bluuebunny/crossref_metadata_2025_split huggingface dataset:
28 Are we measuring what we think we are measuring? Qualitative research exploring the role of the 0–10 pain score within the adult emergency department
Authors: Sampson Fiona , O’cathain Alicia , Goodacre Steve 
Published: November 2017

Objectives and backgroundThe assessment of pain in the emergency department (ED) is difficult but important for appropriate management of pain. Guidelines for the management of acute pain in the ED worldwide advocate using numeric rating scales such as the 0–10 pain score as tools to ensure consistency of documenting patient’s pain, and this is mandated at initial assessment in many EDs. Studies of interventions to improve pain management in the ED indicate that whilst the inclusion of mandatory pain scoring within interventions may improve documentation of pain, there was mixed evidence as to whether this resulted in improvements in provision of analgesia. As part of a wider study looking at barriers and enablers to pain management in the ED, we explored how pain scoring was used in the ED.MethodsQualitative data were collected within 3 case study EDs in the UK. Data comprised 143 hours of non-participant observation, 37 ED staff interviews and 19 patient interviews. Data were analysed using thematic analysis.ResultsObservation showed variation in how the pain score was documented between EDs. Some staff documented the score directly reported by the patient, whilst others documented a score they formulated using a combination of physiological signs, behavioural signs and presence of a ‘known’ painful condition. ED staff appeared to understand the score as an absolute measure used to guide analgesia requirements or triage categories rather than a relative measure used to document changes in pain levels. Even when documenting patient reported scores, they perceived patient reported scores to be inconsistent with their own assessment of the patients pain level, particularly where this could lead to patients being managed under a higher triage category or receiving stronger analgesia than ED staff considered appropriate. Staff documented pain scores that were appropriate for the treatment they planned to provide, rather than the scores reported by the patient, in particular when the pain score was used as a tool for auditing appropriate pain management.ConclusionsThe pain score appeared to have parallel but misaligned roles: to assess patient pain and ED staff practice. ED staff faced conflict between the need to record pain to ensure accountability of pain management, and recording pain to reflect the patient’s report. The role of the pain score needs to be reviewed in order for pain scoring to improve the patient experience of pain management in the ED.
29 Has the licensing ACT 2003 affected levels of violence in England and Wales? A systematic review of hospital and police studies
Authors: Callan Caitríona , Boyle Adrian 
Published: November 2017

BackgroundPopulation-level legislation has been implemented in many countries to try and address alcohol misuse and related harms, including assault. Most violent incidents in the UK are alcohol-related, with alcohol misuse accounting for a substantial proportion of Accident and Emergency Department attendances. The Licensing Act 2003 aimed to reduce alcohol-related crime and disorder by abolishing set closing times and giving local authorities control over premises licensing in England and Wales. Concerns were raised, however, that greater availability of alcohol would lead to increased consumption and violence. This review examines primary research from hospital and police settings to evaluate whether the implementation of the Act in 2005 reduced or increased violence rates in England and Wales.MethodsWe performed an inclusive systematic review of the major biomedical databases. We included original research that evaluated changes in violence rates before and after the implementation of the Licensing Act, including hospital- and police- defined measures for this primary outcome. Our secondary outcome was whether there was change in temporal distribution of violent incidents after implementation of the Act.ResultsWe identified 184 studies. 15 studies were included. The evidence was of overall poor quality, with the majority of included studies being uncontrolled before-after studies. 8 of these studies were conducted in the hospital setting, and 7 were from the police setting. Overall, 7 studies found reduced violence rates after implementation of the Licensing Act, 3 found increased rates, and 5 found no significant change. A subset of 9 papers analysed temporal distribution of violent incidents, 8 finding evidence of temporal displacement of assaults further into the early hours of the morning.ConclusionThis is the most complete analysis to date of the effects of the Licensing Act on violence. There is no evidence for the Act having a significant or consistent effect on community violence rates, either in emergency departments or policing. There is consistent evidence from both hospital and police settings of a proportional increase in late-night violence since the implementation of the Act.
34 A systematic literature review of the pre-hospital lessons identified following mass casualty deliberate bombing incidents
Authors: Cooke Thomas , Chesters Adam , Grier Gareth 
Published: November 2017

BackgroundSince the end of World War II, there has been an emergence of explosives used amongst civilian populations resulting in mass-casualty incidents. The development of pre-hospital medical systems, worldwide, has resulted in an increased response at these incidents. However, information about the pre-hospital medical response is sparse and not collated. This review aimed to collect and appraise the literature on the pre-hospital management of mass-casualty bombing incidents. The primary objective was to identify and discuss the common themes highlighted as problems in the pre-hospital medical response. The secondary objectives reviewed the injury patterns in victims and psychological impacts on pre-hospital responders.MethodsA systematic literature search on the PubMed, SCOPUS and Web of Science databases took place. It included literature published from the 1 st of January 2000 to April 3rd 2017, with the last search performed on April 3rd 2017. Literature was included if it offered description, analysis, reflection or review of the bombing incidents.Figure 1The minimum number of recorded deaths and injuries from 11 deliberate mass casualty bombing incidents (note: two simultaneous marauding terrorist firearm attack and bombing incidents excluded)Figure 2Percentage of included literature identifying the following themes as problems in the pre-hospitals medical responseResults1345 articles were found, with 54 included in analysis. 13 mass-casualty bombing incidents were described. Two of these included marauding terrorist firearm attacks (MTFA). In the 11 bombing-only incidents the death of 592–642 people and injury of 3,842–5229 more is described, with a further 301 deaths and 604 injuries from bombings with MTFA attacks. Quality appraisal showed a variation in reporting among incidents and a lack of uniform reporting.ConclusionsFunctioning and reliable communication, alongside regular training exercises with other emergency services, is important in the pre-hospital response. This is aided through accurate triage, in a safe area, to ensure even casualty distribution. A visible and established command and control enables scenes to be led effectively. Access to suitable and adequate supplies of equipment fosters improvement in patient outcomes. Awareness of secondary devices, as well as chemical, radiological and nuclear exposure, is vital in ensuring responder safety. A variety of injury patterns was found. Finally, psychological complications and support systems amongst pre-hospital responders varied.
36 Frailty flying squad: an emergency department focussed acute care of the elderly service DR genevieve robson, royal united hospital NHS foundation trust
Authors: Ballham Samantha , Buxton Scott , Camacho Rosa , Sinclair Adrianna , Dyer Chris , Jakeman Nicola 
Published: November 2017

IntroductionThe over 75 s make up 20% of our ED attendances. The greatest increase has been in the over 85 s. This very elderly cohort are more likely to be frail and are 10X more likely to require admission than 20–40 year olds and once in hospital have longer stays. There is evidence that multidisciplinary care and early Comprehensive Geriatric Assessment (CGA) improves outcomes for older patients, reducing readmissions, long term care, greater satisfaction and lower costs. The aim of this project was to improve the acute care provided to our older patients at the Front Door of the hospital.Methodology3 month pilot project underpinned by Big Room Quality Improvement methodology. The Frailty Big Room meets weekly and includes input from clinicians, QI experts and a data analyst. This project was driven by the following aims:Frailty Flying Squad to see as many older±frail patients referred for admission as close to the front door as possible.CGA at the front door with discharge planning from first reviewMDT approachExpedited discharge or transfer to other services from ED.Review following day to make sure management plans being followed through or discharge without ward teams having to become involved.Frailty Flying Squad Team:2 Medical Nurse PractitionersPhysiotherapistConsultant geriatricianKey Performance Indicators:Length of StayReadmission within 30 days of initial reviewResults355 patients were seen. 168 (47%) of patients were over 85 and the median Rockwood frailty score for the whole cohort was 6. 209 patients were ED referrals and 85 were GP referrals for admission. 237 (67%) patients were seen in ED, 49 in MAU and 7 in ED obs. During the pilot period, 97 patients who had been referred for admission were discharged direct from ED. 56 (16%) of patients had zero length of stay. A low number (9.4%) of patients were readmitted within 30 days.Figure 1LOSFigure 2Length of stay for the > 85s 2016 and 2017 comparedConclusionA multidisciplinary Acute Care of the Elderly Team predominantly based in the Emergency department can provide effective early Comprehensive Geriatric Assessment; facilitating discharge home from the Emergency Department, reducing length of stay for those admitted and reducing readmission rates within 30 days.
38 A comparison of two interventions in the treatment of severe ankle sprains and distal fibular avulsion fractures: a patient perspective
Authors: Powell Sarah 
Published: November 2017

Stable ankle injuries are highly prevalent in Emergency Departments across the UK. Appropriate management to enable patients to experience a smooth recovery and prevent chronic ankle instability or reoccurrence is a priority. Current literature states that stable ankle fractures and severe ankle sprains can be successfully managed with the below knee plaster or the aircast brace and crutches. The functional brace has proved to be clinically effective in several reports. There has however, been no research to measure patient satisfaction levels between these two treatments.An experimental, mixed method approach to the researching of this issue was performed in a busy, central London Emergency Department; a randomised controlled trial undertaken to compare the two devices and quantitative and qualitative data collection by means of a tailored questionnaire to determine patient satisfaction. Thirty nine patients were recruited during hospital attendance over 9 months. Patients were requested to complete the questionnaire 7 days into their treatment via post; stamped addressed envelopes were provided. Telephone interview was adopted as a secondary measure when postal responses failed. The primary outcome measured was patient satisfaction levels regarding comfort of the device, pain relief, daily activities, sleep, work, care of dependents and social life measured by use of a likert scale; ranging from very unsatisfactory to very satisfactory. The null hypothesis is that there is no significant difference in satisfaction levels between the two devices. Data was analysed using the unrelated t test.31 responses were obtained; 16 participants with avulsion fractures to the distal fibular and 15 severe ankle sprains, 16 allocated to the ankle brace and 15 to the plaster. The findings demonstrate that there were statistically significant higher patient satisfaction levels in patients treated with an aircast brace than with the plaster cast. Using a probability level of 0.01, the critical value was 2.756, the t value 4.996; therefore the null hypothesis was rejected. The main indicators contributing to these findings were in the levels of comfort, daily activities, sleep work and social life. Overall it appears that patients preferred treatment with the aircast brace. Both forms of treatment were clinically equally effective in this study.Evidence indicates that our current department guidelines may need to be re-evaluated. In addition, this a study focused on patient-centred care. The questionnaire developed, could potentially be used to measure patient satisfaction in other fields.
5 A study analysing the diagnostic performance of ECG interpretation for 30-day major cardiac events in the emergency department
Authors: Morris Niall , Body Rick 
Published: November 2017

Study objectiveThis study evaluates the diagnostic accuracy of an Emergency Medicine (EM) clinician at identifying ischaemia on an ECG using 30-day major adverse cardiac events (MACE) as the primary outcome.MethodsThis is a secondary analysis of a prospective, multi-centre, observational cohort at 14 centres: the Bedside Evaluation of Sensitive Troponin study. All fourteen Emergency Departments were based in the United Kingdom. Emergency physicians’ assessments of the ECG were collected using a standardised form. Clinicians were asked to judge whether the ECG demonstrated ischaemia, the presence of ST depression (STD) and if there was abnormal T wave inversion (ATWI). Patients provided written informed consent and underwent serial high sensitivity troponin testing. 30 day follow-up was performed by research nurses using a standardised form via telephone. The primary outcome was 30-day major adverse cardiac events, defined as acute myocardial infarction, any cause of death and coronary revascularisation.ResultsIn total, 756 patients were included in the analysis. Clinicians’ ECG diagnosis of ischaemia for 30-day MACE: ECG ischaemia produces a sensitivity (Sn) of 19.54% (95% CI:11.81% to 29.43%), specificity (Sp) of 93.27% (95% CI:91.10% to 95.05%), positive predictive value (PPV) of 27.42% (95% CI:18.47% to 38.65%) and negative predictive value (NPV) of 89.91% (95%CI 88.92% to 90.83%). ECG ST depression produces Sn of 16.09% (9.09% to 25.52%), Sp of 89.69% (87.13% to 91.89%), PPV 16.87 (10.68% to 25.62%), and NPV 89.15% (88.19% to 90.04%). ECG ATWI produces Sn of 4.60% (1.27% to 11.36%), Sp of 91.63% (89.27% to 93.62%), PPV of 6.67% (2.59% to 16.12%) and NPV of 88.07% (87.52% to 88.6).ConclusionThis is the first prospective, multi-centre cohort study, that assess the diagnostic performance of EM clinician’s ECG interpretation, with 30-day MACE as the primary outcome. The findings are highly relevant to EM as they represent the ECG terms used by popular acute coronary syndrome clinical decision rules. In this study a clinician’s overall judgement of ischaemia has a better diagnostic performance compared to simple STD and ATWI. This may be due to an appreciation of morphology and the amount of deviation; future work should explore the effect of measuring deviation and analysing morphology.
50 How can informal support impact child PTSD symptoms following a psychological trauma?
Authors: Halligan Sarah 
Published: November 2017

BackgroundAn estimated 20% of children who present to hospital emergency departments following potentially traumatic events (e.g., serious injuries, road traffic accidents, assaults) will develop post-traumatic stress disorder as a consequence. The development of PTSD can have a substantial impact on a child’s developmental trajectory, including their emotional, social and educational wellbeing. Despite this, only a small proportion will access mental health services, with the majority relying on informal sources of support. Parents, in particular, are often the primary source of support. However, it remains unclear what types of parental responses may be effective, and parents themselves report experiencing uncertainty about the best approach. To address this gap in knowledge, we examined the capacity for specific aspects of parental responding in the aftermath of child trauma to facilitate or hinder children’s psychological recovery.MethodWe conducted a longitudinal study of 132 parent-child pairs, recruited following the child’s experience of trauma and subsequent attendance at one of four regional emergency departments. At an initial assessment, within 1 month post-trauma, we examined how parents appraised and responded to their child following the event, using both questionnaires and direct observations. Child-report questionnaires were used to assess PTSD symptom severity at 1 month, and at a follow up 6 months later. Children also reported on their own appraisals of the trauma and their coping behaviours, which were considered as potential mediators between parental support and later child symptoms.ResultsControlling for relevant covariates and initial PTSD symptoms, parent negative appraisals of the trauma and encouragement of avoidant coping in children were associated with higher child-reported PTSD symptoms at 6 month follow-up. There was some evidence that children’s own trauma related appraisals and coping styles mediated these effects.ConclusionFindings indicate that children’s social support can influence their post-trauma psychological outcomes. That parenting was associated with 6 month PTSD, even after controlling for the child’s initial symptoms, suggests that parenting responses in the posttrauma period actively influence the child’s poorer longer-term adjustment, rather than simply being a response to the child’s initial distress. The results suggest that helping parents to provide fewer negative appraisals about the trauma/their child’s response, and to encourage more adaptive coping styles, could be effective in improving child psychological outcomes. As emergency departments provide primary care and support for families affected by trauma, they could play an important role in making this advice available to parents.
54 Paediatric traumatic cardiac arrest in England and Wales a 10 year epidemiological study
Authors: Vassallo James , Webster Melanie , Barnard Edward , Iniguez Marisol Fragoso , Lyttle Mark , Smith Jason 
Published: November 2017

IntroductionTraumatic cardiac arrest (TCA) has traditionally been described as futile, with poor outcomes. Reported survival rates vary widely, with higher rates observed from mechanisms leading to a respiratory cause of traumatic cardiac arrest (e.g., drowning and hanging). Currently there is little evidence regarding outcomes following TCA in children. The primary aim of our study was to describe 30 day survival following TCA. Secondary aims were to provide an analysis of injury patterns (severe haemorrhage or traumatic brain injury), describe the functional outcome at discharge and to report the association between survival and interventions performed.MethodsUsing the Trauma Audit and Research Network (TARN) database, we conducted a population-based analysis of all paediatric (<18 years) trauma patients presenting to hospitals in England and Wales between 2006–2015. Patients with TCA in the pre-hospital setting and/or in the Emergency Department were included. Those without a GCS entry were excluded. Basic demographics are reported as number (%) and median (interquartile range), as appropriate. Survival odds ratios (95%CIs) and Chi Square tests were used during statistical analysis.ResultsDuring the study period, 21 710 paediatric patients were included in the database with 129 (0.6%) sustaining traumatic cardiac arrest and meeting study inclusion criteria (1.3%). The majority had a pre-hospital traumatic cardiac arrest (103 (79.8%)). Overall, 62.8% were male, aged 11.7 years (3.4–16.6), ISS 34 (25–45) and 110 (85.3%) had blunt injuries with road-traffic collision the most common mechanism (56.6%). 123 (95.3%) had severe haemorrhage and/or traumatic brain injury.Table 1Table 2Table 3Overall survival was 5.4% (95% CI:2.6 to 10.8) with 7 cases surviving to 30 days. ‘Pre-hospital only’ traumatic cardiac arrest (13.0%) had a significantly higher survival than ‘pre-hospital and Emergency Department’ traumatic cardiac arrest (1.8%), (p=0.04). Those with injuries to the thorax predominated the severe haemorrhage group (67.6%). There were no survivors from ‘Emergency Department only’ traumatic cardiac arrest. Treatment at a major trauma centre was associated with a statistically significant increase in survival (p=0.02). There was no difference in survival between different times of day of presentation. Of those with Glasgow Outcome Scale recorded at discharge (n=6), four (66.7%) had either a moderate disability or good functional outcome.ConclusionAlthough a rare event, this study has demonstrated that resuscitation of children in traumatic cardiac arrest is not futile with overall outcomes comparable to survival rates seen in adults. Survival from pre-hospital traumatic cardiac arrest is possible and the early identification and aggressive management of these patients is advocated.