bluuebunny/crossref_metadata_2025_split huggingface dataset:
32 Do low-risk patients with non-cardiac chest pain prefer early discharge after rapid rule-out in the emergency department?
Authors: Hancock Isabelle , Carlton Edward 
Published: November 2017

BackgroundThere has been a recent drive to implement rapid rule-out strategies which allow the early discharge of low-risk patients with suspected cardiac chest pain directly from the Emergency Department (ED). Previously, such patients would have been admitted to a hospital bed for observation and delayed biomarker testing. While the drive to implement rapid rule-out strategies comes from healthcare providers, there has been little assessment of patient perspectives on early discharge, in what is known to be a high-anxiety presentation. We aimed to explore patient perspectives on the acceptability of early discharge strategies.MethodsThis prospective quantitative survey was conducted on consecutive patients admitted from the ED to a short-stay ward for evaluation of suspected cardiac chest pain at a single centre in the UK. All patients were discharged within 36 hours with a diagnosis of low-risk chest pain. The written questionnaire was designed with closed answer questions with responses standardised along a 5-point Likert scale and was completed by patients upon discharge. Ethical approval was obtained.ResultsOf 739 patients requested to complete the survey, 278 (37.6%) responded. Mean age 56.6 years (SD 13.4), 263/278 (94.6%) White British, mean length of stay 15.5 hours (SD 6.6), 6/278 (2.2%) had a major adverse event (MACE) at 30 days. Responders were more likely to be female than non-responders (49.6% vs 37.5%, p=0.001), otherwise groups were matched in age, cardiac risk factors, length of stay and the presence of MACE (p>0.05 for all).Table 1Summary of patients’ responses from questionnaireThe majority of patients, 197/278 (70.8%) would have been satisfied or very satisfied with early discharge directly from the ED, with 36/278 (13.0%) expressing dissatisfaction with a proposed rapid rule-out strategy. However, 249/277 (89.9%) of responders were reassured by admission to the ward and 112/273 (41.0%) felt they could not have spent any less time in hospital. Through binary logistic regression we analysed potential predictors of dissatisfaction with early discharge, these were sex, age, severity and type of pain at presentation, previous ischaemic heart disease, family history and found none were significant.ConclusionsMost patients would be satisfied with a rapid rule-out strategy, however, it should be acknowledged that patients receive reassurance from hospital admission and over 10% of patients would be dissatisfied with discharge direct from ED. Improved patient information and shared decision making is required when rapid discharge strategies are incorporated into practice.
33 Systematic review of the effectiveness of prehospital critical care following out-of-hospital cardiac arrest
Authors: Vopelius-Feldt Johannes von 
Published: November 2017

BackgroundImproving survival after out-of-hospital cardiac arrest (OHCA) is a priority for modern emergency medical services (EMS) and prehospital research. Advanced life support (ALS) is now the standard of care in most EMS. In some EMS, prehospital critical care providers are also dispatched to attend OHCA. This systematic review presents the evidence for prehospital critical care for OHCA, when compared to standard ALS care.MethodsWe searched the following electronic databases: PubMed, EmBASE, CINAHL Plus and AMED (viaEBSCO), Cochrane Database of Systematic Reviews, DARE, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, NIHR Health Technology Assessment Database, Google Scholar and ClinicalTrials.gov. Search terms related to cardiac arrest and prehospital critical care. All studies that compared patient-centred outcomes between prehospital critical care and ALS for OHCA were included.ResultsThe review identified six full text publications that matched the inclusion criteria, all of which are observational studies. Three studies showed no benefit from prehospital critical care but were under-powered with sample sizes of 1028–1851. The other three publications showed benefit from prehospital critical care delivered by physicians. However, an imbalance of prognostic factors and hospital treatment in these studies systematically favoured the prehospital critical care group.Table 1ConclusionCurrent evidence to support prehospital critical care for OHCA is limited by the logistic difficulties of undertaking high quality research in this area. Further research needs an appropriate sample size with adjustments for confounding factors in observational research design.
35 To pan-scan or not to pan-scan? Further analysis of the tarn database 2012–2017
Authors: Hunt Paul , Lecky Fiona , Bouamra Omar 
Published: November 2017

BackgroundA ‘whole body’ or ‘pan-scan’ computed tomography (CT) imaging approach is now becoming the standard of care during the early management of adult patients with suspected severe blunt multitrauma. A number of studies have variously reported a mortality benefit or no benefit from a pan-scan approach compared to that of carrying out body region-focused CT and/or plain radiographs or a mixture of imaging modalities. However, unanswered questions still remain due to the significant heterogeneity in practice between institutions, and the limitations of published studies. The potential risk for harm from ionising radiation or intravenous contrast-induced nephropathy is still a concern, especially where mortality benefit from an unselective pan-scan approach is yet to be definitively proven.We present the results of our latest analysis of the Trauma Audit and Research Network (TARN) database; updated to take into account the establishment of the regional trauma network system and focusing on the Major Trauma Centre’s (MTC’s).MethodsWe analysed retrospective, multicentre data of severe blunt multitrauma (ISS >15) direct MTC admissions aged >15 years recorded in the UK TARN database from 2012–2017 to compare survival at 30 days between two groups of patients: (1) those undergoing pan-scan, and (2) those in receipt of a focussed/non-pan-scan approach as part of their initial management within the first 4 hours in the Emergency Department (ED). The final dataset included 44 407 cases.Results15 645 (35.2%) of 44 407 cases underwent pan-scan from the ED. The median ISS for the pan-scan group was 18 (IQR 10–29) compared to 16 (IQR 9–25) for the non-pan-scan group. The calculated crude mortality rate for the pan-scan group was 11.2% compared to 10.6% in the focussed CT group (p=0.0673). Patient characteristics are shown in table 1.Table 1Patients characteristicsPropensity scoring (PS) was used to create a balance in patient characteristics between the two groups and various statistical models derived to analyse the effect of imaging type (exposure factor) on outcome (mortality at 30 days) as shown in table 2.Table 2Modelling morality using pan-scan as exposure factorThe results show that pan-scan has an adverse effect on outcome in all of the models, although not statistically significant in all except Model 2 (adjustment based only on stratified PS).ConclusionThe results of our investigation demonstrate that there is no risk adjusted mortality benefit observed from current practice in MTCs in England and Wales. Key issues remain to be addressed such as pan-scan selection criteria and the significant heterogeneity observed in practice across institutions.
37 Routine testing of salicylate levels in overdose patients: still needed?
Authors: Hardy Elaine , Toro Clare , Dorrian Susan , Salanke Umesh 
Published: November 2017

Introduction and aimsOverdose is a common presentation in Emergency Departments (EDs) across the UK. Salicylate poisoning is potentially fatal; however it is becoming increasingly uncommon in the UK. This may be due to restriction of pack sizes in over the counter medicines as well as the use of aspirin as an analgesic being superseded by other NSAIDs, particularly ibuprofen.In conjunction with clinical features of salicylate toxicity, measurement of plasma salicylate concentration can help guide management. Many EDs routinely test for salicylate levels in all cases of overdose, and yet this may not be necessary as recommended by the NPIS.This study aims to assess the cost implication of over testing for salicylate in overdose patients, as well as the prevalence of salicylate poisoning in three EDs in the West Midlands.MethodA multicentre retrospective case note study was undertaken from January 2016 to March 2017. Data were collected from 3 EDs in the West Midlands. Cases of overdose where salicylate levels were requested were identified in conjunction with biochemistry departments, and information gathered regarding age, gender, nature of overdose, patient weight, GCS, clinical features of salicylate toxicity and plasma salicylate concentration.ResultsAcross the three centres, 4296 requests were made for salicylate levels during the study period. Of those samples, just 115 detected any salicylate at all (2.7%). The majority of these samples had levels just over limit of detection.This is in keeping with the previous observation that salicylate poisoning is uncommon.Of the 4296 samples sent, 3651 were not indicated, i.e., no clinical features, patient alert, and denied aspirin overdose.With the cost of plasma salicylate concentration analysis being £4.58 (average over the 3 sites) there is a potential cost saving of £16 721 per year.ConclusionsSalicylate poisoning appears to be uncommon among patients presenting with overdose.Results show that it is likely that EDs are over testing for salicylate levels.In accordance with NPIS advice, there is no need to measure salicylate levels in conscious overdose patients who have no features of toxicity and deny salicylate ingestion.This may have cost implications, allowing departments to save money by reducing the amount of routine salicylate testing overall.
39 Violence intervention and prevention in emergency rooms: the viper study
Authors: Price James , Martin Michael , Dean Jon , Ahmed Haroon , Waite Matthew , Boyle Adrian 
Published: November 2017

BackgroundNearly half a million people are killed each year as a consequence of intentional injury and many more seriously injured. Information sharing by Emergency Departments with local government for crime prevention purposes has previously been described as an effective, cost effective, low cost and low risk intervention for tackling community violence. The UK Department of Health and the Home Office support this process known as the Information Sharing to Tackle Violence (ISTV) program. In 2007, we implemented ISTV and have witnessed a substantial reduction in assault related attendances. We aimed to examine the epidemiology of our assault victims over the introduction period. We hypothesiseda priorithat there would be reductions in the proportions of patients who attended at the weekend and late at night, reductions in the proportions of young adult males, and reductions in the more seriously injured patients.MethodsWe extracted all the cases of assault from our patient administration system between the 1 st of January 2005 and the 31 st of December 2014 and analysed the data using Poisson regression. To estimate the trend over the 10 year period, we used indicator variables for each year (other than 2005 which was treated as the reference category) to allow for non-linearity. Deviance tests of the models were used to assess whether the inclusion of the interaction terms improved model fit. When there was evidence of statistically significant interactions, we re-ran the model looking at the rate of change over time separately for each strata of the effect modifier.ResultsOver the study period, the rate of emergency department presentations following an assault decreased up until 2014, at which point it was 37% lower (IRR=0.63; 95% CI:0.57 to 0.69) than in 2005. There were greater reductions for presentations on weekends (IRR=0.57; 95% CI:0.50 to 0.64) versus weekdays (IRR=0.72; 95% CI:0.62 to 0.83); presentations with no hospital follow-up (IRR=0.51; 95% CI:0.45 to 0.56) versus those leading to either an inpatient (IRR=1.05; 95% CI:0.84 to 1.31) or outpatient (IRR=1.23; 95% CI:0.93 to 1.64) follow-up over the 10 year period.ConclusionsThe ISTV program in this single ED has been associated with substantial reductions in violence related presentations. This effect is most marked in presentations at the weekend, younger patients and in those who appear to be least seriously injured.
4 The risk of deterioration in CT identified mild traumatic brain injury: a systematic review and meta-analysis
Authors: Marincowitz Carl , Lecky Fiona , Townend William , Borakati Aditya , Sheldon Trevor 
Published: November 2017

BackgroundThe optimal management of minor head injured patients with brain injury identified by CT imaging is unclear. Some guidelines recommend routine hospital admission of GCS13–15 patients with traumatic brain (TBI) injury identified by CT imaging. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED).ObjectiveTo estimate the risk of death, neurosurgery and clinical deterioration minor head injured patients with TBI identified by CT imaging, and assess which factors affect the risk of these outcomes.Figure 1Risk of neurosurgery stratified by the initial GCS of the study populationMethodsA systematic review and meta-analysis adhering to PRISMA standards of reporting. Four electronic data bases and a range of additional literature were searched using a highly sensitive search strategy. Study selection was performed by 2 independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks of: clinical deterioration, neurosurgery and death. Meta-regression was used to explore between study variation in outcome estimates using study characteristics. Factors assessed by individual studies as affecting the outcomes of interest were recorded and pooled within study risk factor effects were estimated where possible.Results4431 studies were identified by the search strategy, of which 123 studies were fully retrieved and 49 primary studies and 5 reviews met the inclusion criteria. The estimated pooled risk of the outcomes of interest were: clinical deterioration 11.7% (95% CI:11.7 to 15.8; neurosurgery 3.5% (95% CI:2.2% to 4.9%); death 1.4% (95% CI:0.8% to 2.2%). A large degree of between study variation in the estimates of the outcomes was identified. Multivariable meta-regression of study characteristics identified that mean age of the study population and mean initial GCS accounted for up to half of the variation in reported study outcomes. Within studies the following factors were found to affect the risk for these adverse outcomes: age; severity of injury; type of injury; initial GCS; anti-coagulation; anti-platelet medication; and injury severity scoring. When univariable within study risk factor effect estimates were pooled patients with isolated subarachnoid haemorrhage had an odds ratio of 0.19 for deterioration compared to other injury types.Figure 2Meta-regression of study factors predictive of neurosurgeryConclusionMinor head injured patients with brain injury identified by CT imaging have a clinically important risk of serious adverse outcomes. Research has identified the possible factors that affect this risk. However, these factors need to be incorporated into a validated multivariable prognostic model before low-risk patients can be reliably identified clinically and triaged to lower levels of care.Figure 3PRISMA flow-diagram showing selection of studies for inclusion in the systematic review
40 ED crowding: the acceptability of dysfunction
Authors: Kavanagh Karl , Shields Darragh , Staunton Paul 
Published: November 2017

BackgroundCrowding in the Emergency Department is internationally recognised as one of the greatest challenges to healthcare provision. Numerous studies have highlighted the ill-effects of crowding, including increased length of stay, mortality and cost per admission. Crowding is typically a manifestation of a hospital at full capacity and its main contributor is the practice of boarding patients in the ED. Therefore, a functioning flow system is advised to ease the burden. Different predictive tools/algorithms assess the degree of crowding. The National Emergency Department Overcrowding Scale (NEDOCS) is used effectively in other countries but has not been validated in Ireland.AimsTo assess crowding in a major Irish teaching hospital over a three week period at regular time periods using the NEDOCS.To look at the time from decision to admit to ward bed availability in order to improve flow through the department.Staffs perception of crowding was assessed at a random single time point.MethodsApplication of the NEDOCS score in the Emergency Department along with the use of internal Patient Administration System (PAS) to track patient movement through the ED.ResultsDuring the three week period, the NEDOCS score was frequently at level 6 (dangerously overcrowded) or level 5 (severely overcrowded) (see figure 1). Emergency patient registrations peaked between 1000 hours to 1300 hours whereas the peak admission time to wards was between 1900 hours and 2300 hours. At a random time point, Universal staff perception of crowding in the department was perceived as ‘It’s a nice day’. However the NEDOCS level was 4 (overcrowded) suggesting significant crowding.Figure 1Figure 2Average reception activity per 24 hourConclusionOur Hospital is operating at a consistent level of crowding that can negatively impact on patients. Access to inpatient beds is available late in the day, creating a time lag between decision to admit and transfer to ward. Staff perception did not correlate with NEDOCs score, possibly reflecting a conditioning and acceptance of staff to crowding.DiscussionWe plan to validate the NEDOCS score in an Irish Emergency Department. Crowding is a significant issue in the Irish Healthcare setting. The ‘40% of inpatient beds by 11 am’ needs to be adopted by our hospital. Our study suggests that our emergency staff accept the dysfunctional as the norm.
41 Simultaneous trauma patients in emergency department’s: a difference in mortality?
Authors: Morrow Laura , Nutbeam Tim 
Published: November 2017

BackgroundThe presentation of multiple simultaneous trauma patients in an Emergency Department, is likely to place significant stress and strain on trauma care resources. Currently there is limited data available to understand the impact simultaneous trauma demands on patient outcomes. For the purposes of this project we define simultaneous trauma as occurring when there is more than one TARN qualifying major trauma patient within an Emergency Department at any one time. We hypothesise that with increasing numbers of simultaneous trauma patients a relative increase in mortality will be seen.MethodsData was obtained from the Trauma Audit and Research Network for calendar years 2010–2015 on TARN qualifying trauma patients presenting directly to Emergency Departments. Simultaneous patients were identified and the data was categorised by total number of TARN qualifying patients within the Emergency Department (range 2–6). Patient characteristics were obtained which included sex, age, Glasgow Coma Score and Injury Severity Score (ISS). A standardised comparison using a stratified W statistic (Ws) was conducted to assess mortality and the Charlson co-morbidity score was used to assess morbidity outcomes.ResultsResults were obtained for 2 07 094 of which 66 734 (33.7%) patients were eligible simultaneous patients.The distribution of simultaneous patients was 2 patients, 24.9% (51,466), 3 patients, 6.7% (13,820), 4 patients, 1.7% (3,539), 5 patients, 0.3% (671), and 6 patients, 0.01% (185). The median age was 61 (IQR 39.5–80.3), 55.7% of patients were male, median ISS score was 9 (IQR 9–16) and median GCS was 15 (IQR 15–15)Isolated and simultaneous patients, regardless of number of patients, showed no difference in W statistic.The average mortality for all patients was 7.2% (range 6.5%–7.6%).ConclusionThe impact of simultaneous trauma patients on patient outcomes within the UK has not been previously defined. Simultaneous trauma patients do not appear to have an impact on overall mortality rate.Table 1Further work planned will understand the impact of multiple trauma patients on length of stay and time to CT/operating theatre.
42 Assessing factors affecting the quality of chest compressions during training for laypersons using a novel CPRCARD
Authors: Sim Zariel , White Alexander Elgin , Wah Win , Ready Steven MJ , Mohd Jalil Nurul Asyikin , Ng Han Xian , Ong Marcus EH 
Published: November 2017

ObjectiveThe quality of cardiopulmonary resuscitation (CPR) has been shown to affect the survival of out-of-hospital cardiac arrest cases (OHCA). There are various individual factors that can affect the quality of chest compression. We aimed to determine if age, gender and physical attributes (height, weight and BMI) affected the quality of chest compressions administered by laypersons during training.Design and methodsThe CPRcard™is a novel device that captures and provides real-time visual feedback on chest compression quality through a 2 metre display. We analysed data from our layperson CPR and AED training sessions from October 2015 to November 2015. Measurement parameters were adequate depth, adequate rate and flow fraction. Adequate depth was the percentage of total chest compressions with depth 5 cm. Adequate rate was the percentage of compression with rate between 100–120 chest compressions per minute. Flow fraction is the percentage of time chest compressions were performed without more than a 3 s pause. An adequate flow fraction target was >80%.Results77 participant’s data were analysed. 35% were male and 65% were female, with majority (34%) being 35–44 years old. The mean height was 1.63 m±0.10 m, mean weight 61.4 kg ±14.0 kg and mean BMI 23±4 kg/m2. Median adequate rate decreased significantly with age (p value=0.02). Median adequate depth and flow time showed no association with age (p=0.56, p=0.46 respectively). Males managed a significantly better median adequate depth (82.0% vs 56.0%, p value=0.01). There was no significant difference in chest compression quality with height, weight and BMI.ConclusionsOverall, at least 1 parameter of chest compression quality decreased with age, and was better in males than females. A possible application of these results is to have differences in training methods for different ages and sexes, targeting parameters that they are weaker at.