bluuebunny/crossref_metadata_2025_split huggingface dataset:
THE VALUE OF ADMITTING PATIENTS FOLLOWING A POSITIVE MYOGLOBIN USING A RAPID POINT OF CARE TRIPLE CARDIAC PANEL TEST
Authors: Coates J , Walker C 
Published: September 2013

Objectives & BackgroundAdmissions to the Emergency Department with chest pain constitute a significant proportion of the work-load. In England it represents 6% of all Emergency Department (ED) attendances. These attendances translate to accounting for approximately 25% of acute medical admissions. One method of excluding myocardial infarction is the use of a rapid point of care Triple Cardiac Marker test. This allows testing at time point 0 and 90 minutes and negates the need for a delayed troponin. One of the markers, myoglobin, has a high sensitivity but low specificity. If there is a 25% rise in myoglobin between two tests then it is considered a positive result. The patient then requires a 12-hour troponin. Locally, there was concern over the value of including myoglobin in the triple test as it was felt that it lead to inappropriate admissions.MethodsThis was a retrospective case review. The Triage© Cardiac Panel machine from Alere records patient numbers and test results. Patient numbers and results were extracted over a continuous 8 month period. The Emergency Department notes were then interrogated and this was combined with data from the hospital pathology system, looking specifically for patients that were admitted on the basis of positive myoglobin result. Hospital notes were requested if points needed to be clarified.ResultsA total of 636 paired tests were analysed. 103 (16.3%) of patients had a positive myoglobin rise. The range of myoglobin rises can be seen in Figure 1. 100 notes were available, of which only 56 were admitted for a 12 hour troponin. 54 underwent 12 hour troponin testing and three were positive (5.6%). There appeared to be no correlation between the % rise in myoglobin and the rise in troponin. 44 patients were discharged after achieving a positive triple test result. 35 of these were felt to be inappropriate. 16 sets of notes reported mentioned somewhere that the triple test was “negative.” The use of the chest pain proforma did not seem to improve the performance of the doctors–Figure 2.Abstract 011 Figure 1Range of Myoglobin Rises.Abstract 011 Figure 2Effect of completion of Chest Pain Protocol on patient disposition.ConclusionThe use of myoglobin in the triple test does appear to be appropriate for the local population. There is a significant short-coming in the application of the triple test that is putting patients at risk of an adverse outcome. The current chest pain proforma as it stands does not appear to prevent inappropriate discharges.
INTRODUCING CHECKLISTS FOR SEDATION AND INTUBATION INTO THE EMERGENCY DEPARTMENT; A CHALLENGE WORTH RISING TO?
Authors: Galloway R I , Swann F 
Published: September 2013

Objectives & BackgroundThe Emergency Department (ED) is a fertile ground for medical error. In numerous other areas checklists (and the associated cultural changes) have been brought in to reduce error. Following the National Audit Project into airway complications in 2011, guidelines were produced recommending the use of a checklist prior to rapid sequence induction (RSI) along with capnography in the ED. Similarly, College of Emergency Medicine (CEM) guidelines recommended ‘checks’ prior to sedation and capnography use. The project objectives were firstly to review the national use of checklists (and capnography). Secondly, within one trust which has already implemented the checklists, to ascertain if they were used in reality. Finally, the study looked into attitudes and how barriers to implementation could be overcome.MethodsA telephone survey of all English Emergency Departments was conducted to determine the use of checklists (and capnography) for intubation and sedation. Within Brighton and Sussex University (BSUH) NHS trust, a retrospective notes audit was conducted to determine checklist use. Finally, staff involved in patient care were interviewed regarding their experiences of checklists.Results138 out of 178 EDs agreed to take part in the survey. 48.6% and 58% of the EDs reported using a RSI and sedation checklist, respectively. An association (p<0.0003) between checklist use and capnography in sedation was identified. The audit data from BSUH NHS trust showed checklists were used in 21.5% of RSIs and 57.8% of sedations. Interviews showed that barriers included problems of implementation across multiple specialties and overcoming staff's pre-conceived attitudes towards the checklists.ConclusionThe use of checklists within Emergency Medicine remains limited. Their uptake within a trust that has implemented them has been slow. Cultural resistance within the workplace remains a barrier that needs to be overcome.
SEE AND TREAT FOR MAJOR TRAUMA? AN EVALUATION OF THE USE OF A TWO-TIERED TRAUMA TEAM ACTIVATION SYSTEM IN A UK MAJOR TRAUMA CENTRE
Authors: Jenkins P E , Rogers J , Kehoe A , Smith J 
Published: September 2013

Objectives & BackgroundAppropriate activation of multi-disciplinary trauma teams improves outcome for severely injured patients, but can disrupt normal service in the rest of the hospital. Derriford Hospital uses a two-tiered trauma team activation system. The emergency department (ED) trauma team is activated in response to a significant traumatic mechanism; the hospital trauma team is activated when this mechanism co-exists with physiological abnormality or specific anatomical injury. The aim of this study was to compare characteristics, process measures and outcomes between patients treated by ED or hospital trauma teams to evaluate the approach in a UK setting and to estimate any cost savings involved. Figure 1 outlines the composition and activation criteria of the teams.Abstract 014 Figure 1(a) ED trauma team activation and (b) Hospital trauma team activation.MethodsA retrospective database review was performed, using the TARN database and the local source trauma database. All patients who activated a trauma team between 1 Apr 12 to 30 Sep 12 were included. Patients were categorised according to the type of trauma team activated to receive them. Data included time to primary survey X-rays, time to CT, time to intubation, numbers discharged from ED, ICU admission, injury severity score (ISS), and mortality. Cost savings associated with activating an ED rather than hospital response were extrapolated from previously described methodology.ResultsDuring the study period 456 patients activated a trauma team, 358 ED and 98 hospital (see Figure 2). Patients seen by the ED team were significantly less likely to have severe injury or require hospital admission, intubation, emergency operation or blood transfusion. Differences in time taken to key investigations were statistically but not clinically significant. The cost saving of avoiding hospital team activation for those patients not requiring specialist care was estimated at £180,663 per annum.Abstract 014 Figure 2Statistics comparing Hospital and ED calls.ConclusionA two-tiered trauma team activation system is an efficient, safe and cost-effective way of dealing with trauma patients presenting to a Major Trauma Centre in the UK.
WHEN DO ED TRAINEES GET ASSESSMENTS DONE?
Authors: Townend W 
Published: September 2013

Objectives & BackgroundFormative assessments support learning. Ideally then, such trainee/ trainer interaction would occur throughout the training year and include cases that are stretching. In this way areas for trainee development could be identified and a training plan refined and executed. Such an approach would give time to revisit themes with further assessments towards the end of the year.MethodsThe CEM e-portfolio was interrogated and anonymised data retrieved. Records for ‘Formative mini-cex’ were collated for 3rd August 2011 to 4th August 2012. The date and outcome were recorded for each assessmentResults2022 ‘Formative mini-cex’ records were found. Of these, 94 (5%) were completed in the first 2 months, and 787 (39%) in the 2 months prior to ARCP. The monthly completion of these assessments was August 24 (1.4%), September 70 (3.5%), October 119 (6%), November 128 (6.3%), December 103 (5%), January 245 (12%), February 118 (6%), March 135 (6.7%), April 181 (8.9%), May 343 (17%), June 444 (22%), July 101 (5%). Each episode included an opportunity to evaluate eight domains of practice. 85% of evaluations across all domains were of excellent practice. 14% of evaluations included recommendations that the trainee ‘should consider…’ and 1% that the trainee ‘must consider…'. Written narrative feedback was recorded in 1874 (93%) of assessments. 1346 (67%) were assessed by consultants, 177 (9%) by SAS doctors and 495 (25%) by ST4-6 trainees.ConclusionThere is a high rate of excellence recorded is assessments, and around half of assessments are performed at the end of the academic year. There were more assessments performed in the month of ARCP (June) than in the first 5 months of the academic year. Future iterations of the assessment schedule will include means of ensuring trainee/trainer interaction is scheduled throughout the year and includes a case mix that stretches the trainee with trainer support.
ACUTE ALLERGY AND ANAPHYLAXIS IN THE EMERGENCY DEPARTMENT–A REVIEW OF 1 YEAR'S PATIENT PRESENTATIONS
Authors: Noble R , Friedlaender G , Cuthbertson B , Gray A 
Published: September 2013

Objectives & BackgroundThere is limited epidemiological data for allergy Emergency Department (ED) presentations. Following recent launch of NICE guidelines and World Allergy Organisation (WAO) severity descriptions we investigated the epidemiology, management and outcomes of allergy patients presenting to a single ED.MethodsA retrospective review of consecutive presentations to a single tertiary ED (assessing 112,000 adults annually) between 28/02/2011 and 29/02/2012 was conducted. Key-word search of ED PAS records identified a suitable cohort. WAO criteria were used to define severity of allergic presentation.Results405 patients were identified (268 acute allergy patients, 137 anaphylaxis). Median age 33 (range 13 to 92) years. Male to female ratio was 0.6:1. 28 patients met criteria for life-threatening reactions. 259 (64%) patients self-presented and 141 (34.8%) presented via ambulance. 6 (21.4%) patients with life-threatening anaphylaxis self-presented. Precipitants were identified in 235 (58%) patients. 89 (21.9%) patients had a known allergy to the precipitating agent, including 38 (27.7%) anaphylaxis patients. 33 (12.8%) acute allergy and 65 (47.4%) anaphylaxis patients received pre-hospital adrenaline (48 from ambulance service, 49 self-administered). In the ED, 103 (75.2%) anaphylaxis patients received H1 antagonists, 86 (62.8%) received oral or IV steroids, 24 (17.5%) received IM adrenaline and 23 (16.8%) received salbutamol. Only 63 (15.5%; n=405) were admitted to hospital including 3 anaphylaxis patients to critical care. Of those admitted; 57 (90.5%) received adrenaline pre-hospital or in the ED. Overall 21 (5%) patients re-presented within 72 hours of discharge; 3 of these patients had been admitted. An epipen was prescribed on discharge to 82 (20.2%) patients overall and 44 (10.9%) were referred to allergy services. 34 (54%) admitted patients were not referred to specialists and 36 (57.1%) did not receive an epipen.ConclusionNICE guidelines were not consistently followed but this did not seem to result in measurable short terms complications. A significant number of patients had a known precipitant.
THE PAEDIATRIC OBSERVATION PRIORITY SCORE (POPS): A USEFUL TOOL TO PREDICT LIKELIHOOD OF ADMISSION FROM THE EMERGENCY DEPARTMENT
Authors: Kelly J , Rowland A G , Cotterill S , Lees H , Kamara M 
Published: September 2013

Objectives & BackgroundNo specific early warning score universally validated for use in all children presenting to the Emergency Department (ED) exists. POPS is a novel aggregate scoring system, designed for ED use.MethodsProspectively collected physiological and observational data were used to calculate POPS on 2068 patients aged under 16 presenting over one month to a UK District General Hospital Paediatric ED. Logistic regression was used to investigate the effect of POPS at first presentation on admission to hospital within the subsequent 72 hours.Results46% of patients were diagnosed with trauma and 54% with a medical condition. Mean age was 5.6 years (SD 4.6). 15.3% were admitted on first presentation. 76 re-presented within 72 hours of discharge from the ED and 19.7% were admitted. The mean POPS on first presentation was 0.87 (SD 1.58) overall (medical patients 1.03 (SD 1.70), trauma patients 0.68 (SD 1.41), p<0.001). POPS had a statistically significant positive effect on admission. A one point increase in POPS was associated with a 70% increase in the odds ratio (OR) of admission (p<0.001), with an area under the ROC of 0.72 (medical patients OR 1.67, area under ROC 0.73, p<0.001; trauma patients OR 1.77, area under ROC 0.69, p<0.001). The sensitivity and specificity of POPS to predict admission likelihood were: POPS≥2 (sensitivity 50%, specificity 85%), POPS≥3 (sensitivity 36%, specificity 93%).ConclusionPOPS is a useful tool to predict the admission likelihood from the ED. POPS≥2 correctly predicts 50% of children who should be admitted and 85% of children who should be discharged. Multi-centre validation would help to refine POPS, increasing its sensitivity and specificity to admission likelihood, to improve the safety of discharge decisions and healthcare resource utilisation.
ESSENTIAL ETAT: ONE-DAY PAEDIATRIC RESUSCITATION TRAINING IN A RESOURCE-LIMITED SETTING
Authors: Dyer B , Pollock L , Morar N , Clarke E , Kampmann B , Anderson S 
Published: September 2013

Objectives & BackgroundWHO ETAT training courses provide comprehensive training in paediatric emergency care over 3.5–5 days and have been shown to improve outcome in resource-limited settings. However, the logistics, cost and impact on local service delivery of a five-day course may limit training opportunities in some settings. In this context, we aimed to determine whether a shorter, more focused course would be feasible.MethodsA one-day training course, ‘Essential ETAT’, was adapted from WHO ETAT training materials and included practical and lecture-based sessions on triage, cardiopulmonary resuscitation and recognition and management of key paediatric emergencies. Practical sessions in airway management, bag-valve-mask ventilation and intra-osseous needle insertion were included. A short manual summarizing ETAT guidelines was provided. Participants were all nurses or doctors working in primary or secondary care settings in The Gambia. The main outcome measure was participant knowledge, assessed by improvement in scores between pre and post-course multiple-choice tests. This was compared to similar data from a historical control group (n=76) who had completed standard 3.5 day ETAT training.Results57 participants completed the Essential ETAT one-day training course. Participants showed a significant improvement in post-course test scores; mean score pre-course 62.6% (95% CI 58.5–68.7%), post-course 78.4% (75.1–81.7%), p<0.0001. There was no significant difference in mean improvement in post-course test scores between Essential ETAT participants and the standard ETAT historical control (15.8% (12.1–19.5%) vs 14.7% (11.5–17.9%), p=0.67).Conclusion‘Essential ETAT’ was well received by participants and improvements in post-course test scores compared well to results from standard ETAT courses. Further evaluation is required to indicate whether knowledge is retained and changes clinical practice. Focused, short duration resuscitation training may offer a pragmatic and potentially cost-effective alternative to standard courses.
RESEARCH IN EMERGENCY CARE–THERE'S AN APP FOR THAT!
Authors: Crede A , Roland D , Alade J , Bryceland C , Lock R , Coats T 
Published: September 2013

Objectives & BackgroundMany emergency medicine clinical trials have struggled to recruit to ‘time and target’ with investigators having to make a large additional effort or extend the time for recruitment. This study was performed to describe our experience in the use of a computer ‘app’ to facilitate the process of research subject identification and communication between the ED staff and the research team. Key questions were:1) Does the introduction of an iPad ‘app’ result in a greater rate of patient notification to the research team?2) Which type of notification method was most used?MethodsAn observational ‘before and after' study was performed where ED staff had the choice of using a telephone ‘research hotline', verbal notification, a sticky label on the clinical notes or an iPad app (in the second phase of the study). A ‘gold standard' was provided by a manual search of the notes of every patient who presented to the ED. We developed the specification for an ‘app’ that presented the trial entry criteria coupled with an easy embedded method of emailing the research team using only three ‘clicks'. The iPads were secured to walls in key locations (such as triage areas) and ED staff simply entered the patient's identification number and pressed ‘send' for a message to be emailed. We reviewed the method of patient notification for 3 months before and after the introduction of the iPad system.ResultsThere was a significant (Fisher's Exact Test. p<0.0001) increase in ‘real time' notification of patients to the research team from 18% to 33% after the introduction of the iPad app. The mode of notification also changed–with no use of the ‘research hotline' telephone number after the app system was introduced. The use of sticky labels and the number of verbal notifications was also greatly reduced (See table 1).ConclusionThere was a significant increase in the immediacy of communication after the introduction of the iPad app. This occurred without a large amount of input from the research team, and seemed to be due to the staff knowing a specific location for the system and the ease of use, with the whole process taking less than 20 seconds. ED staff seemed to prefer using the ‘app', as after it was introduced there was very little use of the well publicised ‘research hotline' phone number. Information and communications technology can aid in the timely identification of potential research subjects in emergency care.
VALIDATING THE ICMED (INTERNATIONAL CROWDING MEASURE IN EMERGENCY DEPARTMENTS)
Authors: Boyle A , Coleman J , Sultan Y , Dhakshinamoorthy V , O'Keeffe J , Raut P , Beniuk K 
Published: September 2013

Objectives & BackgroundEmergency department crowding is recognised as a major public health problem. While there is agreement that emergency department crowding harms patients, there is less agreement about the best way to measure emergency department crowding. We have previously derived an eight point measure of emergency department crowding by a formal consensus process, the International Crowding Measure in Emergency Departments (ICMED). We aimed to test the feasibility of collecting this measure in real time, and to partially validate this measure.MethodsWe conducted a cross-sectional study in four emergency departments in England. We conducted independent observations of the measure and compared this to senior clinician's perceptions of crowding and safety (see tables 1 and 2).ResultsWe obtained 84 measurements, spread evenly across the four emergency departments. The measure was feasible to collect in real time, except for the ‘Left Before Being Seen’ variable. Increasing numbers of violations of the measure were associated with increasing clinician concerns. The Area under the Receiving Operator Curve was 0.80 (95% CI 0.72–0.90) for predicting crowding and 0.74 (95% CI 0.60–0.89) for predicting danger. The optimal number of violations for predicting crowding was three, with a sensitivity of 91.2 (95% CI 85.1–97.2) and a specificity of 100.0 (92.9–100). The measure predicted clinician concerns better than individual variables such as occupancy.Abstract 007 Table 1BeforeAfterResearch ‘hotline'2 (3%)0Verbal10 (15%)3 (3%)Notes label21 (32%)14 (14%)iPad030 (30%)Not notified32 (49%)52 (52%)Total6599ConclusionThe ICMED is easily to collect in multiple emergency departments with different IT systems. The ICMED seems to predict clinician's concerns about crowding and safety well, but future work is required to validate this before it can be advocated for widespread use.
CANCER INCIDENCE IN FIRST NATIONS AND MéTIS ADULTS IN CANADA: FOLLOW-UP OF THE 1991 CENSUS MORTALITY COHORT
Authors: Withrow Diana , Marrett Loraine , Tjepkema Michael , Pole Jason 
Published: September 2013

IntroductionCancer incidence amongst First Nations has historically been lower than that in the general population, but preliminary province-level evidence suggests it is rising to meet or exceed that in the general population.ObjectivesWe aim to estimate incidence rates of lung, prostate, breast and colorectal cancers in First Nations and Métis (FN&M) and compare these to the rates in non-Aboriginal Canadians nationwide.MethodsA cohort of 1991 Long Form Census respondents was probabilistically linked to the Canadian Cancer Registry (1992 to 2003) and the Canadian Mortality Database (1992 to 2006). Age-standardized, site-specific incidence rates and time trends will be generated over the next 4 months and results will be available for presentation. This will be the first national study of cancer incidence in FN&M. Further, this linked cohort provides a rare opportunity to include groups typically under-represented in health research (e.g. Métis and non-Status Indians) since FN&M will be identified based on self-report of Aboriginal ancestry, Registration and band membership in the Census.ResultsThe cohort includes 2.7 million adults 25 and older on Census day in 1991, equivalent to a 15% sample of the population of that age at the time. Of these, approximately 62,000 reported either First Nations ancestry or are registered under the Indian Act of Canada. Preliminary analyses show that crudely, cancer incidence from 1992 to 2003 was higher in non-Aboriginals than in FN&M nationwide. FN&M have similar incidence of breast and colorectal cancers, both lower than the general population. The Métis have significantly lower incidence of prostate cancer than the general population, but significantly higher rates than First Nations. Incidence rates of lung cancer in Métis are comparable to those in the general population, while First Nations have lower lung cancer incidence.ConclusionsUsing an innovative approach, this study will provide much needed data to inform effective, culturally-appropriate cancer prevention and control activities for FN&M in Canada. New cancer incidence data will help justify and re-prioritize FN&M cancer programs by identifying issues that require the most attention.