Emergency medicine journal : EMJ
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There has been a recent drive to implement rapid rule-out strategies which allow the early discharge of low-risk patients with suspected cardiac chest pain directly from the Emergency Department (ED). Previously, such patients would have been admitted to a hospital bed for observation and delayed biomarker testing. While the drive to implement rapid rule-out strategies comes from healthcare providers, there has been little assessment of patient perspectives on early discharge, in what is known to be a high-anxiety presentation. We aimed to explore patient perspectives on the acceptability of early discharge strategies. ⋯ Most patients would be satisfied with a rapid rule-out strategy, however, it should be acknowledged that patients receive reassurance from hospital admission and over 10% of patients would be dissatisfied with discharge direct from ED. Improved patient information and shared decision making is required when rapid discharge strategies are incorporated into practice.
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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.
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This project aimed to identify issues patients would like to see improved when interacting with the Minor Injuries Unit (MIU) and as a result generate measurable and feasible Always Events (AEs) based on patient feedback that can be implemented via a Quality Improvement (QI) process. We then looked to assess and improve on the delivery of the agreed AEs to enhance MIU patient experience. ⋯ Baseline results stood at 80% for patient satisfaction regarding information provision, rising to 88% by the end of the poster intervention and 92% by the end of the video intervention. Understanding of how the ED functions stood at 83% in the baseline sample before rising to 86% throughout the poster and video intervention. Composite survey results rose from a baseline level of 82.2% to 86.3% for the poster intervention and 88.8% by the end of the video intervention stage. Patient questionnaires indicated that information provision directly from staff was variable throughout the study period.emermed;34/12/A890-b/F1F1F1Figure 1emermed;34/12/A890-b/F2F2F2Figure 2 DISCUSSION: Implementing the AE approach in the MIU has had a positive effect on patient experience. The poster intervention had the greatest impact on enhancing patient understanding. Our study indicated that direct information provision from staff was sufficient for patients and improvements in responses were due to the project interventions. Next steps should be to further implement the video in the department via inclusion on the patient Wi-Fi homepage and waiting room television to maximise the impact of the video. The patient-staff co-design nature of this study shows the AE methods strength in improving patient-centred care. In summary, this project emphasises that the AE method is an effective, valid and beneficial form of Quality Improvement to be used within EDs which has the potential for widespread future use.
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The predominant cause of preventable death from trauma is bleeding. Many patients need resuscitation with massive blood transfusion (MBT). In some theatres of military operation there is limited blood product availability and walking donor panels can be required. This study aimed to produce a tool to predict the need for MBT using information available on patient arrival at the ED for patients sustaining battlefield trauma. ⋯ The derivation dataset was made up of 1298 casualties with a massive blood transfusion rate of 21.2% (n=275). The validation dataset contained 1186; MBT rate 6.7% (n=79). The majority of patients were young, male and with penetrating injury. Univariate regression analyses showing the predictive value of the variables within the MASH score are shown in table 1. A decision rule was produced using a combination of injury pattern, clinical observations and pre-hospital interventions. The test characteristics for three cut off thresholds for the rule are shown in Table 2 alongside the sensitivity analysis. The proposed rule, using a score of 3 or greater, demonstrated a sensitivity of 82.7% and a specificity of 88.8% for prediction of MBT, with an AUROC of 0.93 (95% CI:0.91 to 0.95).emermed;34/12/A869-b/T1F1T1Table 1Univariate regression analysis of variables included in the MASH score in the derivation dataset which predict the requirement for 6 units of pRBCs in 4 hours or 10 units of pRBCs in 24 hoursemermed;34/12/A869-b/T2F2T2Table 2Performance of the MASH score in derivation and validation datasets showing test characteristics for three values of the MASH score with 95% confidence intervals with sensitivity analysis for a score of 3 in the validation dataset CONCLUSIONS: This study has produced the first military scoring system that uses clinical observations, injuries sustained and pre-hospital interventions to predict the need for MBT and therefore the requirement for an emergency donor panel in resource-limited environments. The MASH score has higher sensitivity and specificity than previous military prediction tools, and has the advantage of only using information which is rapidly available in the resuscitation bay. This is of importance to civilian practitioners with increasing possibility of major terrorist attacks.
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Overdose is a common presentation in Emergency Departments (EDs) across the UK. Salicylate poisoning is potentially fatal; however it is becoming increasingly uncommon in the UK. This may be due to restriction of pack sizes in over the counter medicines as well as the use of aspirin as an analgesic being superseded by other NSAIDs, particularly ibuprofen.In conjunction with clinical features of salicylate toxicity, measurement of plasma salicylate concentration can help guide management. Many EDs routinely test for salicylate levels in all cases of overdose, and yet this may not be necessary as recommended by the NPIS.This study aims to assess the cost implication of over testing for salicylate in overdose patients, as well as the prevalence of salicylate poisoning in three EDs in the West Midlands. ⋯ Salicylate poisoning appears to be uncommon among patients presenting with overdose.Results show that it is likely that EDs are over testing for salicylate levels.In accordance with NPIS advice, there is no need to measure salicylate levels in conscious overdose patients who have no features of toxicity and deny salicylate ingestion.This may have cost implications, allowing departments to save money by reducing the amount of routine salicylate testing overall.