UK Emergency Departments Research Articles

Service use following attendance at an emergency department with an head injury: a 6-month survey

To survey the attendance of patients presenting with a head injury (HI) at a UK emergency department (ED), identifying numbers, types of service and referral routes; to survey subsequent service use and to highlight the challenges in service planning and identifying which patients may potentially benefit from follow-up/rehabilitation input. A retrospective population-based case series study using multiple prospective and retrospective data sources. Adults from the National Health Service (NHS) Cambridgeshire catchment area attending an ED over a 6-month period with a HI were identified from detailed ED reports, and any service use within the hospital after injury was tracked using a number of data sources. 1036 patients presented on 1081 occasions with a HI during the 6 months. Of the 1081 HIs, 979 (91%) were mild (Glasgow Coma Scale (GCS) score 13-15), 70 (6%) were moderate (GCS score 9-12), and 32 (3%) were severe (GCS score <9). A number of types of referral routes and systems were identified and analysed: 873 (81%) patients were discharged directly from ED, with four offered HI-specific follow-up. Of 208 admissions, 27 (2%) were to neurosurgical care, and 35 (3%) patients were offered HI-specific follow-up, 24 of these being in a specialist neurotrauma clinic. Follow-up started between 1 and 18 months after injury. At 24 months after injury, follow-up for 10 of these was still ongoing. These study findings highlight the difficulties in identifying patients who would benefit from follow-up, in particular after mild HI. Our study findings will form the basis of a long-term follow-up study.

Can ocular ultrasound predict intracranial hypertension? A pilot diagnostic accuracy evaluation in a UK emergency department

To determine if ultrasound guided measurement of the optic nerve sheath diameter accurately predicted elevated intracranial pressure (ICP) as demonstrated by cranial computed tomography (CT) in at-risk emergency department patients. Optic nerve sheath diameters were measured on a convenience sample of adult patients presenting with suspected elevated ICP to the emergency department of a large teaching hospital over a 6-month period. A cut off for optic nerve sheath diameter of 5 mm was considered positive for elevated ICP. All patients had a subsequent cranial CT scan on the same day reported by a radiologist. Signs of elevated ICP on cranial CT include midline shift with a mass effect of at least 3 mm, sulcal effacement with evidence of significant oedema, collapse of ventricles, and cisternal compression. Twenty-four patients were recruited with a sensitivity of 100% [95% confidence interval (CI), 83.8-100] and specificity of 75% (95% CI, 30.1-95.4) with a cut-off of 5 mm for optic nerve sheath diameter to predict elevated ICP on cranial CT scan. The positive predictive value for an increased optic nerve sheath diameter for elevated ICP was 95.4% (95% CI, 74.13-99.75) and negative predictive value was 100% (95% CI, 31-100). The positive likelihood ratio of a wide optic nerve sheath diameter for elevated ICP on cranial CT was calculated to be 4.00 (95% CI, 0.73-21.84). This study shows that the ultrasound guided optic nerve sheath diameter is a sensitive and specific test for predicting elevated ICP. A prospective validation study across emergency departments would test applicability of this test. We propose an algorithm for incorporating ultrasound for the management of suspected intracranial hypertension in emergency departments.

Using a computerised patient-alert system

SThe information technology systems used in most modern emergency departments alert staff to patients who require special management, including those with infections or histories of violence, or children on the child protection register. These systems can improve care for patients, protect staff and prevent infection, although their benefits must be weighed against the risks involved in storing sensitive data on computers. It is essential, therefore, that such systems are professionally maintained and updated. This article reports how one UK emergency department uses a computerised alert system to improve patient care.

Association between ASA grade and complication rate in patients receiving procedural sedation for relocation of dislocated hip prostheses in a UK emergency department

ObjectiveTo determine the association between the American Society of Anesthiologists (ASA) grade and the complication rate of patients receiving procedural sedation for relocation of hip prosthesis in an adult emergency...

A review of blood component usage in a large UK emergency department after implementation of simple measures

ObjectivesTo review clinical indications and demographics of transfusion and the patterns of blood component ordering, transfusion, wastage and traceability, before (2007) and after (2011) implementation of simple improvement strategies.MethodsRetrospective case...

Premature death after self-harm: a multicentre cohort study

People who self-harm have an increased risk of premature death. The aim of this study was to investigate cause-specific premature death in individuals who self-harm, including associations with socioeconomic deprivation. We undertook a cohort study of patients of all ages presenting to emergency departments in Oxford, Manchester, and Derby, UK, after self-poisoning or self-injury between Jan 1, 2000, and Dec 31, 2007. Postcodes of individuals' place of residence were linked to the Index of Multiple Deprivation 2007 in England. Mortality information was supplied by the Medical Research Information Service of the National Health Service. Patients were followed up to the end of 2009. We calculated age-standardised mortality ratios (SMRs) and years of life lost (YLL), and we tested for associations with socioeconomic deprivation. 30 950 individuals presented with self-harm and were followed up for a median of 6·0 years (IQR 3·9-7·9). 1832 (6·1%) patients died before the end of follow-up. Death was more likely in patients than in the general population (SMR 3·6, 95% CI 3·5-3·8), and occurred more in males (4·1, 3·8-4·3) than females (3·2, 2·9-3·4). Deaths due to natural causes were 2-7·5 times more frequent than was expected. For individuals who died of any cause, mean YLL was 31·4 years (95% CI 30·5-32·2) for male patients and 30·7 years (29·5-31·9) for female patients. Mean YLL for natural-cause deaths was 25·9 years (25·7-26·0) for male patients and 25·5 years (25·2-25·8) for female patients, and for external-cause deaths was 40·2 years (40·0-40·3) and 40·0 years (39·7-40·5), respectively. Disease of the circulatory (13·1% in males; 13·0% in females) and digestive (11·7% in males; 17·8% in females) systems were major contributors to YLL from natural causes. All-cause mortality increased with each quartile of socioeconomic deprivation in male patients (χ(2) trend 39·6; p<0·0001), female patients (13·9; p=0·0002), and both sexes combined (55·4; p<0·0001). Socioeconomic deprivation was related to mortality in both sexes combined from natural causes (51·0; p<0·0001) but not from external causes (0·30; p=0·58). Alcohol problems were associated with death from digestive-system disease, drug misuse with mental and behavioural disorders, and physical health problems with circulatory-system disease. Physical health and life expectancy are severely compromised in individuals who self-harm compared with the general population. In the management of self-harm, clinicians assessing patients' psychosocial problems should also consider their physical needs. Department of Health Policy Research Programme.

Improving mortality after extradural haematoma in England and Wales

Introduction. Head injury is an important cause of death and disability in young people, with 1.4 million presentations each year in the UK. Extradural haematoma (EDH) is a potentially fatal head injury, which is easily remedied surgically. Several factors influence the mortality of EDH. The mortality of isolated EDH ranges from 1.2 to 33%. EDH outcome within the UK has not been recently described. Materials and methods. The Trauma Audit and Research Network (TARN) database was used to collate data on patients in England and Wales, with ‘isolated’ EDH between 1997 and 2003. Age, gender, GCS at 1st emergency department (ED), haematoma size, presence of a skull fracture, outcome (alive or dead) and injury-to-operation time were required. Where this time was unavailable, an estimation could be made using another time collected for the patient. Data co-ordinators at several hospitals were contacted in order to collect extra information missing from the database. The mortality for this group was then calculated and comparisons between this and previous series were made. Results. A total of four-hundred and eighty four (484) patients with isolated EDH were identified. One-hundred and ninety-seven (197) patients were operated on in England and Wales in this TARN dataset, between 1997 and 2003 for ‘isolated’ EDH. The mortality rate for this operative series was 2% (4 patients) (95% CI 0.1–4%). The non-operative mortality rate was 3% (95% CI 0.9–5.0%). Conclusion. This study has found a low EDH operative mortality rate of 2%. This is lower than that of previous studies on isolated EDH in the UK. This is likely to be valid as TARN is the largest European trauma registry, although we acknowledge that this first EDH sample derived from UK EDs may represent a selected series.

National audit of antidote stocking in acute hospitals in the UK

BackgroundInadequate stocking of essential antidotes in hospitals for the treatment of poisoned patients has been reported worldwide. Joint National Poisons Information Service (NPIS)/College of Emergency Medicine (CEM) guidelines for antidote...

What is the burden of alcohol-related injuries in an inner city emergency department?

BackgroundThe annual cost to the NHS of alcohol-related injury and illness is estimated to be £2.7 billion. Alcohol-related violence has become a concerning public health issue. This study set out...

2-DPMP (desoxypipradrol, 2-benzhydrylpiperidine, 2-phenylmethylpiperidine) and D2PM (diphenyl-2-pyrrolidin-2-yl-methanol, diphenylprolinol): A preliminary review

2-DPMP (desoxypipradrol, 2-benzhydrylpiperidine, 2-phenylmethylpiperidine) and D2PM (diphenyl-2-pyrrolidin-2-yl-methanol, diphenylprolinol) are psychoactive substances, sold primarily over the Internet and in 'head' shops as 'legal highs', 'research chemicals' or 'plant food'. Originally developed in the 1950s for the treatment of narcolepsy and ADHD, 2-DPMP's use soon became very limited. Recreational use of 2-DPMP and D2PM appears to have started in March 2007, but only developed slowly. However, in the UK their popularity grew in 2009, increasing rapidly during summer 2010. At this time, there were many presentations to UK Emergency Departments by patients complaining of undesirable physical and psychiatric effects after taking 2-DPMP. In spring 2011 there were similar presentations for D2PM. Recreational use of these drugs has been reported only occasionally in on-line user fora. There is little scientifically-based literature on the pharmacological, physiological, psychopharmacological, toxicological and epidemiological characteristics of these drugs. Here we describe what is known about them, especially on their toxicity, including what we believe to be the first three deaths involving the use of 2-DPMP in August 2010. There are no international controls imposed on 2-DPMP or D2PM. However, a ban on their UK importation was imposed in November 2011 and they became Class C drugs on 13 June 2012. It is critical that any other cases, including non-fatal overdoses, are documented so that a scientific evidence-base can be established for them.

Validation of evidence-based heart rate and respiratory rate centiles

<h3>Aims</h3> We have previously developed evidence-based centiles for normal heart rate and respiratory rate in children. The predictive value of these centiles has been assessed using independent data collected in an emergency care setting. <h3>Method</h3> Predictive value was assessed using data previously gathered from children attending a UK emergency department with medical illness. The ability of various centiles to predict admission for more than 24 hours; and admission for more than 24 hours, administration of oxygen, or the need for IV interventions in respiratory illness were assessed. The performance of evidence-based centiles was compared to that of the existing APLS clinical thresholds. <h3>Results</h3> The 3rd and 97th evidence-based centiles produce sensitivities and specificities that are similar to those of the existing APLS thresholds for heart rate. For respiratory rate, similar results to the existing APLS thresholds are observed using the 25th and 75th evidence-based centiles. The c-statistic (estimated area under the ROC curve) shows that individual vital signs have moderate predictive ability for admission and serious respiratory illness in this cohort (ranging from 0.585 for prediction of admission using heart rate alone, to 0.695 for prediction of serious respiratory illness using both heart rate and respiratory rate). <h3>Conclusion</h3> Evidence-based centiles and APLS thresholds for heart rate and respiratory rate have similar predictive ability. The choice of centiles allow appropriate trade-offs between sensitivity and specificity to be made in different clinical situations.

Track and trigger in an emergency department: an observational evaluation study

ObjectiveTo evaluate the utilisation of paper-based track and trigger (T&T) charts in a UK emergency department (ED).MethodsA single-centre prospective observational cohort study was conducted in the ED of a medium-sized...

Impact of the introduction of emergency ultrasound to one large UK emergency department: the REBUS study

AimFirstly, to detail the experiences of one UK training region in establishing an emergency ultrasound (EU) training programme and secondly, to report the initial 30 months of EU scanning experience.MethodsProspective...

Survey of the use of therapeutic hypothermia after cardiac arrest in UK paediatric emergency departments

ObjectivesTo ascertain current use of therapeutic hypothermia (TH) after paediatric cardiac arrest in UK emergency departments (EDs), and views on participating in a UK randomised controlled trial (RCT) incorporating early...

Continuing Professional Development: Diagnosis and management of minor head injury in the UK

Overview Head injury accounts for a large amount of emergency services work in the UK. This article summarizes the findings of studies undertaken for the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme examining the available evidence regarding the diagnostic management of minor head injuries. These studies included a review of current practice in the management of minor head injured patients (GCS 13–15) by way of a survey of UK emergency departments. We also performed a systematic review of the head injury literature to identify the most accurate clinical decision rule for adults (Canadian CT Head Rule) and children (Paediatric Emergency Care and Research Network) and commented on the applicability of these in the UK population. This review helped to identify the most significant clinical findings that increase the likelihood of intracranial and neurosurgical injury, following minor head injury in adults, children and infants. Finally, we have highlighted where these findings may be relevant to UK paramedic practice, in particular in influencing the decision to transfer patients to the emergency department. Learning Outcomes After completing this module you will: • Have an understanding of the significant clinical characteristics following head injury • Understand potential pathological problems following head injury • Be able to assess the relevant clinical features of all patients following head injury • Be familiar with key clinical decision rules for patients with head injury • Be able to provide the appropriate pre-hospital management for all head injured patients.

Specialist care for frail older people

At Leicester Royal Infirmary, the care of frail older people occupies a disproportionate amount of emergency department (ED) staff's time and resources. Too few ED staff are trained to deal with the complex comorbidities associated with older patients, 90 per cent of whom are therefore admitted to hospital. To take the pressure off the ED and reduce the number of avoidable admissions, the hospital has set up an emergency frailty unit to treat patients over the age of 70 who need not be admitted to hospital and to ensure they can receive community care as soon as possible. This article describes how the unit operates.

A randomised trial comparing the clinical effectiveness of different emergency department healthcare professionals in soft tissue injury management

ObjectivesTo evaluate the clinical effectiveness of soft tissue injury management by emergency nurse practitioners (ENPs) and extended scope physiotherapists (ESPs) compared to the routine care provided by doctors in a...

Reproducibility of the cervical range of motion (CROM) device for individuals with sub-acute whiplash associated disorders

The objective of this study was to evaluate the reproducibility of the cervical range of motion device when measuring both active and passive range of motion in a group of individuals with sub-acute Whiplash Associated Disorders (WAD). Participants were recruited as part of a large multi-centre Randomised Controlled Trial from UK emergency departments. Experienced research physiotherapists measured active and passive cervical spine movements in all directions. Both intra- and inter-observer reliability and agreement were assessed using the intra-class correlation coefficient, standard error of measurement and limits of agreement methods. Different groups of 39 and 19 subjects were included in the intra and inter-observer studies, respectively. The CROM device demonstrated substantial intra- and inter-observer reliability and agreement for all the active and passive half-cycle movements (ICC range 0.82-0.99) with the exception of one (passive right lateral flexion for inter-observer; ICC 0.77). The CROM device has proven to be a reproducible measurement method for a symptomatic WAD population using the measurement protocol described and can be used with confidence to differentiate individuals according to a single measurement.

019 Nerve blocks: the next hip thing?

Objectives and BackgroundsFractured neck of femur (NOF) is a common presentation to UK emergency departments (ED) with approximately 75 000 patients admitted annually. Pain control and time to admission are...

Diagnosis and management of minor head injury in the UK

Head injury accounts for a large amount of emergency services work in the UK. We performed a review of current practice in the management of minor head injured patients (GCS 13-15) by way of a survey of UK emergency departments. Nearly all departments (∼95%) reported unrestricted access to computer tomography (CT) scans. Admission rates for minor head injured patients were 18% for adults and 9% for children. From our systematic review, we identified the most accurate clinical decision rule for adults (Canadian CT Head Rule) and children (Pediatric Emergency Care and Research Network) and commented on the applicability of these in the UK population. We also identified the most significant clinical findings that increase the likelihood of intracranial and neurosurgical injury, following minor head injury in adults, children and infants. Finally, we have highlighted where these findings may be relevant to UK paramedic practice, in particular in influencing the decision to transfer patients to the emergency department. This article summarizes the findings of studies undertaken for the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme examining the available evidence regarding the diagnostic management of minor head injuries. It will be published in a number of articles and a full report for the HTA programme.