The aim of this study was to develop an evidence-based guideline for use primarily by junior clinicians to assist with the management of children presenting to the hospital with an acute breathing difficulty.
An overview of the literature provided a framework of clinical questions for the management of a child with an acute breathing difficulty on which to base a systematic literature review. Relevant articles were appraised by the research fellow and graded according to their quality. A national panel of 50 clinicians was provided, by post, with the clinical questions, research papers, appraisals and the grades of recommendations generated. They were asked to check the grades allocated to the recommendations and the accuracy of the language used. They were also provided with all the clinical questions for which there was insufficient evidence to reach a conclusion but for which a consensus recommendation was required. A Delphi method was used to formalise the consensus process. For all recommendations, panel members were asked to rate their level of agreement on a 1–9-point Likert scale. The results of the first round were fed back, and appropriate alterations to the recommendations made or additional recommendations included. The process of rating was repeated, and the final guideline was developed based on the consensus reached.
Following two iterative rounds, the guideline was completed as a full technical document, with a series of key recommendations and an algorithm. It was based on 10 grade A (evidence from systematic review or meta-analyses), 5 grade B, 17 grade C and 31 grade D (consensus or expert opinion) recommendations.
We have developed an evidence-based guideline that has subsequently been successfully implemented in the paediatric emergency departments and disseminated nationally. Results showing the effect of the guideline upon practice will be published separately.
Proximal interphalangeal joint (PIPJ) hyperextension injuries are common in children. There is a range of opinion on management but little evidence to suggest best practice.
To determine from a convenient sample size, the overall and significant fracture rate. Whether significant injuries can be differentiated from the insignificant clinically and whether children get complications.
Data were collected on all PIPJ hyperextension injuries (thumb excluded) presenting to a children’s emergency department between October and December 2006. Staff were trained to perform standardised assessment and documentation and all injuries were x rayed. The diagnosis was cross-referenced with x ray reports. All notes were reviewed for 4 months. Management, complications and unscheduled returns were noted.
From the population of 134 patients, there was a fracture rate of 55% (74/134). Of those, 57% (42/74) were defined as significant. Others included buckle (9/74), flake (14/74) and avulsion (9/74) fractures. Obvious deformity and inability to touch pulp to palm were significantly associated with a fracture. Except for those with clinical deformity requiring manipulation, all injuries were treated conservatively. There were no unscheduled returns with any complications 4 months post-injury.
There is a significant risk of a fracture in children sustaining hyperextension injuries to the PIPJ. These results show that, except in those with an obvious deformity, it is difficult to differentiate clinically between those with a sprain, minor or significant fracture. Even those with a significant fracture were managed conservatively. Children appear not to have the complications seen in the adult population with similar injuries.
In the emergency department (ED), clinicians can benefit greatly from having access to information at the point of care. It has been suggested that using computerised information systems could improve the accessibility of information. However, making information accessible, while maintaining confidentiality, is one of the main challenges of implementing information systems. This article presents the ED staff perspectives about the accessibility and confidentiality of information in the ED.
The authors undertook a qualitative study in March–April 2007. Data were collected using in-depth semi-structured interviews with the ED staff of an ED located in Northern England. In total, 34 interviews were conducted and transcribed verbatim. Data were analysed using framework analysis.
The results showed that the ED staff had role-based access to the current information systems, and these systems met only a small part of their information needs. As a result, different sources were used to get access to the needed information. Although the ED staff believed that improving the accessibility of information could be helpful in emergency care services, there were concerns about the confidentiality of information. The confidentiality of information could be threatened—for example, by sharing passwords, misusing patient information or by unauthorised staff having access to patient information.
To design a system, the accessibility and confidentiality of information should be addressed in parallel. A balance between these two is needed, as the failure of each of these may negatively influence the use of the system.
The aims of this study were to compare the estimated size of primary spontaneous pneumothorax (PSP) calculated on inspiratory and expiratory radiographs using the volumetrically derived Collins method and to determine whether radiograph type influences size classification for treatment according to published guidelines.
This retrospective cohort study included patients treated for PSP in the emergency departments of two metropolitan teaching hospitals. Data collected included patient demographics and interpleural distances required to calculate pneumothorax size by the Collins method and to classify PSP according to guidelines. The outcomes of interest were the difference in size estimate between radiograph types and agreement in size classification for treatment according to guidelines. Analysis is by bias-plot analysis, kappa analysis and descriptive statistics.
A total of 49 pneumothoraces (44 patients) were studied. Median age was 22 years; 66% were men. Median PSP size on inspiratory radiographs was 24% (IQR 14% to 31%, range 5% to 100%). The average size difference between expiratory and inspiratory films was 9%, with size on expiratory radiographs being larger. The 95% limits of agreement were wide (–5% to 23%). For each guideline, size estimation on expiratory rather than inspiratory radiographs would have suggested a change in treatment for an additional seven patients (14%, 95% CI 7% to 27%).
On average, PSP size calculated on expiratory radiographs is 9% higher than that calculated on matched inspiratory radiographs. Applying current management guidelines, the size difference between inspiratory and expiratory x-rays may alter initial treatment recommendation for some patients.
To evaluate the use of protocol-driven trauma resuscitation strategies in UK emergency departments.
Postal/internet questionnaire survey of emergency departments to evaluate the existence of guidelines or protocols to direct resuscitation, blood component treatment, second line imaging of patients who had major trauma and the existence of a trauma team/trauma call system.
243 departments were identified and contacted, 183 responded. Five replies were excluded. Of the remaining 178 departments, 139 (78.1%) had a trauma team or trauma call system, but only 49 (27.5%) had a guideline or protocol for resuscitation. 92 (51.7%) had guidelines or protocols for blood component treatment in trauma, and 88 (49.4%) had guidelines or protocols for the use of second line imaging in trauma. The use of protocols and guidelines did not correlate with emergency department size, as measured by volume of activity.
The utilisation of trauma resuscitation protocols and guidelines in British emergency departments is limited. Given the clear benefits of these strategies, consideration should be given to greater integration of such algorithms into practice.
Clinical features may be used to determine which patients with suspected acute coronary syndrome (ACS), but a normal or non-diagnostic ECG, should be selected for further investigation or inpatient care. We aimed to measure the diagnostic value of clinical features for ACS.
Standardised data relating to presenting characteristics, associated features and risk factors were collected at seven chest pain units established for the ESCAPE trial. All patients received troponin measurement at least 6 h after last significant symptoms, creatine kinase MB(mass) gradient over 2 h and, if appropriate, treadmill exercise testing. The reference standard of ACS was defined as troponin >0.03 ng/ml, creatine kinase MB(mass) gradient >3.0 ng/ml or early positive treadmill exercise test.
1576 patients were analysed, including 132 (8.4%) with ACS. Patients with ACS were older, had longer symptom duration, were more likely to be a man, hypertensive and an ex-smoker or have pain radiating to their right arm. On multivariate analysis, only age, duration, sex and radiation of pain to the right arm were independently associated with ACS. Likelihood ratios (95% CI) were radiation of pain to the right arm, 2.9 (95% CI 1.4 to 6.3), male sex 1.2 (95% CI 1.0 to 1.3) and female sex 0.79 (95% CI 0.62 to 1.0). The area under the receiver operator characteristic curve for age was 0.629 (95% CI 0.573 to 0.686) and for duration was 0.546 (95% CI 0.481 to 0.610).
Clinical features have very limited value for diagnosing ACS in patients with a normal or non-diagnostic ECG. Radiation of pain to the right arm increases the likelihood of ACS.
Conflicting evidence exists surrounding the increased risk of adverse outcome conferred by preinjury anticoagulant and antiplatelet treatment in patients with head injury. The aim of this study was to determine the epidemiology of patients with head injury on anticoagulant and antiplatelet treatment admitted to a hospital from an emergency department (ED).
This was a retrospective analysis of all patients with head injury admitted to a hospital from a major UK ED between 1 January 2005 and 31 December 2007.
399 patients met the inclusion criteria. 110 patients underwent CT, with 24 having traumatic haemorrhage. Of 271 patients on aspirin, 75 (28%) underwent CT, with 19 of these (25%) having traumatic haemorrhage. Of 89 patients on warfarin, 27 (30%) underwent CT, with 4 of these (15%) having traumatic haemorrhage. Seven of the 24 (29%) patients with traumatic haemorrhage on CT did not undergo urgent ED scanning. All these patients were on aspirin.
This study confirms the need for caution in the early discharge of patients with head injury taking anticoagulant medication. This study also raises concerns that patients taking antiplatelet medication prior to injury may also be at high risk of developing covert serious intracranial haemorrhage and suggests the need for a well-designed cohort study looking at antiplatelet risk in head injury.
Ambulance paramedics are now trained routinely in advanced airway skills, including tracheal intubation. Initial training in this skill requires the insertion of 25 tracheal tubes, and further ongoing training is attained through clinical practice and manikin-based practice. In contrast, training standards for hospital-based practitioners are considerably greater, requiring approximately 200 tracheal intubations before practice is unsupervised. With debate growing regarding the efficacy of paramedic intubation, there is a need to assess current paramedic airway practice in order to review whether initial training and maintenance of skills provide an acceptable level of competence with which to practice advanced airway skills.
All ambulance patient report forms (anonymised) for the period 1 January 2007 to 31 December 2007 were reviewed, and data relating to airway management were collected. Paramedic and technician identification codes were used to determine the number of airway procedures undertaken on an individual basis.
Of the 269 paramedics, 128 (47.6%) had undertaken no intubation and 204 (75.8%) had undertaken one or less intubation in the 12-month study period. The median number of intubations per paramedic during the 12-month period was 1.0 (range 0–11). A total of 76 laryngeal mask insertion attempts were recorded by 41 technicians and 30 paramedics. The median number of laryngeal mask insertions per paramedic/technician during the 12-month period was 0 (range 0–2). A survey of ongoing continuing professional development across all ambulance trusts demonstrated no provision for adequate training to compensate for the lack of clinical exposure to advanced airway skills.
Paramedics use advanced airway skills infrequently. Continuing professional development programmes within ambulance trusts do not provide the necessary additional practice to maintain tracheal intubation skills at an acceptable level. Advanced airway management delivered by ambulance crews is likely to be inadequate with such infrequent exposure to the skill.
Safety in prehospital practice is a paramount principle. Personal protective equipment (PPE) use is intrinsic to safe practice. There is varied guidance as to what constitutes effective PPE. No evidence is available of what current provision encompasses.
A questionnaire-based study directed to all ambulance trusts, British Association for Immediate Care (BASICS) schemes and air ambulance operations in England, Scotland and Wales.
Total response rate was in excess of 66%. A specific protocol for PPE use was issued by 81%, 89% and 38% of ambulance trusts, air ambulance and BASICS schemes, respectively. There was a wide variation in provision of PPE both within and between different groups of providers. Fewer than 55% of providers had an evaluation system in place for reviewing PPE use.
Many reasons account for the differences in provision. There is a clear need for a standard to be set nationally in conjunction with locally implemented evaluation and re-accreditation processes.
It is widely believed that placing a patient who has been subjected to suspension trauma in a horizontal position after rescue may cause rescue death. The discussion whether position is important has been dominated by non-medical personnel. Subsequently, this has led to a general advice on emergency treatment of these patients, which may cause incorrect or even fatal treatment.
To determine whether there is any medical evidence supporting that horizontal positioning after suspension trauma may cause rescue death, the authors located publications, reports, expert opinions and other sources of information addressing the acute treatment of suspension trauma. These sources were then evaluated.
Several thousand hits regarding suspension trauma were located on the internet and five articles on the PubMed. Although most of them warned of the dangers of rescue death brought about by assuming the horizontal position after prolonged suspension, the authors found no clinical studies, and none of the sources offered any conclusive evidence as to whether the horizontal position increases the risk of rescue death. Neither the authors, nor the suspension trauma experts who were contacted, had ever experienced or heard of case reports supporting the causal relation between the horizontal position and rescue death.
After evaluating the current literature, the authors found no support for the view that the horizontal position may be potentially fatal for patients exposed to suspension trauma. In the absence of any evidence to the contrary, the authors suggest that the initial management of patients who have had suspension trauma should follow normal guidelines for the acute care of traumatised patients, without special modifications.
Patient’s triage is a key element of mass-casualty incidents (MCIs) response, although performance of healthcare professionals in triage proved to be poor. It was assessed if specific teaching methods based on pattern recognition skill development can help healthcare students to improve their performance in triage.
128 medical and nursing students have been assessed while performing triage during disaster medicine exercises. Half of them (group 1) had previously been involved in a standard curriculum. The remaining half (group 2) benefited from specific teaching methods based on pattern recognition skill development.
Performance of group 2 was significantly higher compared with group 1 (p<0.01). Group 2 had a lower overtriage rate.
Disaster medicine courses based on pattern recognition skill development improve triage performance of healthcare students during simulated MCI. This study may have a high impact on healthcare students and professionals’ education in the perspective of MCIs preparedness and response.