District General Hospital Emergency Department Research Articles

Early Management of Paediatric Wrist and Forearm Fractures in a Busy District General Hospital Emergency Department: A Retrospective Cohort Comparison Study and Audit of BOAST Guidelines.

In response to the strain that the COVID-19 pandemic put on hospitals in the UK, the British Orthopaedic Association, in May 2021, set out British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guidelines for the early management of distal forearm fractures in children. Following this, a local pathway was introduced at our Trust to manage these injuries in the Emergency Department (ED).The aim of this audit was to monitor compliance with the BOAST guidelines and compare the practice with a similar pre-COVID cohort. A fixed-date retrospective cohort study was conducted that included cases that presented to the emergency department during a six-month period (August 1, 2021 to January 31, 2022). Data was analysed for rates of primary EDmanipulation, documentation of consent and neurovascular status in the notes, orthogonal X-ray data, time till the clinic follow-up, theatre time saved and complications. The ED fracture manipulation rate was also compared with another similar pre-COVID cohort (August 1, 2019 to January 31, 2020) to look for any improvement in the practice. A total of 86.31% cases were found to have primary fracture manipulation in the ED following the introduction of Trust guidelines in accordance with the BOAST recommendations. This is an improvement in comparison to the 31.94% fracture manipulation rate before the COVID pandemic. Implementation of the Trust pathway in accordance with the BOAST guidelines along with staff education has standardized the practice at our Trust. It saved approximately 63 hours of trauma theatre time for the six-monthdata collection period. Our findings also suggest that this has favourable outcomes for the patients with no complications.

An Assessment of the Potential Benefits of Video Consultation in the Emergency Department: Mixed Methods Study.

BackgroundDistrict general hospital emergency departments may refer patients to a tertiary center depending on the information available to a generalist clinician in discussion with a specialist team. If there is uncertainty, the lowest-risk strategy is often to transfer the patient. Video consultation allowing the specialist team to see and talk to the patient and local clinician while still in the emergency department could improve decision-making for patient transfer.ObjectiveThe aim of this study is to assess the potential benefit of real-time video consultation between remote specialists and emergency department patients and clinicians across all specialties.MethodsDetailed patient data were collected prospectively for 6 months (between January 16, 2012, and July 15, 2012) on all patients presenting to a district general hospital emergency department who required input from a specialist team at the nearest tertiary care center. These patients were discussed retrospectively with the specialist teams to determine whether videoconferencing could have benefited their management. The logistics for the use of videoconferencing were explored.ResultsA total of 18,799 patients were seen in the emergency department during the study period. Among the 18,799 patients, 413 referrals (2.2%) were made to the tertiary center specialist teams. A review of the patients transferred indicated that 193 (46.7%) of the 413 patients who were referred might have benefited from video consultation (193/18,799, 1% of all patients). If the specialist team could be accessed via videoconferencing only while a senior member was available in the hospital (8:00 AM-10:00 PM), then a maximum of 5 patients per week across all specialties would use the equipment. If 24-hour specialist access was available, this would increase to 7 patients per week.ConclusionsIn regions where there is direct transportation of patients by ambulance to specialist centers and there is a regional picture archiving and communication system in place, video consultation between emergency department patients and specialists has limited potential to improve patient management.

Seizures and emergency department: characteristics and factors of repeat adult attendees.

To identify risk factors and characteristics for the repeated attendance at an emergency department (ED) following a seizure. A retrospective cohort study was conducted using non-identifiable data of individuals attending ED at least twice between 2015 and 2018, following a seizure. Data were drawn from the patient administration system of an English rural medium-sized teaching district general hospital emergency department (ED), serving a population of 566,000 people. It was analysed for bio-psycho-social features associated with repeat attendances. Of 3522 seizure-related attendances in the four years, 450 people were identified to be repeaters attending on two or more occasions (range 2-12). Just over a quarter (27%) were 18-29years old. Higher likelihood of re-attendance was associated with social deprivation and no fixed abode. Mental illness was a significant co-morbidity influencing repeat attendances. Nearly half (47%) had no recorded anti-seizure medication (ASM). Three fifth (60%) were on general medication and a quarter (25%) on psychotropics. Nearly a quarter (22%) had alcohol and recreational drug concerns. Just over a quarter (28%) had no previous epilepsy diagnosis. Nearly a fifth (n = 85, 19%) died during the study period. People who present repeatedly with seizures at ED are at significant risk of death over a four-year period and require pro-active clinical follow-up. People who are homeless or from socially deprived areas are over-represented in this group, as are those with alcohol problems, co-morbid mental health conditions and compliance issues. This suggests enhanced targeted intervention for this cohort is needed.

Implementing a quality framework for storing emergency department point-of-care ultrasound examinations on a picture archiving and communication system.

There is a lack of a quality framework in most emergency departments despite the set national standards for storing point-of-care ultrasound (PoCUS) examinations. To explore and address this problem, a quality improvement project was undertaken in an emergency department.Methods and interventions: A consecutive sample of the most recent PoCUS examinations in a district general hospital emergency department in the United Kingdom was audited. None was handled and stored on the picture archiving and communication system (PACS). Quality improvement project tools, such as plan, do, study, act (PDSA) cycles, were utilised to analyse and improve practice. The PoCUS machine was connected to the local area network to allow transfer of images to PACS. For requesting and booking the examinations, specific requests on the integrated clinical environment were created akin to the computerised radiology information system codes. Other interventions were introduced such as a reporting proforma. The success of the quality improvement project depended partly on key stakeholders such as emergency department consultants, radiology staff and PACS teams. The number of stored examinations on PACS was the main process measure, but others were also considered, for example reporting and documentation. Over a 10-month period (September 2018-July 2019), there were three PDSA cycles, which included a total of 195 performed emergency department PoCUS examinations. The implemented quality framework led to 90% of examinations stored to PACS, with a mean of 63%. No negative impacts were reported, and feedback was positive. Implementing a quality framework for storing emergency department PoCUS examinations on PACS is feasible and significantly improves practice. Further work is required to sustain and improve the process.

Fatal primary dengue-induced Haemophagocytic Lymphohistiocytosis (HLH) in a returning traveller from India treated with anakinra for the first time

Abstract Background Dengue fever is an arthropod-borne flavivirus infection that is highly prevalent in the tropics. A proportion of clinical cases develop severe dengue, defined by life-threatening complications including haemorrhage, capillary leak and multi-organ failure. Recently there has been increasing recognition that some cases of severe dengue may be a consequence of HLH. To our knowledge, this is the first report of treatment with Anakinra for dengue-induced HLH. Case report We report a case of Dengue fever triggering HLH in an eighteen-year-old female returning traveller from India, diagnosed with systemic lupus erythematosus (SLE) two months prior to presentation. The patient initially presented to a district general hospital emergency department (ED) with a three-day history of flu-like symptoms, fever, erythematous rash, widespread joint pain, nausea and chills. Acute Dengue virus infection was confirmed with serum polymerase chain reaction (PCR) testing. On day two, she was admitted to intensive care for multi-organ support necessitated by refractory hypotension, oligo-anuric severe acute kidney injury (AKI), acute liver failure with lactataemia and type one respiratory failure. The possibility of Dengue-induced HLH was considered early with multiple criteria for diagnosis met including hyperferritinaemia, pancytopenia, lipaemia and a marked transaminitis. HLH-directed therapy was commenced with intravenous immunoglobulins (IVIG), intravenous methylprednisolone (IVMP) and Anakinra. Subsequent bone marrow biopsy analysis demonstrated clear evidence of HLH, in the context of a persistent and marked Dengue viraemia. We observed resolution of HLH markers as well as reducing requirements for multi-organ support after initiation of Anakinra therapy. During her recovery, the patient unexpectedly developed focal neurology; intracranial imaging demonstrated widespread, discreet parenchymal lesions thought to be haemorrhagic in nature, which were deemed too severe an insult to recover from. On day 19, the difficult decision of withdrawing care after deep discussion with the family was reached, soon after which the patient passed away. A post-mortem examination was not arranged.

Comparing the effectiveness of fascia iliaca block with standard analgesia in neck of femur fractures in a district general hospital emergency department—a prospective study with review of literature

Background: The incidence of hip fractures is increasing as the population ages with current estimates of 101,000 per year by the year 2020 in the United Kingdom. Pain has both a physiological and a psychological component to it. Early and effective analgesia has been proven to benefit patients and possibly lead to earlier return to baseline function. Through the years fascia iliaca blocks (FIBs) have been used as an adjunct management for analgesic relief in neck of femur fractures Methods: We carried out a preliminary study to assess the use of stickers to document various measures of pain management. There was patchy uptake of the aforementioned stickers, we subsequently reverted back to the use of our pre-existing hip fracture proforma for documentation of pain scores. There were two main parameters measured in our study in our Emergency Department in our District General Hospital. The first parameter was the time to reassessment from initial assessment. The second parameter was assessing the effectiveness of FIBs and the associated pain scores. In total we had 42 patients included in our study over a 6-month period with 25 patients undergoing FIBs. Results: The average time to reassessment was noted to be 72 min. In patients that underwent FIBs there was a 41.8% improvement in pain scores. From the study we noted that 9 patients refused to have the FIB (21.4%). From the 25 patients that underwent FIB, it was noted that 11 patients had no improvement of their pain scores from the pain score at reassessment (44%). However, it is worth noting the longer acting nature of the FIB provides patients with pain relief for longer periods especially if there is a delay to theatre. Conclusions: FIBs provide an effective adjunct to analgesia. We identified various measures that could be implemented for better analgesic control in patients with neck of femur fractures. We hope to undertake studies with larger number of patients to better assess the effectiveness of FIBs.

Better safe than sorry? Frequent attendance in a hospital emergency department: an exploratory study.

Pain accounts for the majority of attendances to the Emergency Department (ED), with insufficient alleviation of symptoms resulting in repeated attendance. People who frequently attend the ED are typically considered to be psychologically and socially vulnerable in addition to experiencing health difficulties. This service development study was commissioned to identify the defining characteristics and unmet needs of frequent attenders (FAs) in a UK acute district general hospital ED, with a view to developing strategies to meet the needs of this group. A mixed-methods multi-pronged exploratory approach was used, involving staff interviews, focus groups, business data and case note analysis. Findings reflect an absence of a coherent approach to meeting the needs of FAs in the ED, especially those experiencing pain. FAs to this ED tend to be vulnerable, complex and report significant worry and anxiety. Elevated anxiety on the part of the patient may be contributing to a 'better safe than sorry' culture within the ED and is reported to bear some influence on the clinical decision-making process. It is recommended that a systemic approach is taken to improve the quality and accessibility of individualised care plans, provision of patient education, psychological care and implementation of policies and procedures. Change on an organisational level is likely to improve working culture, staff satisfaction and staff relationships with this vulnerable group of patients. A structured care pathway and supportive changes are likely to lead to economic benefits. Further research should build on findings to implement and test the efficacy of these interventions.

TIME IS MUSCLE: MANAGEMENT OF CHEST PAIN IN THE EMERGENCY DEPARTMENT

Objectives & BackgroundMany chest pain assessment protocols include delayed troponin assays, which makes assessment within the Emergency Department (ED) 4-hour UK national target difficult, and increases pressure on medical admissions....

The management of acute urinary retention in a district general hospital (DGH) emergency department: How safe and effective is our current practice?

s / International Journal of Surgery 23 (2015) S15eS134 S46 We audited our preoperative maintence fluid prescribing against the guideline. Methods: 20 patients aged 18e65, operated on in February 2014 were randomly selected. Exclusion criteria: Complex fluid requirements/significant co-morbidities (renal impairment, shock, sepsis). Notes were examined documenting weights and fluids prescribed since being made NBM. The quantity of water & electrolytes prescribed was calculated. Weights were used to calculate the ‘ideal’ amount of each component according to the guideline and time frame. A fluid ‘flashcard’was produced to guide the prescribing. We re-audited in August 2014 Results: Initial audit demonstrated on average (mean) patients were prescribed 19.7% of the recommended potassium & 11.5% of glucose however 519.2% of sodium, 459.3% chloride and 155.9% of water. The reaudit showed improvements with increases in potassium and glucose prescribed, 31.9% and 62.3% respectively and decreases in sodium 450.5% and Chloride 423.3%. Water 157%. Conclusion: This audit shows that further education is required. Our flashcardmade improvements. Further dissemination& incorporation into a hospital protocol would be the ideal next step. 0730: THE SURGICAL ASSESSMENT UNIT: A SOLUTION TO EMERGENCY WAITING TIMES? M. Dunstan, K.W.J. Mok, U. Wali, I. Drami, S. Vig. Croydon University

Identifying Patients Suitable for Discharge After a Single-Presentation High-Sensitivity Troponin Result: A Comparison of Five Established Risk Scores and Two High-Sensitivity Assays

We compare the ability of 5 established risk scores to identify patients with suspected acute coronary syndromes who are suitable for discharge after a modified single-presentation high-sensitivity troponin result. This was a prospective observational study conducted in a UK district general hospital emergency department. Consecutive adults recruited with suspected acute coronary syndrome for whom attending physicians determined evaluation with serial troponin testing was required. Index tests were definitions of low risk applied to modified Goldman, Thrombolysis in Myocardial Infarction (TIMI), Global Registry of Acute Cardiac Events (GRACE), History, ECG, Age, Risk Factors, Troponin (HEART), and Vancouver Chest Pain Rule risk scores, incorporating either high-sensitivity troponin T or I results. The endpoint was acute myocardial infarction within 30 days. A test sensitivity threshold for acute myocardial infarction of 98% was chosen. Clinical utility was defined as a negative predictive value greater than or equal to 99.5% and identification of greater than 30% suitable for discharge. Nine hundred fifty-nine patients underwent high-sensitivity troponin T analysis and 867 underwent high-sensitivity troponin I analysis. In the high-sensitivity troponin T group, 79 of 959 (8.2%) had an acute myocardial infarction and 66 of 867 (7.6%) in the high-sensitivity troponin I group. Two risk scores (GRACE <80 and HEART ≤3) did not have the potential to achieve a sensitivity of 98% with high-sensitivity troponin T, and 3 scores (Goldman ≤1, TIMI ≤1, and GRACE <80) with high-sensitivity troponin I. A TIMI score of 0 or less than or equal to 1 and modified Goldman score less than or equal to 1 with high-sensitivity troponin T, and TIMI score of 0 and HEART score of less than or equal to 3 with high-sensitivity troponin I had the potential to achieve a negative predictive value greater than or equal to 99.5% while identifying greater than 30% of patients as suitable for immediate discharge. With established risk scores, it may be possible to identify greater than 30% of patients suitable for discharge, with a negative predictive value greater than or equal to 99.5% for the diagnosis of acute myocardial infarction, using a single high-sensitivity troponin test result at presentation. There is variation in high-sensitivity troponin assays, which may have implications in introducing rapid rule-out protocols.

Evaluation of demand in a rural English hospital emergency department

The purpose of this article is to analyse the patient demand placed on a rural district general hospital (DGH) emergency department within the context of the Purpose, Process, People (PPP) framework used in the private sector. This analysis was undertaken to inform wider evaluation of the implementation of the enterprise culture—the NHS policy to adopt private sector best practice to produce resource use, quality and efficiency improvements. The article concludes with a view that the PPP framework provides methods of calculating the level of discharge necessary to meet the four-hour wait target. Data describing the characteristics and patterns of attending patients can be used to develop an emergency department's processes and people to achieve its time-based target.

Acute testicular pain in children: collaboration in timely management.

Acute scrotal pain in a child is a urological emergency. Surgeons should be involved early and exclude torsion promptly, often by surgical exploration. This short report compares the time taken by different medical practitioners [Emergency Department (ED) doctors and surgeons] to assess children presenting to the ED with acute scrotal pain. A retrospective observational study was carried out in a district general hospital ED over a 2-year period. A total of 205 children presented with testicular pain, 48 of whom were clinically diagnosed with torsion in the ED. Surgeons reviewed patients with testicular pain quicker than ED doctors when they were referred directly from triage (P=0.019). Overall, review by a surgeon was more timely if the patient was referred directly from triage rather than after referral by the ED doctor (P<0.0001). A direct fast-track referral system to surgeons is needed in the ED to prevent unnecessary delays in definitive management of patients with testicular pain.

G34(P) The management of children diagnosed with torus (buckle) fractures of the distal radius: wrist splint and written self-care information versus wrist splint and hospital outpatient follow-up

Background and objectivesIn July 2013, the Paediatric Emergency Department (ED) of a UK District General Hospital ED seeing approximately 30000 children aged under 16 years of age per year in...

The safety netting behaviour of first contact clinicians: a qualitative study.

BackgroundAcute illness is common in childhood, and it is difficult for healthcare professionals to distinguish seriously ill children from the vast majority with minor or self-limiting illnesses. Safety netting provides parents with advice on when and where to return if their child deteriorates, and it is widely recommended that parents of acutely sick young children should be given safety netting advice. Yet little is known about how and when this is given. We aimed to understand what safety netting advice first contact clinicians give parents of acutely sick young children, how, when, and why.MethodsThis was a qualitative study. Interviews and focus groups were held with doctors and nurses in a general practice surgery, a District General Hospital emergency department, a paediatric emergency department, and an out-of-hours service. Data were analysed using the method of constant comparison.ResultsSixteen clinicians participated. They described that safety netting advice includes advising parents what to look for, when and where to seek help. How safety netting was delivered and whether it was verbal or written was inconsistent, and no participants described being trained in this area. Safety netting appeared to be rarely documented, and was left to individual preference. Limitations of written materials, and structural barriers to the provision of safety netting, were perceived. Participants described that safety netting was influenced by clinicians’ experience, confidence, time and knowledge; and perceived parental anxiety, experience, and competence. Participants noted several limitations to safety netting including not knowing if it has been understood by parents or been effective; parental difficulty interpreting information and desire for face-to-face reassurance; and potential over-reassurance.ConclusionFirst contact clinicians employ a range of safety netting techniques, with inconsistencies within and between organisations. Structural changes, clinician training, and documentation in patient notes may improve safety netting provision. Research is needed into the optimal components of safety netting advice so that clinicians can consistently deliver the most effective advice for parents.

LP or not LP, that is the question: gold standard or unnecessary procedure in subarachnoid haemorrhage?

ObjectiveTo measure the sensitivity of modern CT in patients presenting to the emergency department and evaluated for possible subarachnoid haemorrhage, with particular attention to those presenting within 12 h of...

G209 Managing Substance Misuse in Young People – What Works?

Alcohol and Drug use in Young People is a current national topic of great curiosity which occasionally, junior doctors manage with less interest during busy A&E shifts and pressing admission...

1479 Referral of Children from a Uk District General Hospital Emergency Department to Primary Care General Practitioners

BackgroundThis preliminary audit aimed to assess the feasibility of referring children presenting to a UK District General Hospital Emergency Department (ED), seeing 27500 children per year, to their own Primary...

The impact of a computerised whiteboard system on digit preference bias in the recording of emergency department process times

Digit preference bias has previously been described in a number of different clinical settings including the emergency department. This study aimed to assess whether the implementation of a computerised recording system affects the digit preference bias in recording of times of arrival, assessment and departure at an emergency department. A preintervention/postintervention study was undertaken in a type 1 district general hospital emergency department that receives approximately 70 000 attendances per annum. Consecutive 8-week samples were taken before and after the introduction of an electronic whiteboard/patient tracking system. Timings of arrival, nursing and medical assessment and departure were compared. Twelve thousand four hundred and ninety-three patients presented during the 8-week control period and 11 758 patients presented in the 8-week period after the introduction of electronic data capturing. Within the control group, over 80% of the nursing assessment (82.7%), medical examination (92.5%) and departure times (92.7%) ended in '0' or '5', compared with just over 20% after electronic recordings (22.0, 21.7 and 21.8% respectively). The introduction of the patient tracking system eliminated the digit preference bias found in recording of the time of nursing assessment, examination and departure that was present in the preintervention data.

Therapeutic hypothermia for out-of-hospital cardiac arrest: implementation in a district general hospital emergency department

BackgroundThe use of therapeutic hypothermia is recommended for unconscious adult patients with return of spontaneous circulation (ROSC) after out-of-hospital ventricular fibrillation cardiac arrest. There is evidence that the time taken...

The impact of the introduction of a ward-based automated medicines vending unit on nursing tasks and time in the Emergency Department

Abstract Objectives This study assessed the impact of the introduction of medicines vending units (MVUs) into an Emergency Department (ED) on nursing time spent on medicines-use processes. The objectives included identification of changes in nursing activities pre- and post-automation and the impact of automation on the time needed for nurses to access medicines and replenish ward stock. Methods This study was carried out in a district general hospital ED which is attended by over 65 000 patients each year. Staff were observed using work sampling techniques to compare activity before and after the introduction of MVUs. To assess possible changes in dose acquisition time, staff were timed withdrawing doses of medicines from traditional storage units and then from MVUs. To obtain baseline data about traditional methods of replenishing stock, nursing staff recorded the time at which traditional stock replenishment was carried out and the time required to do it. Key findings Nursing staff spent approximately 11% of their time on work activities related to medicines pre-automation and 12% post-automation (P = 0.234). The median time to acquire a dose of medication decreased from 139.5 s pre-automation to 44 s post-automation (P &amp;lt; 0.0001). Following automation, a total of 7.1 h/day could be saved in nursing time. A mean saving of 46.5 min/week was also identified because nursing staff are no longer involved in stock replenishment. Conclusions A significant release of nursing time was identified from the observed acquisition of doses of medicines from the MVU. Work sampling techniques suggest this does not appear to have translated into significant savings on nursing time dealing with medicines, although the nature of these activities has changed.