levels) when CPR was started, presumably due to effective circulation. The post-mortem CT confirmed circulation had been achieved, as contrast was seen in the pulmonary vessels, and also confirmed that the endotracheal tube placement. A further novel finding was that end-tidal CO2 was again higher after the pause in ventilation required for the CT scan, presumably due to diffusion of CO2 down a concentration gradient created by the ventilation-induced fall in alveolar partial pressure.ConclusionThis initial case suggests that end-tidal CO2 in cadavers might have a role; (a) in a protocol for post-mortem CT (as it may indicate effective ventilation and circulation of contrast), or (b) in the comparison of the effectiveness of different methods of CPR.Figure 1
THE ESCAPE OF EMERGENCY MEDICINE TRAINEES FROM IRELAND
Authors: Pflipsen J , Kennedy U 
Published: November 2015

Objectives & BackgroundEmergency Medicine (EM) is facing a worsening recruitment and retention crisis in Ireland. We sought to document the numbers of doctors applying to, resigning from, and completing Core Specialist Training in EM (CSTEM), as well as applying to and resigning from Advanced Specialist Training in EM (ASTEM).MethodsRecords of CSTEM and ASTEM data were interrogated by hand search following approval from the Irish Committee for Emergency Medicine Training (ICEMT) for the time periods from 2011 to 2015 for CSTEM and 2007 to 2015 for ASTEM.ResultsFollowing a peak in 2013, the numbers of CSTEM applicants decreased by 28% by 2015 (75 to 54). The percentage of CSTEM trainees who resigned during their 3-year Training Programme increased from 4% in 2011 to 15% in 2014. Only 1–2 CSTEM trainees out of up to 26 who started first year applied to ASTEM on completion of CSTEM each year. Following an increase between 2007 and 2009, the number of doctors applying to ASTEM decreased by 66% between 2009 and 2015 (29 to 10 trainees). The number of doctors accepted to ASTEM decreased by 70% from its peak of 10 in 2012 to 3 in 2015. A total of 7 trainees who completed CSTEM since it was established have been accepted for ASTEM. There has been no attrition from ASTEM in recent years.ConclusionICEMT data demonstrates a dramatic decrease in the number of doctors applying to both CSTEM and ASTEM in Ireland, coupled with an increase in the number of trainees resigning from CSTEM. Significant improvement in terms and working conditions must be implemented if we are to recruit and retain trainees, and make EM a more attractive and sustainable specialty in Ireland.
BENCHMARKING OF “SINGLE CHECKER” PATIENT GROUP DIRECTIONS (PGDS) DURING INITIAL NURSE ASSESSMENT WITHIN PERUKI EDS
Authors: Bird C , Hartshorn S 
Published: November 2015

Objectives & BackgroundNew ways to optimise ED patient flow, without sacrificing quality of care, are at a premium.1 Doubt has been cast on the efficacy of double checking in all but high risk medications,2 and a study in Geelong, Australia, showed no difference in error rates between double-checked and single-checked medications.3 We aimed to benchmark single-checked PGD medications at triage within PERUKI EDs (Paediatric Emergency Research in the UK and Ireland).A PGD is a legal instruction that allows the supply/administration of a select group of licensed medicines by a select group of healthcare professions, approved beforehand by a doctor, to groups of patients who might not be identified individually prior to presentation.MethodsOnline survey distributed to the research representative at each PERUKI site. The survey was open for 5 weeks (March–April 2015) and was completed by any appropriate clinician within the site.ResultsThe response rate was 84% (36 out of 43 EDs). From these, 22 out of 36 EDs (61%) were using single-checker PGDs. The commonest single-checker medications in use were paracetamol and ibuprofen for pain(Figure 1).22% of EDs reported drug errors related to standard (double-checked) PGDs, while 14% of those with single-checked PGDs reported drug errors. The commonest errors reported were: duplicated dose, incorrect weight, incorrect volume drawn up, contraindication missed.Barriers to single-checked medications in the 11 EDs that did not use them included lack of training courses, lack of staffing in pharmacy for policy preparation and variation in practice from other paediatric areas.ConclusionSingle checker PGDs are currently in use in nearly two thirds of PERUKI sites, with no evidence for increased medication errors with their use. Barriers to the introduction of this practice, together with solutions, have been shared amongst all PERUKI sites.Figure 1
HOW TO MAKE FRIENDS (WITH COMMISSIONERS) AND INFLUENCE ADMISSION RATES—OPENING A PAEDIATRIC OBERVATION UNIT IN THE CHILDREN'S EMERGENCY DEPARTMENT
Authors: Robinson G , Surridge J , Lewins I , Mott J 
Published: November 2015

Objectives & BackgroundContinuing building pressure on Emergency departments across the country are well documented in the media. Annual increases in activity (currently 7% locally) are also being seen in the Children's Emergency departments, within a system that has not seen Paediatric inpatient bed numbers increase. There is a commissioning drive to reduce inpatient admission rates, targeting those with a ‘zero length of stay'. Staffing in paediatric emergency departments has an emphasis on a senior decision maker but this continuity if lost when patients are subsequently admitted to an inpatient area.We opened a paediatric observation unit in April 2014 with the aim of managing patients beyond the UK Government set 4 hour target with a maximum length of stay of 8 hours and hypothesised by restricting admission to a number of simple conditions we could safely reduce hospital inpatient admission.MethodsRetrospective observational study reviewing the impact on the children's hospital of patients admitted to a newly built paediatric observation unitResultsIn year 1 we have reduced hospital inpatient admission by 27% with no increase in reattendance rates. Triage times have improved significantly. Breaches remain the same. The main conditions admitted to the observation unit were children with respiratory problems, gastroenteritis, and children awaiting blood results. Average length of stay on the observation unit is 3:07 hrs with a total average stay (ie including time spent for the CED attendance) is 6:52 hrs. High patient satisfaction is also seen, particularly with regards to improved continuity of care: – ‘Having the observation unit I found much better than being sent up to the ward as my daughter was able to see the same doctor throughout her stay. She was also able to be moved from A and E to the observation ward sooner, and I did not have to explain to several people what had brought us into hospital. I also found the discharge process was completed faster.ConclusionOpening a paediatric observation unit within an existing Children's Emergency department significantly reduces inpatient admission to general paediatric wards. It allows for greater turnover of patients than traditional ward round systems, improved continuity of care, supports commissioning agendas and most importantly leads high patient satisfaction.
WHAT DO YOUNG PEOPLE WANT FROM THE EMERGENCY DEPARTMENT?
Authors: Browning J , Bryans A , Camilleri-Brennan J , Patel N , Price R 
Published: November 2015

Objectives & BackgroundAdolescents' opinions regarding health care is under-represented. The Royal Hospital for Sick Children Edinburgh is due to relocate to a new site in 2017 when it will also increase its age limit to <16 years (currently <13 yrs). This study investigates adolescents' opinions on the Emergency Department (ED) and determines what is important to them to ensure that we get it right.MethodsAn extensive literature search was performed which identified four key topics which formed the design of the questionnaire. Inclusion criteria were individuals aged between 12–16 years, presenting to the Royal Infirmary ED where adolescents are currently seen. The questionnaire was distributed to the ED for a month. Qualitative interviews were also conducted throughout the month using a template based on the questionnaire.ResultsIn total, 140 responses were received. The most important factor in an ED, according to adolescents was cleanliness (average importance rating of 4.69). The least important factor was entertainment which was given an importance rating of 2.46. However, when prompted to select one factor, being treated quickly was the most important (figure 1). Only 21% of respondents knew of the proposed move of the ED department, and overall this was deemed a positive idea (78%).Four main areas were considered when evaluating the results of our study. As age increased, the proportion of individuals preferring to be treated with adults increased. However, greater satisfaction was achieved when treated in child or adolescent-specific wards which suggests the use of age specific areas. Privacy was a concern expressed by adolescents potentially giving scope for improvement. The majority of respondents felt safe within an ED setting, however a small proportion did not. Our study suggested the feeling of safety is created by healthcare workers and familiarity with staff and the environment. Waiting times were consistently deemed important and reduced this would increase patient satisfaction.ConclusionLiterature specifically focusing on adolescents in this topic is limited. Our study attempts to fill in some of these gaps. Being seen quickly, cleanliness and clear explanations of treatments and procedures are the most important factors throughout the sample. The implications derived from our results suggest that the new ED adopt some changes including improving safety and waiting times to ensure we achieve high patient satisfaction.Figure 1
SWEET ON THE OUTSIDE BUT NOT ON THE INSIDE -LIQUITAB INJURIES IN A TERTIARY PAEDIATRIC EMERGENCY DEPARTMENT (PED)
Authors: Mullen S , Maney J , Casey C 
Published: November 2015

Objectives & BackgroundFollowing the near fatal aspiration of a liquitab in RBHSC, a review of the department's management of this increasingly common issue was undertaken.The aims of the audit were:1) Identify the frequency of liquitab injuries2) Assess the range of injuries caused by liquitabsMethodsThe electronic system uses to register and track patients (Symphony) was used to collect the data. Data was reviewed for the years 2012/2013. Cases were included only if the injury was due to a liquitab.Results275 cases were identified from the preliminary search. 40 of these were documented liquitab injuries (15% of non-medicinal ingestions). 　Type of injury:Ingestion – 28/40 (70%) and eye injury – 12/40 (30%). No children had inhalation or skin injury noted.Ingestion–17/28 (60%) of these patients presented with vomiting. Treatment was supportive in all cases.Eye injury　– Eye irrigation was carried out 100%– pH was tested 11/12 cases– Corneal abrasion was seen in 2 cases– Ophthalmology were involved in 7 cases (58%) 　Outcome–95% (38/40) of children were discharged after observation–2.5% admitted (1/40) under ophthalmology–2.5% (1/40) of discharged from triage; described as low risk　–12.5% (5/40) had follow up appointments with ophthalmology the following dayExplanation of injury:Unsupervised play in 37.5% (15/40) with the remainder not documented.275 cases were identified from the preliminary search. 40 of these were documented liquitab injuries (15% of non-medicinal ingestions).ConclusionThe results highlight the difficulties that children can encounter from liquitab injuries. The colourful nature, “sweet-like” appearance and soft texture of liquitab detergents make them appealing to young children. A key issue was to improve parental awareness. We have achieved this via a national press release through Rospa,(Royal Society of the Prevention of Accidents), BBC news interviews and national press articles.
Condensate-enclosed chiral-bag model of the proton and pp elastic scattering at LHC 13 TeV
Authors: Islam M. M. , Luddy R. J. 
Published: November 2015

Our investigation of high energy [Formula: see text] and [Formula: see text] elastic scattering over the last ten years has led us to consider that the proton has three regions: (i) an outer region consisting of a quark–antiquark [Formula: see text] condensate ground state (also described as quark–antiquark outer cloud), (ii) an inner shell of topological (geometrical) baryonic charge of size [Formula: see text] 0.44 fm, and (iii) a core of size [Formula: see text] 0.2 fm, where the three valence quarks of a proton with baryonic charges are confined. The proton structure that has emerged leads to four main elastic scattering processes in [Formula: see text] scattering. The first process (which gives rise to diffraction scattering) is described by a profile function. The second process involves multiple [Formula: see text]-exchanges. The third process in [Formula: see text] scattering is quark–quark scattering via gluon–gluon interaction. The fourth process — which appears for the first time in our investigation of [Formula: see text] scattering — is a glancing collision at the boundary of a proton with that of the other proton. To describe quantitatively the four processes, their parameters have to be determined. For this purpose, we investigate: (i) [Formula: see text] 7 TeV [Formula: see text] measured by the TOTEM Collaboration and (ii) [Formula: see text] 1.96 TeV [Formula: see text] measured by the D0 Collaboration. Once the parameters are satisfactorily obtained, we calculate [Formula: see text] [Formula: see text] at 7 TeV and compare with the TOTEM data. We also calculate [Formula: see text] [Formula: see text] at 1.96 TeV and compare with the D0 data. We then predict [Formula: see text] elastic [Formula: see text] at 13 TeV which will soon be measured at LHC by the TOTEM Collaboration. This measurement will establish how well we have predicted the 13 TeV [Formula: see text] and determined the structure of the proton.