bluuebunny/crossref_metadata_2025_split huggingface dataset:
THE SHOCKING TRUTH—TIME BETWEEN DEFIBRILLATION ATTEMPTS DURING PRE-HOSPITAL RESUSCITATION OF VF CARDIAC ARREST
Authors: Mitchell Kirsty , Short Steven , Clegg Gareth 
Published: August 2014

Objectives & BackgroundTimely defibrillation and high-quality cardiopulmonary resuscitation (CPR) are the only pre-hospital interventions which have been demonstrated to save lives after OHCA (out-of-hospital cardiac arrest). Standard resuscitation using the advanced life support (ALS) algorithm specifies a period of two minutes of CPR after delivering a shock before re-assessing the rhythm and delivering a further shock if indicated. Recent work has focused on improving quality of CPR, but few studies have examined how effectively defibrillation is carried out in pre-hospital practice. This study aims to assess the timing of shocks during resuscitation after OHCA.MethodsDefibrillator (Philips MRX) data is routinely downloaded after all OHCA in Edinburgh as part of routine audit. We analysed a consecutive series of arrests 1-April-2013 and 31-March-2014. Only arrests where >1 consecutive shocks were delivered were included, in order to allow inter-shock intervals to be calculated. Event Review Pro software (Philips) was used to visualise ECG and CPR data, to determine time between shocks with no interrupting period of non-shockable rhythm. Inter-shock intervals between 2:00 min and 2:30 min were deemed compliant with ALS guidelines.ResultsThere were 189 cardiac arrests in the study period, with 70 cases eligible for inclusion. Mean time between shocks was 3:06 min (0:15 min–18:23 min, SD 1:54 min). 53% of inter-shock intervals were >2:30 min and 21% were <2:00 min. Only 26% of intervals were compliant with ALS guidelines. Figure 1 shows a scatter plot of the inter-shock intervals for each OHCA resuscitation episode. The red bar indicates the 'compliant' zone of 2:00–2:30 min.ConclusionThe majority of intervals between shocks delivered in out-of-hospital cardiac arrest were non-compliant with current ALS guidelines. Whilst the underlying reasons for this finding remain unclear, the extreme outliers appeared to be related to transporting the patient from the scene of the arrest. It was still the case, however, that the majority of defibrillation attempts were delivered either earlier than 2 min or later than 2:30 min, which may reflect a loss of situational awareness in the distracting environment of an OHCA resuscitation. Further work needs to be done to establish the cause of this deviation from recommended shock timing in order to develop strategies to optimise practice.
WHAT IS THE ROLE OF ADVANCED NURSE PRACTITIONERS (ANPs) IN A MAJOR TRAUMA TEAM (MTT)?
Authors: Adkins Charlotte V , Trivedy Chetan , Stanhope Benjamin 
Published: August 2014

Objectives & BackgroundANPs are autonomous practitioners and form a core part of many Emergency Departments (EDs). However, there is little data on their role in major trauma and deployment within MTTs. The project aimed to explore clinicians' views on the role of ANPs within MTTs in Major Trauma Centres (MTCs).MethodsA two-part project using an anonymised questionnaire was designed to explore attitudes towards the role of ANPs as part of the MTT. Part one was distributed to members of the MTT at an MTC in the West Midlands (the author's workplace); using an online survey tool, part two was sent to the clinical leads of all 26 MTCs in England. Resultant data includes current national use of ANPs in MTTs, reasons for inclusion/exclusion, and understanding, attitudes and opinions regarding their involvement.ResultsAt the author's workplace, 93% of responses felt that ANPs should form part of an MTT (remaining 7% unsure). Data suggests that there is a lack of understanding of the ANP role (45% stating they fully understand the role, 55% partially) and of ANP training in regard to managing major trauma, with resultant uncertainty regarding abilities. 76% feel ANPs should have a role in clinical assessment of patients, 68% that they should have a role in breathing interventions (ie manual ventilation) and 90% circulatory interventions (cannulation/pelvic splint application). 85% of national MTCs responded; 81% of these have ANPs in their ED but only 11% utilise ANPs as a core MTT member. Where ANPs are part of the MTT, their roles tend to be in line with normal nursing roles (ie circulatory interventions 100%, drug preparation/administration 50%). Only 50% of respondents utilised ANPs for clinical assessment, part of their day-to-day role. 13% felt that ANPs do not have a role in MTTs. Barriers to ANP involvement include rota capacity (35%), clinical competence (25%), training priorities (22%), supervision (16%), ANP training (52%), ability (68%) and skills (36%).ConclusionThe project data shows that, although ANPs are now part of many ED teams and are increasingly taking on extended autonomous ED roles, there is still a level of uncertainty and lack of clarity on their role as part of an MTT. There needs to be a national policy outlining and standardising ANP training, qualification and utilisation within the ED as well as a robust programme to promote their education, training and skills, to optimise their deployment.
ADHERENCE TO THE NICE HEAD INJURY GUIDELINES 2007 AND 2014 IN ANTICOAGULATED PATIENTS
Authors: Kuczawski Maxine , Mason Suzanne , Stevenson Matt , Holmes Michael , Teare Marion D , Ramlakhan Shammi , Goodacre Steve , Morris Francis , Harper Rosemary 
Published: August 2014

Objectives & BackgroundUntil January 2014, The National Institute of Clinical Excellence (NICE) Head Injury Guidelines (CG56) issued to clinicians advised anticoagulated patients with a head injury should only receive CT imaging if loss of consciousness or amnesia was experienced. These guidelines have recently been updated to advise CT imaging for all anticoagulated patients. We aimed to investigate how closely the 2007 guidelines were followed and whether the guideline update will mean considerable changes to existing practice.MethodsData was analysed from the AHEAD Study, a large prospective observational multicentre study involving 33 emergency departments in England and Scotland. Within the cohort of anticoagulated patients, those that complied with the NICE guidelines (2007 and 2014) were identified and categorised into 3 groups depending on the NICE CT imaging advice a) <1 hr, b) <8 hrs and c) all patients. The symptoms, treatment and outcomes of these patients were described and compared with actual clinical practice.ResultsApplying NICE 2007 criteria to the 3534 patients, 779 (22%) patients were identified as eligible candidates for CT imaging—within 1hr, 558 (72%) patients and within 8hrs, 221 (28%) patients. Of the eligible patients, 82% (n=641) actually did have a CT head scan of which 17% (n=111) had a significant head injury-related finding. Adherence in the time to CT was achieved for 16% within 1hr and 90% within 8hrs (Mean 285 and 243 minutes respectively). Neurosurgery was performed in 14 (1.8%) patients and 27 (3.5%) patients died of a head injury-related death. Of those patients that did not fulfil the NICE 2007 criteria (n=2755), 54% (n=1473) had CT imaging on average 431 minutes after ED attendance. A significant CT finding was found in 5.9% (n=87) patients, neurosurgery performed in 5 (0.2%) patients and 15 (0.5%) patients died of a head injury-related death. Applying the updated NICE 2014 advice which states all anticoagulated patients should receive CT imaging, found only 60% (n=2114) of this cohort received it.ConclusionThe majority of patients that fulfilled the NICE 2007 criteria did have CT imaging performed (82%). However, a significant number of patients not fulfilling the criteria also had CT imagining performed. Overall, 60% of the anticoagulated patient cohort had CT imaging, this will need to increase considerably to follow the updated NICE 2014 guidelines of CT imaging for all patients.
DO GP USER-FEES AFFECT A&E USAGE? GP CHARGES DRIVE A&E DEMAND, FOR RICHER, FOR POORER
Authors: Arun-Castro Sriskantharajah 
Published: August 2014

Objectives & BackgroundTo establish whether the need to pay for GP services including consultations, phlebotomy and referrals, affects how households utilise A&E in Jersey. To describe the reasons why households have previously utilised A&E instead of a GP.BackgroundOutside of the NHS, Jersey's primary healthcare service is funded through direct user-fees and co-payments, whilst secondary care including the island's sole Emergency Department is free. The average GP consultation in Jersey costs £37.50.MethodsA postal questionnaire survey exploring household health seeking behaviours was commissioned, designed and piloted following a user-led approach with the Jersey Consumer Council's Primary Care Users Group. A census design was applied to collect data from all households (41,595) during the month of July 2012. Inclusion criteria: All households in Jersey, one return per household. Exclusion Criteria: Incomplete/soiled questionnaires. Data were managed in SPSS, with a population-based weighting applied to maximise the representativeness of the sample.ResultsData were obtained from 6,508 households, reflecting a response rate of 16% (6508/41,595).One in three respondents (1934/5998; 32.2%) stated that their household had previously chosen to attend A&E instead of a GP practice. Primary care user-fees were the most commonly cited reason explaining this behaviour, reported by 43.9% of respondents (849/1934).Almost one in five households (1099/5950; 18.5%) stated that they had attended A&E for problems they self-reported as being “neither an accident nor emergency.” Both highest (>£104,000) and lowest (<£25,000) annual income groups contributed to this use of A&E. 17.5% (86/492) of high income households and 20.8% (412/1977) low income households reported using A&E for such non-urgent care.ConclusionThis study confirms that in Jersey, GP user-fees create cost-related demand for the Emergency Department.Willingness to pay for primary care does not reflect ability to pay in Jersey, evidenced by both high and low income groups reporting use of A&E for non-urgent problems.Further research is indicated to examine whether A&E cost-related demand would arise if GP user-fees were introduced in the NHS.
CIRCULATING LEUCINE-RICHα-2-GLYCOPROTEIN glycoprotein 1 TO DETECT ACUTE APPENDICITIS IN PATIENTS WITH ACUTE ABDOMINAL PAIN
Authors: Rainer Timothy H , Leung Ling Yan , Chan Pui Yee Cangel , Leung Yuk Ki , Lai Bo San Paul , Cheung Yue Sun , Graham Colin A 
Published: August 2014

Objectives & BackgroundCirculating leucine-rich α-2-glycoprotein-1 (LRG1) protein has been found in the plasma and urine of patients with acute appendicitis (AA) and may be useful for diagnosis. The present study aimed to investigate whether circulating LRGI mRNA levels also improve the early diagnosis of AA.MethodsA prospective study was conducted between December 2011 and October 2012 on patients presenting to the ED with acute abdominal pain (<7 days of symptom onset). AA was confirmed if there were histopathological findings of an inflammed or necrotic appendix in appendicectomy specimens. Real-time polymerase chain reaction was used to analyze whole blood LRG1 mRNA level taken from these patients within 24 hours of arrival (mean 12.4 h). The primary outcome was AA.ResultsEighty-four consecutive patients (40 (47.6%) with AA and 44 (52.4%) without AA; mean age 35 years; 41.6% males) were recruited. Median whole blood LRG1 mRNA levels were higher in AA patients than in non-AA patients (2.2 (95% CI 1.3–2.6) vs 1.3 (95% CI 0.8–1.8)×105copies/ml,p=0.0122). Of 40 AA patients, 13 (32.5%) were diagnosed as complicated AA, and had median LRG mRNA level higher than in patients with simple AA (3.2 (95% CI 2.2–4.1) vs 1.6 (95% CI 1.1–2.5)×105 copies/ml,p=0.0479). At a LRG1 mRNA cutoff of 1.9×105 copies/ml, the optimal sensitivity and specificity were 57.5% and 72.7% respectively. At this cutoff, the odds ratio for AA was 3.6 (95% CI 1.5–9.0;p=0.0047).ConclusionWhole blood LRG1 mRNA levels may be useful to diagnose simple and complicated AA from other causes of abdominal pain.AcknowledgementThis research study was supported by a Direct Grant for Research from the Chinese University of Hong Kong (reference no.: 2041642) (HK$18000).
FIX FREDDIE! – PULLING STRINGS TO REDUCE PRESSURE ON MINORS
Authors: Cleugh Francesca , Langseth Annette , Clements Charlotte , Salam Menai , Manfredi Lucia 
Published: August 2014

Objectives & BackgroundEmergency and urgent care workload is becoming unsustainable.1 2NW London has higher than average use of unscheduled care;3significant proportion with low acuity conditions.2 4 5As a paediatric emergency care provider, Imperial College Healthcare (ICHT) recognise a need to become proactive in tackling this challenge. ICHT collaborated with a professional puppet company to produce Fix Freddie!6A pilot tour ran in NW London March and April 2014. Objectives included:better understanding of how local community accesses unscheduled caregathering professionals across the whole system to support families in feeling confident to navigate system and care for their children's health needsreducing pressures on unscheduled care systemMethodsPilot tour explored different settings and workshop styles. Audience 484 children, 134 adults(image1)Parents and carers asked to complete pre show questionnaire about child health and services. After the show issues raised explored in various ways:small parent focus groupsclassroom-based discussionfete style event promoting conversations with professionalsFeedback obtained with Post-It comments on “Freddie Feedback” poster(image 2).Filmed to capture impact of events on children, parents, professionals.Leaflet distributed with information about how to seek advice, self management and local services.Results:Pre show questionnaireCompleted by 46 parents of 85 children. 53% white british; 47% diverse ethnicies.Chart A -How they seek child health advice(image 3)Chart B -Services use when worried(image 3)Parents consistently worried by fever: 52% would seek GP review 41% would go to ED.Attended ED and the GP with similar illnesses.26% reported issues in accessing care, primarily lack of same day GP appointments.Key themes surfaced from Fix Freddie! Feedback(image 4)Better understanding of local services, notably 111Improved confidence managing minor ailmentsPositive feedback for puppet show and eventsImmediate impact captured on film, currently being analysed. Short documentary being produced by June 2014.ConclusionFix Freddie! has provided a fun and engaging way to make connections across the whole system, facilitating co-design of local solutions to problems of healthcare accessibility and confidence in self management. Local CCG commissioners are keen to fund a wider local tour and we are looking at next steps to broaden the reach of events.
STAFF PERCEPTIONS OF THE IMPACT OF OVERNIGHT RESIDENT PED CONSULTANTS ON PATIENT CARE AND TRAINING
Authors: Doubal Kim , Hore Carolyn , Ross James 
Published: August 2014

Objectives & BackgroundEM and Paediatrics are specialties at the forefront of the move towards 24/7 consultant delivered care. This shift has been partly driven in EM by trauma pathways, as well as aiming to provide better patient care, and to support training.Chelsea and Westminster Paediatric ED sees around 34,000 children a year. It is not a major trauma centre. In May 2013, 6 consultant paediatricians were appointed to be resident in PED at night. This study evaluates the PED team's perceptions of the impact of this change on the quality of clinical care, training and job satisfaction, and of trainee's views of undertaking a similar role in the future.MethodsAn online questionnaire was sent to all nursing staff and junior doctors (ST1-ST8) working in PED, in May 2014. Questions were answered on a 5 point Likert scale, with scope for free text responses, and role specific questions for both nursing and medical staff.Results26/35 (75%) of staff responded (42% medical/58% nursing staff). 72% of respondents preferred working with resident consultants.Clinical Care100% of trainees and 80% of nurses felt the quality of care was improved at night. 90% felt it improved the management of a resuscitation, and 100% felt it was easier to discuss safeguarding concerns.Training & SupervisionTrainees felt it improved their supervision in practical procedures (70%), increased their opportunity to complete WBPAs (80%), and increased the number of learning opportunities (70%). Registrars were concerned that opportunities for leadership and management experience were reduced.Nursing staff87% believed decision making was faster, 73% felt children spent less time in the department and 80% felt waiting times were reduced.PerceptionsOnly 30% of trainees would like to work as a resident consultant in the future. 90% believed that resident on call working should be time limited.ConclusionPED staff at C&W have welcomed the move to 24/7 consultant delivered care. The core aims – to improve the efficiency and proficiency of patient care, and to better utilise out of hours working as a training opportunity – are being achieved. Concerns remain about disempowerment of senior trainees and the perceived impact of night shifts in a consultant role on work-life balance. To sustain this model, trainees must be convinced of the benefits of becoming a resident consultant upon their own career.
WHAT'S COMING THROUGH THE FRONT DOOR? PAEDIATRIC AND ADOLESCENT GYNAECOLOGY IN THE EMERGENCY DEPARTMENT
Authors: Westwood Kirsty , Irani Shirin 
Published: August 2014

Objectives & BackgroundPaediatric gynaecology can provide challenging and varied consultations in the emergency department setting. Although the first international journal and society were established in the late 1980's, no specific UK guidelines have been published for the care of children and teenagers in this specialty. Moreover, limited published data is available regarding the types of cases presenting at the “front door”. This study aimed to investigate the scope of paediatric and adolescent gynaecological problems presenting to the emergency department of a UK children's hospital.MethodsA retrospective review of all gynaecological emergency department presentations at Birmingham Children's Hospital from 1stDecember 2012 to 30thNovember 2013.ResultsThe casualty cards for seventy patients were reviewed individually with ages ranging from 4 days to 15 years old. A spectrum of 16 different diagnoses was found, with the majority relating to vulvovaginitis (46%) and menstrual disorders (20%). The most common presenting complaints were equally divided between vaginal bleeding (21%) and vaginal pain (21%). Patients were mainly treated medically (40%), whereas nearly a third received advice (30%) and a quarter did not receive any treatment (26%). Over 95% of cases were discharged home from the emergency department; the majority of those (63%) needing further follow-up.ConclusionThe study demonstrates the wide variety of paediatric gynaecology cases that present to the emergency department, nearly two thirds of which require ongoing care. This exhibits a need for both national guidance and appropriate training for front line medical staff covering the common gynaecological problems found in children.
THE TRANSITION TO EXPERT: A QUALITATIVE STUDY EXPLORING CLINICAL DECISION MAKING FOR CHILDREN UNDER FIVE ATTENDING THE EMERGENCY DEPARTMENT WITH MINOR RESPIRATORY CONDITIONS
Authors: Bowen Leah , Purdy Sarah , Lyttle Mark D , Heawood Alison 
Published: August 2014

Objectives & BackgroundUnplanned paediatric admissions are increasing for young children and infants experiencing respiratory illnesses. Many admissions are short-stay events, typically lasting less than 48 hrs. The short duration of these admissions could indicate that minor conditions are responsible for many of these events, and could consequently be targets for management by primary care teams.The purpose of this exploratory qualitative research is to understand more about admissions in young children attending the emergency department of a Children's hospital in the UK, with the aim of collaboratively identifying interventions to reduce admissions for minor respiratory conditions. The findings presented here will focus on the theme of clinical decision making by staff in this setting.MethodsSemi-structured interview discussions were conducted with 15 emergency clinical staff with varying levels of experience in paediatrics and/or emergency medicine.Participants considered two clinical cases where they had been responsible for the care of a child presenting to the department with a minor respiratory complaint. These reflective cases facilitated discussion around the decision making process and treatment approach taken during the clinical situation.Interviews were audio-recorded and transcribed verbatim. Themes from the data were extracted and collated using thematic analysis.ResultsThere were clear differences in the approach to decision making taken by experienced clinicians and their junior colleagues. Clinicians with less experience relied heavily on guidelines, admission criteria, clinical theory and second opinions from seniors in order to achieve safe clinical decisions. The ‘informal' learning process was significant among junior staff, where tacit knowledge, clinical intuition and risk tolerance were developed.In direct contrast, senior clinicians used a high level of intuition, tacit knowledge and clinical experience to effectively manage risk to achieve a clinical decision.ConclusionThis research will interest educators and trainers operating in emergency paediatric settings. The emergence of 'informal learning', its acquisition and role in clinical decision making has implications in the development of training programmes for clinicians working in emergency paediatrics.