Emergency medicine journal : EMJ
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The optimal management of minor head injured patients with brain injury identified by CT imaging is unclear. Some guidelines recommend routine hospital admission of GCS13-15 patients with traumatic brain (TBI) injury identified by CT imaging. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED). ⋯ 4431 studies were identified by the search strategy, of which 123 studies were fully retrieved and 49 primary studies and 5 reviews met the inclusion criteria. The estimated pooled risk of the outcomes of interest were: clinical deterioration 11.7% (95% CI:11.7 to 15.8; neurosurgery 3.5% (95% CI:2.2% to 4.9%); death 1.4% (95% CI:0.8% to 2.2%). A large degree of between study variation in the estimates of the outcomes was identified. Multivariable meta-regression of study characteristics identified that mean age of the study population and mean initial GCS accounted for up to half of the variation in reported study outcomes. Within studies the following factors were found to affect the risk for these adverse outcomes: age; severity of injury; type of injury; initial GCS; anti-coagulation; anti-platelet medication; and injury severity scoring. When univariable within study risk factor effect estimates were pooled patients with isolated subarachnoid haemorrhage had an odds ratio of 0.19 for deterioration compared to other injury types.emermed;34/12/A862-a/F2F2F2Figure 2Meta-regression of study factors predictive of neurosurgery CONCLUSION: Minor head injured patients with brain injury identified by CT imaging have a clinically important risk of serious adverse outcomes. Research has identified the possible factors that affect this risk. However, these factors need to be incorporated into a validated multivariable prognostic model before low-risk patients can be reliably identified clinically and triaged to lower levels of care.emermed;34/12/A862-a/F3F3F3Figure 3PRISMA flow-diagram showing selection of studies for inclusion in the systematic review.
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Observational Study
Identifying discordance between senior physicians and trainees on the root cause of ED revisits.
Analysis of 72-hour ED revisits is a common emergency medicine quality assurance (QA) practice. Our aim was to compare the perceived root cause for 72-hour ED revisits between senior physicians (attendings) and trainees. We proposed that discordance in perception of why the revisit occurred would guide improvements in 72-hour revisits QA and elucidate innovative educational opportunities. ⋯ Attendings and trainees frequently disagree on whether a potential medical deficiency was the root cause for an ED revisit, with more disagreement noted for cases requiring admission. These findings support the premise that there may be opportunities to improve 72-hour revisits QA systems through trainee integration. Finally, reuniting attending-trainee pairs around revisit cases may be a novel educational opportunity.
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The burden of litigation within the NHS should not be underestimated. Indemnity costs rise in response to the rising frequency and costs of claims, with recent changes to the discount rate projected to increase NHS Litigation Authority (NHSLA) costs by £1 Billion per year. Litigation also has a significant psychological impact on staff. This study represents the first examination of litigation and Coroner's 'Prevention of Future Deaths' reports relating to emergency department care in the UK. ⋯ Annual claim numbers have increased by 117% over the study period and mean claim cost has increased by 111% (far in excess of any rise expected due to inflation). Causation cannot be determined by this observational study, but potentially contributory factors include: the increasingly litigious nature of society in general; rising patient expectations and the worsening crisis in staff retention, recruitment and morale.This analysis of litigation patterns and PFD reports provides an insight that enables further focus on the underlying causes, subsequent improvement in patient care and a reversal of current litigation trends.
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Frequent Attenders (FA) to Emergency Departments (ED) are a vulnerable population which we perceive to have a high morbidity and mortality. ED clinicians find this population challenging and they are at risk of being stigmatised. There has been little published work in the UK quantifying the risk of death in this population. Here we aim to quantify the 5 year mortality of this population and identify key risk factors. ⋯ Frequent Attenders to Addenbrooke's ED have a risk of death much greater than the normal population. A large proportion of the patients who died were very elderly and so 5 year mortality is less surprising but may suggest a need for further community care involvement to reduce ED attendance.The crucial finding is that the risk of death for adult FAs between the age of 16-65 is much higher than would be expected of the normal population. This indicates a need to treat this population with increased care.
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Paediatric Traumatic Cardiac Arrest (TCA) is a high acuity, low frequency event with fewer than 15 cases reported per year to the Trauma Audit Research Network (TARN). Traditionally survival from TCA has been reported as low, with some believing resuscitation is futile. Within the adult population there is growing evidence to suggest that with early and aggressive correction of reversible causes, survival from TCA may be comparable to that seen from medical out-of-hospital cardiac arrests. Key to this survival has been the adoption of a standardised approach to resuscitation.The aim of this study was, by a process of consensus, to develop a national, standardised algorithm for the management of paediatric TCA. ⋯ 41 participants attended the consensus development meeting. Of the 19 statements discussed, 13 reached positive consensus and were included in the algorithm. A single statement regarding initial rescue breaths reached negative consensus and was excluded. Consensus was not reached for five statements, including the use of vasopressors and thoracotomy for haemorrhage control in blunt trauma. The proposed algorithm for the management of paediatric TCA is shown as Figures 1 and 2 for blunt and penetrating trauma respectively.emermed;34/12/A892-b/F1F1F1Figure 1emermed;34/12/A892-b/F2F2F2Figure 2 CONCLUSION: In attempt to standardise our approach to the management of paediatric TCA and to improve outcomes, we present the first algorithm specific to the paediatric population.