bluuebunny/crossref_metadata_2025_split huggingface dataset:
775 Assessment of headache in the emergency department to rule out subarachnoid haemorrhage: a systematic review of diagnostic accuracy
Authors: Wade Ros , Walton Matthew , Harden Melissa , Hodgson Robert , Eastwood Alison , Storey James , Hassan Taj 
Published: June 2022

Aims/Objectives/BackgroundAcute headache accounts for around 2% of Emergency Department attendances. Headache guidelines recommend non-contrast head computed tomography (CT) followed by lumbar puncture to exclude subarachnoid haemorrhage (SAH). Advances in imaging technology have led emergency physicians to question the necessity of routine lumbar puncture after negative CT. This systematic review assessed diagnostic strategies for neurologically intact headache patients.Methods/DesignIn February 2020, 18 electronic databases (including MEDLINE and Embase) were searched for studies of any clinical decision rule or diagnostic test for assessing neurologically intact severe headache patients, reaching maximum intensity within an hour. Studies were quality assessed using the QUADAS-2 tool. Diagnostic accuracy data were extracted into 2x2 tables to calculate sensitivity, specificity, false-positive and false-negative rates. Where appropriate, hierarchical bivariate meta-analysis was used to synthesise results.Results/ConclusionsThirty-seven studies were included. Eight studies assessing the accuracy of the Ottawa SAH clinical decision rule were pooled; sensitivity was 99.5%, specificity was 23.7%. Four studies (with neuroradiology expertise) assessing CT within six hours of headache onset were pooled; sensitivity was 98.7%, specificity was 100%. CT sensitivity beyond six hours was considerably lower (≤90%; 2 studies). Three studies assessing lumbar puncture (spectrophotometric analysis) following negative CT were pooled; sensitivity was 100%, specificity was 95.2%. LP-related adverse events were reported in 5.3–9.5% patients (2 studies).The evidence suggests that the Ottawa Rule has limited value for ruling out SAH; the high false positive rate means that its use would potentially result in 76% SAH-negative patients undergoing further investigation with no additional benefit. Modern CT within six hours of headache onset (with images assessed by a neuroradiologist) is highly accurate and likely to be sufficient to rule out SAH. However, sensitivity reduces considerably over time. The CT-LP pathway remains a highly sensitive pathway for detecting SAH, although LP resulted in some false-positives and adverse events.
943 Creating and employing an admission bloods based diagnostic aide for COVID-19 to assist cohort-based isolation strategies
Authors: Baker Jacob , Day Sara , Marsh Adrian 
Published: June 2022

Aims/Objectives/BackgroundIn the COVID-19 pandemic the Shrewsbury and Telford Hospital NHS Trust has isolated suspected cases in high and low suspicion cohort bays to reduce nosocomial infection. Before rapid PCR swabs were in routine use, we sought tools to aide identifying COVID-19 positive patients.Methods/DesignWe collected data from two cohorts in April and June 2020 totalling 317 patients, with positivity rates of 33% and 5% respectively. We retrospectively correlated neutrophil count, lymphocyte count, LDH and AST to positive and negative swab results. Predictive value of COVID-19 positivity was assessed via their receiver operator characteristic. Areas under the curve were as follows: Neutrophils 0.75, lymphocytes 0.64, combined neutrophil and lymphocyte count 0.82, AST 0.65 and LDH 0.7.We developed a diagnostic aide to assist in allocation of high and low suspicion based on parameters for neutrophil count, lymphocyte count and LDH, each of which was assigned red (higher probability) or green (lower probability) in a ‘traffic light’ system. Combined and applied retrospectively to 252 patients with suspected COVID-19, with a positivity prevalence of 5%, three green values generated a negative predictive value for COVID-19 of 100%, two greens 98% and three reds a positive predictive value for COVID-19 of 44%.Abstract 943 Figure 1Results/ConclusionsThis diagnostic aide was applied from August 2020 within the Trust Emergency Departments and Acute Medical Units to aide cohort decisions. A retrospective application to all 213 patients with positive swabs admitted from August to November 2020 demonstrated that 69% were highlighted as at least two ‘red lights’ and only 1.4% were erroneously highlighted as three ‘green lights’. The aide is an example of a rapidly developed evidence based tool and, particularly if updated with data from other centres, could be widely employed in low-resource healthcare settings.
1023 Improving diagnosis and appropriate specialty referral with a syncope pathway
Authors: Biggers Richard , McIvor Aidan , Reed Matthew J , Thethy Ishwinder , Wojtowicz Martyna 
Published: June 2022

Aims/Objectives/BackgroundSyncope is a common presentation to ED. Patients with an underlying cardiac cause have increased risk of adverse outcome. Initially, aetiology can be unclear leading to high admission rates and associated costs. In August 2018, a syncope pathway was introduced at the Royal Infirmary of Edinburgh (RIE) ED to aid diagnosis and direct patients to appropriate services. Our aim was to assess the impact of this pathway on syncope diagnosis, admission rates, patient outcomes and specialty input.Methods/DesignA search of electronic patient records (EPR) eight months before and after the pathway’s introduction was conducted to identify patients presenting with ‘fainting episode +/- loss of consciousness’. EPR’s were reviewed and non-syncopal presentations excluded. Two reviewers consecutively sampled from both groups. Remaining patients had their EPR’s scrutinised to determine history, examination findings, immediate and 1-year outcomes and referrals to specialties.Results/ConclusionsOur search identified 1055 pre-pathway and 1073 post-pathway patients. Following exclusion of non-syncopal diagnoses, 673 patients remained in the pre-pathway group and 480 in the post-pathway group. Consecutive sampling from these groups generated 199 patients pre-pathway and 102 patients post-pathway with a median age of 65 (range 13–100).A greater proportion of patients were admitted or referred to outpatient services following the pathway’s introduction (46.1% versus 30.2%). Of these, 25.5% were referred to outpatient clinics compared to 20% pre-pathway. Of those admitted, 77.1% received specialty input related to their syncope compared to 25% in the pre-pathway group. After 1-year follow-up, 8.8% of patients had alternative diagnoses for their syncope compared to 2.5% pre-pathway. Post pathway, there were two syncope related deaths – both situational syncope causing falls.Following the introduction of our syncope pathway there was no significant reduction in unscheduled care admissions. However, we have seen more specialty input and improved diagnosis with importantly, no significant increase in syncope related deaths.
766 How emergency physicians make their careers sustainable on the shop-floor and away from it: results from an ethnographic and interview-based study
Authors: Darbyshire Daniel 
Published: June 2022

Aims/Objectives/BackgroundThis study aims to understand how emergency physicians work sustainably in an increasingly challenging environment in the context of a retention crisis across all grades of emergency physician.Senior clinicians provide better care in the emergency department; performing fewer unnecessary investigations, receiving fewer complaints and making fewer errors. Seniority is dependent on retention. Exodus from training and consultant grades is expensive.The problems of staffing an emergency department has not been previously addressed by focusing on how those who work in them manage to do so.Methods/DesignEthnography conducted at a UK emergency department for 12-weeks, totalling nearly 200-hours of observation. A second site was planned but not possible due to COVID-19.Interviews with emergency physicians of all grades from the two initially planned sites, with doctors who have left emergency medicine, and with individuals working for stakeholder organisations. 40 interviews in total, averaging 45 minutes.Systematic scoping review of the relevant academic and policy literature.Reflexive thematic analysis of the ethnographic field notes, interview transcripts and literature.Results/ConclusionsEmergency physicians are active in managing their working day to mitigate the labour and environment. These actions have multiple overlapping motives but are demonstrably forms of retention work. They utilise objects and the environment in creative ways (materialities), for example completing paperwork in the resuscitation room because it is calm and air-conditioned.They utilise humour in a primarily self-deprecating manner and prioritise education as a means of valuing other staff and creating variety in their workday. Emergency physicians describe teamwork as vital to retention, but this is disparate and developed over long periods of time and therefore better described ascommunity.The principle sustainability strategies employed limit exposure to shop floor working. This is achieved through less-than-full-time working and portfolio careers. These strategies predate policy which describes them in terms of flexible working.
752 External validation of a novel TRIP (Cast) score to identify patients at risk of venous thromboembolism after temporary immobilisation for lower limb injury
Authors: Horner Daniel , Howard Stephanie , Campbell Michael , Collins James 
Published: June 2022

Aims/Objectives/BackgroundTemporary immobilisation after lower limb injury incurs a significant risk of venous thromboembolism (VTE). These events are potentially preventable through patient education and risk based pharmacological thromboprophylaxis. Recent evidence has identified a potentially optimal risk assessment model, the TRIP (cast) score. We sought to evaluate the potential impact of implementation within a UK Emergency Department (ED).Methods/DesignA retrospective cohort study, using prospectively collected routine data accessible through electronic health records. All ED patients with temporary lower limb immobilisation and documented VTE risk assessment during 2019 were included. TRIP (cast) scores were calculated retrospectively. Rapid case note review was undertaken to identify VTE, bleeding and mortality events up to 90 days post discharge. The project was formally approved as a service evaluation and had R&D oversight throughout (Ref: S21HIP25).Abstract 752 Figure 1Type of immobilisation applied (N=520)Abstract 752 Figure 2Diagnostic coding data (N=520)Abstract 752 Figure 3Frequency histogram of TRIP (Cast) scores (N=520)Results/ConclusionsWe identified 670 relevant ED patients with lower limb injury. We excluded all subsequent hospital admissions and patients already established on anticoagulation. 520 patients were included in the final dataset, with a mean age of 40.7 (SD 17.1) and a median ED stay of 170 minutes. Discharge diagnoses and immobilisation method are shown in figures 1 and 2.89 (17.0%) patients were offered pharmacological thromboprophylaxis. No VTE events were recorded in this group. However, in 435 (83%) patients who did not receive prophylaxis, 5 VTE events were recorded, including 3 proximal thrombi. We found no evidence of major or clinically relevant non-major bleeding.A frequency histogram of derived TRIP (Cast) score values is shown in figure 3. A threshold of ³6 for prophylaxis would result in 111 (21.1%) patients being offered prophylaxis, with all 3 of the proximal VTE events potentially prevented.In conclusion, use of the TRIP (Cast) score in our ED population appears to outperform current risk assessment practice, at a small overall increase in the population eligible for prophylaxis.
1117 Early and delayed traumatic intracranial bleeding in the anticoagulated head injured patient: a systematic review and meta-analysis
Authors: O’Neill Gavin 
Published: June 2022

Aims/Objectives/BackgroundPatients taking anticoagulant medication frequently attend the Emergency Department following head injuries. Whilst previously these patients were taking warfarin, they are now increasingly taking DOACs. Both classes of anticoagulant are believed to increase the incidence of traumatic intracranial haemorrhage (tICH). However, it is unclear whether DOACs confer the same risks as warfarin. There are also concerns that anticoagulated patients, who have had an initially normal CT scan, are at risk of delayed tICH.This systematic review and meta-analysis compares the incidence of early and delayed tICH in patients attending the Emergency Department on DOACs and warfarin.Methods/DesignA literature search was conducted using the Medline(OVID and PubMed), EMBASE, Web of Science and Cochrane libraries using defined keywords. Prospective studies and retrospective studies were included. The primary outcomes were the incidences of early and delayed tICH. Mortality rates were also assessed. Meta-analyses were performed to compare the rates of early and delayed tICH between the anticoagulant groups. The rates of injury were also compared to patients not receiving anticoagulation.Results/ConclusionsThe literature search found 42 relevant studies. Twenty three studies investigated the incidence of early tICH and 26 assessed delayed tICH. The pooled incidence of early tICH was 5.7% for DOACs and 7.3% for warfarin. Odds ratio for early tICH on DOACs was 0.47% (95% CI 0.34–0.66) when compared to warfarin and 0.96 (95%CI 0.68–1.36) compared to no anticoagulation. The incidence of delayed tICH was 1.2% for DOACs and 1.8% for warfarin (OR 0.70 (95% CI 0.38–1.31)). Odds ratio of mortality following a head injury on DOACs compared to warfarin was 0.4 (95%CI 0.17–0.94).The systematic review and meta-analysis suggests the rate of early tICH and mortality may be lower for patients on DOACs as compared to warfarin. It also finds that the rate of delayed tICH bleeding is low in both groups.
925 Management of older major trauma patients: the impact on mortality since implementation of dedicated guidelines
Authors: Park Stephen , Hicks Derek , Smith Andrea , Kosuge Hannah , Cole Elaine , Woodgate Adam 
Published: June 2022

Aims/Objectives/BackgroundOlder trauma is an increasing challenge for trauma networks and many clinical protocols do reflect age-related changes in physiology and management. In 2018 older trauma guidance was introduced in our trauma system to improve early recognition of injury, admission pathways, clinical management and outcomes for those aged ≥65yrs (LMTS Older Trauma Guidance). The aim of our study was to assess the impact of the guideline on our trauma processes and patient outcomes.Methods/DesignThis retrospective analysis of TARN compared process and outcome data for patients aged ≥65yrs admitted to hospitals within the North East London and Essex Trauma Network, pre (01/01/2016–31/07/2018) and post (01/08/2018–31/07/2020) guidance introduction. The primary outcome was mortality at 30 days post injury.Results/ConclusionsThere were 4317 patients pre and 3992 patient post guidance. Time to CT reduced on average by 57 minutes, Neurotrauma transfers decreased from 2116 patients to 1519 patients and more older patients were discharged for rehabilitation. Older trauma mortality reduced across the network post guidance (13.59% vs 10.64%). The greatest mortality reductions were seen in Trauma Units, (19.20% pre vs 6.99% post) with increasing benefit seen with advancing age: reduced 75–84 years by 2.20%; 85–94 years 2.41%; 95+ years by 7.44%.This analysis suggests that dedicated guidance highlighting the special needs and risk profiles of older trauma patients significantly improves processes and outcomes. Improvements in early assessment and time to imaging appear to result in enhanced survival. Further research at a system level is required.
1062 Disease burden, acuity and patient management in emergency care presentations to Ugandan facilities
Authors: Richardson Sarah , Luggya Tonny , Gray Alasdair , Grant Liz 
Published: June 2022

Aims/BackgroundEmergency care is being provided to, and utilised by, Ugandan patients despite there being no formal system capable of producing optimal outcomes. For the country’s emergency care system to be appropriate and contextualised, there must first be an understanding of the actual utilisation of emergency care services. Current coding systems for analysing and comparing disease burden across sites do not adequately represent the patient population and resources required for quality emergency care to be delivered.ObjectiveTo describe the burden of disease, acuity and management of emergency patients presenting to secondary Ugandan health facilities.Methods/DesignA retrospective review of 4704 emergency care patient charts from November 2018 to April 2019 was performed from 11 sites throughout Uganda. A novel diagnosis coding system was developed for use in LMIC emergency care context consisting of 482 codes, 158 sub-categories and 7 disease classes.Results6506 diagnoses were recorded, 34.98% of patients had 2 or more diagnoses. 33.8% were conditions of non-infective origin, 30.1% conditions of infective origin and 25.7% injury. Top 5 diagnoses were malaria, anaemia, pneumonia, head injury and soft tissue injury. Patient charts documented triage in 0.13% of cases, at least 1 vital sign in 42.3% of cases and at least 1 form of examination in 41.4% of cases. 62.3% patients had at least 1 form of investigation. 73.2% of patients received an IV treatment, most commonly antibiotics (52.5%) and IV crystalloids (33.1%).ConclusionThis is the first study of all-cause disease burden and management of emergency patients presenting across multiple Ugandan facilities. The development and application of an emergency care specific diagnostic coding system applicable to LMICs is a vital step to enable understanding and comparison across facilities. By appreciating the burden of emergency care disease, strategies can be put in place to implement an integrated emergency care system in Uganda.
780 Treatment of life-threatening digoxin toxicity with digoxin immune fab antibody: findings from the UK DigiFab®patient registry
Authors: Thomas Emma , Tomlinson Sam , Thomas Siwan , Ward Suzanne , Daugherty Claire , Gallardo Eva , Hill Christon 
Published: June 2022

Aims/Objectives/BackgroundDigoxin continues to play an important role in the management of atrial fibrillation (AF) and heart failure. Toxicity due to acute over-ingestion of digoxin is generally mild and manageable but can be life-threatening.1Digoxin immune Fab (DIF; DigiFab®) is the mainstay of treatment for life-threatening digoxin toxicity (LTDT). We report findings on efficacy and safety of DIF from the UK DigiFab Patient Registry.Methods/DesignThis prospective, observational study was a post-authorisation requirement from the MHRA. Physicians in all UK hospitals using DIF were invited to submit data for any patient who received DIF for LTDT. All AEs were followed-up according to Good Pharmacovigilance Practice.Results/ConclusionsBetween April 2012 and June 2017, 94 patients were enrolled; 10 were excluded (off-label DIF, n=2; outcome not recorded, n=8). Patients were typically elderly (mean: 81 years) and >80% cases involved chronic vs acute toxicity. Most frequently reported symptoms were bradycardia (74%), abnormal mental status/visual disturbance (40%), hyperkalaemia (33%) and gastrointestinal effects (32%). Other cardiac arrhythmias included 2nd/3rd degree heart block (19%), AF (13%), asystole (5%) and ventricular tachycardia (5%); 85% of patients experienced ≥1 arrhythmia. DT resolved in 57 (67.9%) and persisted in 24 (28.6%) patients at the time of reporting. For the remaining 3 (3.6%) patients, the recorded outcome was death. 7 patients reported adverse drugs reactions, including death (n=3) and AF, bradycardia, cardio-respiratory arrest, acute renal failure, cellulitis and hypoglycaemia (all n=1). No cause was reported/established for the 3 deaths and so these were conservatively assessed as possibly related to DIF but were most likely complications of underlying medical conditions. The results were consistent with earlier reports with digoxin-specific antibody Fab fragments,2with DIF highly effective in resolving LTDT in a real-world setting.ReferencesGummin DD,et al. Clin Toxicol2020;58:1360–541.Schaeffer TH,et al. J Am Osteopath Assoc2010;110:587–92.
797 Diurnal trends in medical student first responder availability and demand
Authors: Watson Adam 
Published: June 2022

Aims/Objectives/BackgroundMedical Student First Responders (MSFRs) are volunteer Community First Responders, who respond to emergency calls and can provide life-saving interventions before the arrival of an ambulance. There is no data on diurnal trends in ambulance service demand for MSFRs, who do not typically work fixed shift patterns and therefore at present do not know when the most beneficial time of day to volunteer is. Thus, the aim of this service evaluation was to asses when demand for MSFRs is highest in central Oxfordshire and assess if MSFRs were available to respond at those times.Methods/DesignAll MSFRs shifts on a single Dynamic Response Vehicle between 1 October to 31 December 2020 were included. The MSFRs operated exclusively in central Oxfordshire (post codes OX1 – OX4) on behalf of South Central Ambulance Service. MSFR dispatch probability was calculated by comparing total time on duty (for each hour between 9 am – 1 am) with the respective number of incidents attended within that hour, and then plotted as a 3-point moving average against time. No patient data was collected.Results/Conclusions163 ‘on duty’ hours and 58 incidents (44% ‘Category 1’ responses, 88% MSFR first on scene) were included. There were clear diurnal trends in MSFR availability and demand (Abstract 797 figure 1). The probability of MSFR dispatch was highest at 56.3% between 6–7 pm; however, MSFRs were most likely to be available later in the day between 9–10 pm.These findings suggest that the majority of MSFRs shifts occur at times when demand is relatively low. MSFRs are a highly flexible resource and should be encouraged to volunteer earlier in the day, as this would significantly improve coverage during the late afternoon when demand is greatest.Abstract 797 Figure 1