bluuebunny/crossref_metadata_2025_split huggingface dataset:
030 Are staff recorded pain scores a ‘gold standard’ for ED pain research?
Authors: Connor Putnam R , Thornton Hilary , Coats Timothy 
Published: April 2023

BackgroundRelief of pain is a key activity of emergency medicine, however pain is often poorly monitored. As part of the evaluation of an electronic patient pain score recording device we needed to smooth a time series of pain scores in order to minimise ‘noise’ and false readings. In order to evaluate different methods we used the staff recorded pain score as a reference standard.Patients used an electronic pain recording device containing buttons set out in the same way as a pain visual analog scale. The button corresponding to the currently level of pain was pressed in response to an audible prompt every 15 minutes. Pain scoring by ED staff continued in the normal way, recorded in the electronic health record.Smoothing was undertaken using 20 and 30 minute bins, with either the median or the maximum patient recorded score being calculated for each bin. The staff recorded pain score nearest to 2 hours was paired with the patient recorded score in the same time window.For each smoothing method a Bland-Altman plot was made of the paired results and Spearman’s correlation coefficient calculated.There was little difference between the smoothing methods (table 1). However the most striking finding was that ED staff overall record a lower pain score (by 1 to 2 points) than is self-reported by patients. There were also very wide limits of agreement - implying variation between patient recorded and staff recorded pain scores (figure 1).Abstract 030 Figure 1Abstract 030 Table 1Better understanding of the dynamic of the interaction between patient and ED staff, including staff perceptions, is important in managing pain in emergency care. Our (perhaps naive) initial presumption that a staff recorded score forms a ‘reference standard’ may not be valid.
033 Diagnostic investigation and prediction of shock (DiPS), in the emergency department: a prospective observational study
Authors: Sorayya Sorayya Kakhi , Nadeem Afaque , Seymour Jamie , Ngua Nicholas , Yousef Zaheer , Rainer Timothy 
Published: April 2023

BackgroundCurrently there exists no widely accepted, objective tool for determining the probability of shock in the emergency department (ED). Associated mortality outcomes remain unacceptably high. Using variables that are associated with shock and available in the ED we aimed to derive an objective tool for estimating the probability of shockMethodsIn a prospective, longitudinal study conducted in the ED, Cardiff, adult patients aged ≥18 years, presenting with NEWS ≥3 were recruited. We derived a model consisting of 8 variables, and validated it using bootstrap (1000 iterations; random number seed: 978). The primary outcome was combined 30-day mortality or ICU admission.Results361 patients were recruited (mean age 69.4 ±15.9 years; male 62.7%; 80 positive outcome) to the study. The multivariate model variables were: Glasgow Coma Scale 3–8 (Odds ratio (OR) 9.1 (95% CI 1.2–69.4) p=0.0324), 9–12 (OR 1.3 (95% CI 0.4–4.2) p=0.6561); capillary return >4 (OR 8.7, (95% CI 2.9–26.1) p=0.0001), 3–4 (OR 3.7 (95% CI 1.3–10.4); p=0.0113); temperature ≤35°C (OR 5.4, (95% CI 1.8–16.3); p=0.0045); bilirubin >34 (OR 4.9, (95% CI 1.6–14.5); p=0.0045); oxygen supplement (OR 1.9, (95% CI 1.0–3.7); p=0.06); respiratory rate >24 (OR 2.6, (95% CI 1.3–5.1); p=0.0069); and albumin <35 (OR 1.9, (95% CI 0.9–3.8); p=0.09).The model was a 100-point scale where 0 was low probability and 100 was maximal probability of shock. The AUC was 0.801 (95% CI 0.756–0.841), accuracy 82%, p<0.0001, Hosmer & Lemeshow test 9.19 (p=0.326). At a cut off >35, and Youden Index 0.4557 the sensitivity and specificity were 56.2% (95% CI 44.7–67.3) and 89.32% (95% CI 85.1–92.7) respectively. At a fixed specificity of 80%, the estimated sensitivity was 60.5% (95% CI 49.4–71.3). At a fixed sensitivity of 80%, the estimated specificity was 62.3% (95% CI 45.9–71.2).ConclusionsAn accurate 7-point ED tool for shock has been derived and internally validated.
036 Feasibility of collecting real-time emergency department patient safety and experience feedback
Authors: Wilson Sally-Anne , Marsh Claire 
Published: April 2023

BackgroundThe NHS Long Term Plan aims to make care more Patient-Centred through listening to patients. The acute nature of ED care presents barriers to collecting patient feedback. We have explored two interventions (PRASE and Y-PET), as mechanisms for collecting and reporting safety feedback (PRASE) and experience feedback (Y-PET) in EDs.An iterative approach was used to develop PMOS10 (PRASE questionnaire) for the ED which was tested in 5 departments with over 100 patients. The Y-PET was used alongside these tools in 2 departments with 40 patients.A mixture of patient volunteers and staff collected the feedback.Two questions from the PMOS10 proved to be unsuitable for the ED setting, and were substituted. Through further iterative tests, we now have a PMOS10(ED).Hospital volunteers and staff not associated with the department are best placed to collect unbiased results. Patients (or their relatives) who are awaiting transport home or a hospital bed are best placed to give feedback. The traffic light display of patient safety feedback provided in PRASE is useful for assurance but staff need more qualitative data to inspire change. PRASE patient comments go someway to providing this but are strongly enhanced by the open answers of the Y-PET. The Y-PET format for presenting qualitative data as headline areas to celebrate or improve was effective in engaging staff in feedback from both tools.ED patients can give valuable insight into how safe their care is and areas to celebrate and improve. Staff can engage with feedback themes and key quotes to initiate improvement.
037 Improving the adult patient experience by introducing a paediatric wound closure method – the hair apposition technique
Authors: Waydia Shree-eesh , Rehnberg Lucas 
Published: April 2023

BackgroundScalp lacerations are a common presentation to the Emergency Department (ED). The Hair Apposition Technique (HAT) is a safe, effective, efficient and patient-centred alternative to sutures and commonly used in paediatrics. This Quality Improvement Project (QIP) was inspired by a patient with dementia who could not tolerate sutures for her scalp laceration therefore HAT was used with excellent results and patient satisfaction. This project aimed to introduce the technique to 50% of all eligible adult patients within 6 months.Method and resultsA retrospective, case-note baseline review demonstrated no use of HAT in adults during a period of three months. Barrier analysis using staff surveys explored why HAT was not standard practice. We introduced HAT using the Institute of Healthcare Improvement (IHI)’s Model for improvement methodology and conducted four Plan, Do, See, Act (PDSA) cycles to implement changes. Our process measure was the number of patients having HAT compared with sutures. Outcome measures were via a qualitative phone survey evaluating pain, satisfaction and inconvenience score on a scale of 0–10. Balancing measures included wound complication and re-attendance.ConclusionsDuring the 6 months following the introduction of HAT 71% patients who were eligible to have HAT had the technique instead of sutures or staples, with improvement in all patient outcome measures compared with those who had sutures. HAT was popular with staff and patients. Our sustainability review at one year showed ongoing use of the technique and we have achieved a significant culture change by establishing the technique as standard practice for adults.Abstract 037 Table 1Breakdown of head lacerations and their closure by month comparing a 3-month period, one year apartAbstract 037 Figure 1Graph to show impact of PDSA Cycles on the No. of Patients Having Either Sutures/Staples vs. HAT Over TimeAbstract 037 Figure 2Run chart comparing the Baseline results with HAT for Pain scoresConclusionHAT should be considered in eligible adult patients with scalp lacerations presenting to the ED. Applying quality improvement methodology resulted in a sustained culture change; the ED involved now offers an effective suture free paediatric technique to adults which has improved patient outcomes and satisfaction.
040 Prehospital national early warning score predicts patient disposition also in japan
Authors: Endo Takuro , Fujitani Shigeki , Taira Yasuhiko 
Published: April 2023

The National early warning score (NEWS) was originally developed in the UK for hospitalized patients. We examined if NEWS can be applied for emergency transported patients in Japan.We assessed the patients transported to one hospital between April 2017 to March 2018. We calculated NEWS from the vitals recorded by ambulance staff. Emergency department (ED) disposition data were categorized into the following groups depending on their outcome: discharged from ED, admitted to a ward, admitted to the intensive care unit or died in ED. We assessed the predictive performance of the NEWS for combined patient dispositions using receiver operating characteristics curves, from which possible cut-off values for risk categorizations were derived. Patient dispositions were compared between NEWS-based three categories adjusting for age, gender and presence of traumatic injury.ResultsOf 2,847 patients, mean (±standard deviation) NEWS of patients who discharged from ED (n=1330), admitted to a ward (n=1263), admitted to the ICU (n=232), and died in ED (n=22) were 3.7±2.9, 6.3±3.8, 9.4±4.0, 11.7±2.9, respectively. Prehospital NEWS’s C-statistics (95% confidence interval) for admission to a ward/the ICU or death in ED was 0.733(0.715–0.751), admission to the ICU or death in ED was 0.807 (0.780–0.833), and death in ED was 0.900 (0.868–0.933). After adjusting for age, gender and trauma, odds ratio (95% confidence interval) for admission to the ICU or death in ED of high-risk NEWS category (≥7) was 13.8 (8.9–21.6) and middle category (5 or 6) was 4.2 (2.5–7.1), each compared to low-risk category (≤4).ConclusionOur study shows prehospital NEWS can identify patients at risk of adverse outcomes also in Japan.
043 Should adults with mild head injury taking direct oral anticoagulants undergo CT scanning? A systematic review
Authors: Fuller Gordon , Evans Rachel , Preston Louise , Woods Helen Buckley , Mason Suzanne 
Published: April 2023

BackgroundPatients taking direct oral anticoagulant medications (DOACs) commonly undergo computed tomography (CT) head scanning following mild head injury, regardless of symptoms or signs. International guidelines have noted a lack of evidence to support management decisions in such patients.MethodsA systematic review, pre-registered (CRD42017071411) and following Cochrane Collaboration recommendations, was performed. Studies of adults with mild head injury (GCS 13–15) taking DOACs, which reported the risk of adverse outcome following the head injury, were eligible for inclusion. A comprehensive range of bibliographic databases and grey literature were examined using a sensitive search strategy. Selection of eligible studies, data extraction, and risk of bias was evaluated independently by separate reviewers. A random effects meta-analysis was used to provide a pooled estimate of the risk of adverse outcome. The overall quality of evidence was assessed using the Grades of Recommendation, Assessment, Development and Evaluation Working Group approach.Results4,185 articles were screened for inclusion, of which 7 cohort studies, including 346 patients, met inclusion criteria. All studies were at high or unclear risk of bias secondary to selection and information bias. Estimates of adverse outcome (any death, intracranial hematoma (ICH), or neurosurgery) ranged from 0% to 8%. A random effects meta-analysis showed a weighted composite outcome risk of 4% (95% CI 2–6%, I2=3%). The overall quality of the body of evidence was low secondary to imprecision, indirectness and risk of bias.ConclusionsThere is limited data available to characterize the risk of adverse outcome in patients taking DOACs following mild head injury. A sufficiently powered prospective cohort study is required to validly define this risk, identify clinical features predictive of adverse outcome, and inform future head injury guidelines.
044 Stemming the flow
Authors: Honour Patrick , McAlpine Graeme 
Published: April 2023

Standardising the practice of epistaxis care in an emergency department to improve patient outcomes.Having a regional ENT centre on site we see a disproportionate number of epistaxis patients with over 500 cases a year.All atraumatic haemodynamically stable epistaxis patients who had active ongoing bleeding in the department were included.Developing a standard operating procedure based around the standard treatment arm of the NoPac study we focused on the step by step management of epistaxis to measure if this improves patient outcomes.A tailored education package for the protocol was used in the department with posters, emails and information during handover to all staff in the department.It follows a step by step method, starting with nasal pegs in triage, clot removal, cautery and adrenaline soaked rolls, depending on the persistence of the bleeding, eventually discharge or referral.I Analysed TRAK data for all ‘Epistaxis’ diagnoses prospectively for 2 months pre and post intervention.Any patient with a documented ‘active’ bleeding that was not haemodynamically unstable or a traumatic injury for the following outcomes;Primary outcome was rate of Admission to ENT.Secondary outcomes were, time in department and reattendance within 2 weeks.A total of 34 patients were studied, 17 before and after the intervention.Primary outcome of ENT admissions – Down from 41% to 11%.Secondary outcomes of time in department - reduced by 39 minutes to 2h36 from 3h03.And re-attendance rate remains the same at 24%In conclusion we have seen a significant drop in ENT admissions alongside a decreased time in department without increasing re-attenders. Having a standardised plan for all epistaxis patients to receive early intervention with a clear protocol for the medical staff has improved patient safety and outcomes. These projects further benefit our department by keeping up with active research projects.Abstract 044 Figure 1
045 We’re going to need a bigger boat! Evening opening of mothballed outpatient areas to reduce crowding in a children’s emergency department
Authors: Hance Katherine , Lyttle Mark , Humphreys Sue 
Published: April 2023

BackgroundEDs are increasingly crowded, with negative impact on care quality. This is multifactorial, but tends to peak during evenings. On mapping our contributing constraints, staffing was adequate, but available ED space was a major factor. We identified evening opening of mothballed clinical areas as a potential strategy, of which one was our outpatient department (OPD); housed one minute away on the same floor this closes at 1700. Through the 2018/19 winter this opened between 1800–2330; we evaluated impact on service provision and staff morale.Method and resultsContinuous PDSA cycles were initiated; a living standard operational policy evolved based on staff/patient feedback. Flow and patient acuity markers were monitored using electronic tracking systems. Staff were surveyed to explore opinions and impact on morale.ConclusionsDuring November 2018–April 2019 the OPD opened on 76 days (50%), with 1082 patients seen. Opening was more frequent during November-February; during peak activity >10% all daily attendances were seen in this stream. Mean time to see clinicians was 77 minutes and mean time to discharge was 133 minutes; both compared favourably with patients remaining in ED. This partly reflects lower patient acuity, but other crowding measures including total patients in department, and total patient minutes, also improved. The most common diagnoses were soft tissue injury, fracture, head injury, and URTI. No safety incidents occurred and <1% left without being seen. Staff feedback reflected increased morale, and lower stress and noise levels during peak activity.Novel use of mothballed clinical areas during peak ED activity is an attractive option for families and staff, and appears to improve safety and effectiveness. Use of existing staff was cost effective, with total additional cost pressures for nurses (£20K) and support staff (£500), in comparison to projected costs of £100K for one embedded evening GP over the same period.
048 Computer beats doctor? Estimating the probability of acute coronary syndrome for individual patients
Authors: Oliver Govind , Reynard Charles , Morris Niall , Body Richard 
Published: April 2023

Chest pain is one of the most common reasons for patients attending the Emergency Department (ED). Accurately assessing for Acute Coronary Syndromes (ACS) remains a challenge. There is strong evidence supporting use of the Troponin-only Manchester Acute Coronary Syndrome (T-MACS) risk prediction model. How clinicians perform compared to these models is unknown.We aimed to externally validate the diagnostic accuracy of clinicians’ estimated probability of ACS (gestalt) compared to the T-MACS calculated probability of ACS.The Bedside Evaluation of Sensitive Troponin prospective multi-centre diagnostic accuracy study included adults presenting to the ED with potential ACS. Alongside clinical, ECG and blood sample data, the emergency clinician recorded their estimated probability of ACS (%) following review. The probability of ACS was also calculated using T-MACS. The primary outcome was Major Adverse Cardiac Events (MACE) within 30-days. For this planned secondary analysis, patients from sites using the high-sensitivity cardiac troponin T (Roche Diagnostics Elecsys) were eligible.Of 782 included, 116 (14.8%) had MACE. The C-statistic for clinician gestalt and T-MACS were 0.76 (95% CI 0.71–0.81) and 0.93 (0.90–0.95) respectively (p<0.0001). Compared to T-MACS, clinicians overestimated the probability of ACS (positive bias 18.0%) and were less likely to stratify patients to extremes of probability. For ‘rule out’ of ACS, clinicians identified 72 (9.3%) patients as ‘very low risk’ (<2%) compared to 385 (49.2%) with T-MACS. For ‘rule in’ of ACS, clinicians identified 16 (2.1%) patients as ‘high risk’ of ACS (≥95%) in comparison with 50 (6.4%) with T-MACS. Assessment of model calibration comparing observed against predicted outcomes gave an R square of 0.78 and 0.97 for clinicians and T-MACS respectively.Clinician gestalt has inferior diagnostic accuracy to T-MACS. T-MACS requires a clinician’s skill for appropriate application. Our conclusion is therefore not that computers are better, but that clinician performance can be augmented using T-MACS.
Comaneci-assisted coiling of a right posterior communicating artery aneurysm: an unusual case of coil retention
Authors: Sioutas Georgios S , Salem Mohamed M , Burkhardt Jan-Karl , Srinivasan Visish M , Jankowitz Brian T 
Published: April 2023

Although endovascular embolization has become the main treatment option for intracranial aneurysms,1 2 wide-necked intracranial aneurysms remain difficult to coil.3 Both stent- and balloon-assisted coiling are used for wide-necked aneurysms because they provide a scaffold that protects the parent vessel during coiling.4 5 However, stent-assisted coiling requires dual antiplatelet therapy, which increases the risk of bleeding, whereas balloon-assisted coiling temporarily obstructs blood flow.4 6 7 The Comaneci device (Rapid Medical, Yokneam, Israel) has recently received US Food and Drug Administration approval as a ‘temporary coil embolization assist device’.5 It temporarily covers the aneurysm neck and allows safe coiling, avoiding the disadvantages mentioned above.6–8 A potential complication of Comaneci-assisted coiling is coil retention when it adheres to the device on recapture; this complication should be promptly recognized and managed.5 9 10 In this video, we present an unusual case of coil retention with the Comaneci device (Video 1).Video 1
Vitamin D status in active duty Navy military personnel: a systematic review
Authors: Henriques Moisés , Rodrigues Diogo , Viegas Susana , Serranheira Florentino , Sacadura-Leite Ema 
Published: April 2023

ObjectivesActive duty Navy military personnel are prone to vitamin D deficiency due to an occupational environment detrimental to sunlight exposure. The main objective of this systematic review is to provide a worldwide overview of vitamin D status in this population.MethodsThe Condition, Context, Population (CoCoPop) mnemonic was used to define the inclusion criteria (vitamin D status; all contexts; active duty Navy military personnel). Studies with recruits or veterans were excluded. Scopus, Web of Science and PubMed/Medline databases were searched from inception to 30 June 2022. Joanna Briggs Institute and Downs & Black checklists were used for quality assessment and data were synthesised in narrative and tabular formats.ResultsThirteen studies published between 1975 and 2022 and conducted in northern hemisphere Navies, including mainly young and male service members, were included. The prevalence of vitamin D deficiency was globally reported as significant. Nine studies included a total of 305 male submariners who performed 30–92 days submarine patrol and reported the effect of sunlight deprivation in the decrease of vitamin D levels.ConclusionsThis new systematic review underlines the high prevalence of vitamin D deficiency in the Navy, especially in submariners, and the need to implement measures to prevent vitamin D deficiency. Serum 25(OH)D data available and the heterogeneity of the studies limited a pooled analysis. Most studies included only submariners, which may limit generalisability to all active duty Navy military personnel. Further research on this topic should be promoted.PROSPERO registration numberCRD42022287057.
Risk factors for HIV infection at a large urban emergency department: a cross-sectional study
Authors: Ford James S , Mousa Mohammad A , Voong Stephanie , Matsumoto Cynthia G , Chechi Tasleem , Tran Nam , May Larissa 
Published: April 2023

ObjectivesIn 2019, the US Preventative Services Task Force released updated guidelines recommending HIV screening in all individuals aged 15–64 years and all pregnant females. In the current study, we aimed to identify risk factors for HIV infection in an emergency department (ED) population.MethodsWe performed a cross-sectional study that employed a post hoc risk factor analysis of ED patients ≥18 years who were screened for HIV between 27 November 2018 and 26 November 2019, at a single urban, quaternary referral academic hospital. Patients were screened using HIV antigen/antibody testing and diagnoses were confirmed using HIV-1/HIV-2 antibody testing. The outcome of interest was the number of positive HIV tests. Multiple logistic regression models were used to identify risk factors associated with HIV positivity.Results14 335 adult patients were screened for HIV (mean age: 43±14 years; 52% female). HIV seroprevalence was 0.7%. Independent risk factors for HIV positivity included male sex (adjusted OR (aOR) 3.1 (95% CI 1.7 to 5.6)), unhoused status (aOR 2.9 (95% CI 1.7 to 4.9)), history of illicit drug use (aOR 1.8 (95% CI 1.04 to 3.13)) and Medicare insurance status (aOR 2.2 (95% CI 1.1 to 4.4)).ConclusionsThe study ED services a high-risk population with regard to HIV infection. These data support universal screening of ED patients for HIV. Risk factor profiles could improve targeted screening at institutions without universal HIV testing protocols.