UK multisite evaluation of the impact of clinical educators in EDs from a learner's perspective.

BACKGROUND: In England, demand for emergency care is increasing while there is also a staffing shortage. The Royal College of Emergency Medicine (RCEM) suggested that appointment of senior doctors as clinical educators (CEs) would enable support and development of learners in EDs and improve retention and well-being. This study aimed to evaluate the impact of CEs in ED on learners. METHODS: CEs were placed in 54 NHS Acute Trust EDs for a pilot beginning July 2018 and ending October 2020. Learners from multiple disciplines working at 54 NHS Acute Trust EDs where CEs were deployed were invited to complete an online survey designed to identify the impact of CEs in July of 2019, as part of an interim service evaluation. RESULTS: Respondents numbered 493 from 49 of 54 study sites, including 286 (58%) medical (non-consultant) and 72 (14.6%) all other nursing, allied health professionals. 9 out of 10 learners reported having experienced a change to their learning as a result of the deployment of CEs in their department. 49.9% (246/493) reported that CEs had a positive impact on their well-being. 95% (340/358) reported an improved accessibility to undertaking clinical based assessments. 78% (281/358) perceived that access to CEs increased likelihood of passing assessments. Of those responding, 80.9% (399/493) reported they would remain/return to the same ED with a CE, and 92.5% (456/493) responded that they would prefer to go to a Trust with a CE. CONCLUSIONS: According to survey respondents, deployment of CEs across NHS Trusts has resulted in improvement and increased accessibility of learning and assessment opportunities for learners within ED. The impact of CEs on well-being is uncertain with half reporting improvement and the remaining half unsure. Further evaluation within the project will continue to explore the service benefit and workforce impact of the CEED intervention.

A mixed methods study of the impact of consultant overnight working in an English Emergency Department.

BACKGROUND: There is a growing expectation that consultant-level doctors should be present within an ED overnight. However, there is a lack of robust evidence substantiating the impact on patient waiting times, safety or the workforce. OBJECTIVES: To evaluate the impact of consultant-level doctors overnight working in ED in a large university hospital. METHODS: We conducted a controlled interrupted time series analysis to study ED waiting times before and after the introduction of consultant night working. Adverse event reports (AER) were used as a surrogate for patient safety. We conducted interviews with medical and nursing staff to explore attitudes to night work. RESULTS: The reduction seen in average time in department relative to the day, following the introduction of consultant was non-significant (-12 min; 95% CI -28 to 4, p=0.148). Analysis of hourly arrivals and departures indicated that overnight work was inherited from the day. There were three (0.9%) moderate and 0 severe AERs in 1 year. The workforce reported that night working had a negative impact on sleep patterns, performance and well-being and there were mixed views about the benefits of consultant night presence. Additional time off during the day acted as compensation for night work but resulted in reduced contact with ED teams. CONCLUSIONS: Our single-site study was unable to demonstrate a clinically important impact of consultant night working on total time patients spend in the department. Our analysis suggests there may be more potential to reduce total time in department during the day, at our study site. Negative impacts on well-being, and likely resistance to consultant night working should not be ignored. Further studies of night working are recommended to substantiate our results.

Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study.

BACKGROUND: Increased mortality rates associated with weekend hospital admission (the so-called weekend effect) have been attributed to suboptimum staffing levels of specialist consultants. However, evidence for a causal association is elusive, and the magnitude of the weekend specialist deficit remains unquantified. This uncertainty could hamper efforts by national health systems to introduce 7 day health services. We aimed to examine preliminary associations between specialist intensity and weekend admission mortality across the English National Health Service. METHODS: Eligible hospital trusts were those in England receiving unselected emergency admissions. On Sunday June 15 and Wednesday June 18, 2014, we undertook a point prevalence survey of hospital specialists (consultants) to obtain data relating to the care of patients admitted as emergencies. We defined specialist intensity at each trust as the self-reported estimated number of specialist hours per ten emergency admissions between 0800 h and 2000 h on Sunday and Wednesday. With use of data for all adult emergency admissions for financial year 2013-14, we compared weekend to weekday admission risk of mortality with the Sunday to Wednesday specialist intensity ratio within each trust. We stratified trusts by size quintile. FINDINGS: 127 of 141 eligible acute hospital trusts agreed to participate; 115 (91%) trusts contributed data to the point prevalence survey. Of 34,350 clinicians surveyed, 15,537 (45%) responded. Substantially fewer specialists were present providing care to emergency admissions on Sunday (1667 [11%]) than on Wednesday (6105 [42%]). Specialists present on Sunday spent 40% more time caring for emergency patients than did those present on Wednesday (mean 5·74 h [SD 3·39] vs 3·97 h [3·31]); however, the median specialist intensity on Sunday was only 48% (IQR 40-58) of that on Wednesday. The Sunday to Wednesday intensity ratio was less than 0·7 in 104 (90%) of the contributing trusts. Mortality risk among patients admitted at weekends was higher than among those admitted on weekdays (adjusted odds ratio 1·10, 95% CI 1·08-1·11; p<0·0001). There was no significant association between Sunday to Wednesday specialist intensity ratios and weekend to weekday mortality ratios (r -0·042; p=0·654). INTERPRETATION: This cross-sectional analysis did not detect a correlation between weekend staffing of hospital specialists and mortality risk for emergency admissions. Further investigation is needed to evaluate whole-system secular change during the implementation of 7 day services. Policy makers should exercise caution before attributing the weekend effect mainly to differences in specialist staffing. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme.

Children who leave the emergency department without being seen: a retrospective case note review.

INTRODUCTION: Children who attend an emergency department and then leave without being seen (LWBS) are a major concern as they are a potentially vulnerable group who may come to harm through failure to provide a timely and accessible service. OBJECTIVES: We wished to establish the size of this population and importantly what subsequently happened to them over the following 7 days from their initial attendance, and the relevance of the College of Emergency Medicine LWBS Quality Indicator (QI 4) to this group. METHODS: A retrospective case note review over 6 months of all paediatric attendances who LWBS. SETTING: Southampton Paediatric Emergency Department. RESULTS: During a 6-month study period, 10 795 attended, of which 544 (5%) LWBS. 12.6% (69/544) reattended over the next 7 days, of which 14 were admitted, 7 for <12 h. CONCLUSIONS: The majority who LWBS do so during peak times. Very few paediatric patients who LWBS then reattended required admission for >12 h (7/544, 1.3%). The rate of reattendance of those who LWBS and review of their case notes is potentially more valuable than the LWBS rate alone.

Epidemiology and predictors of spinal injury in adult major trauma patients: European cohort study.

This is a European cohort study on predictors of spinal injury in adult (≥16 years) major trauma patients, using prospectively collected data of the Trauma Audit and Research Network from 1988 to 2009. Predictors for spinal fractures/dislocations or spinal cord injury were determined using univariate and multivariate logistic regression analysis. 250,584 patients were analysed. 24,000 patients (9.6%) sustained spinal fractures/dislocations alone and 4,489 (1.8%) sustained spinal cord injury with or without fractures/dislocations. Spinal injury patients had a median age of 44.5 years (IQR = 28.8-64.0) and Injury Severity Score of 9 (IQR = 4-17). 64.9% were male. 45% of patients suffered associated injuries to other body regions. Age <45 years (≥45 years OR 0.83-0.94), Glasgow Coma Score (GCS) 3-8 (OR 1.10, 95% CI 1.02-1.19), falls >2 m (OR 4.17, 95% CI 3.98-4.37), sports injuries (OR 2.79, 95% CI 2.41-3.23) and road traffic collisions (RTCs) (OR 1.91, 95% CI 1.83-2.00) were predictors for spinal fractures/dislocations. Age <45 years (≥45 years OR 0.78-0.90), male gender (female OR 0.78, 95% CI 0.72-0.85), GCS <15 (OR 1.36-1.93), associated chest injury (OR 1.10, 95% CI 1.01-1.20), sports injuries (OR 3.98, 95% CI 3.04-5.21), falls >2 m (OR 3.60, 95% CI 3.21-4.04), RTCs (OR 2.20, 95% CI 1.96-2.46) and shooting (OR 1.91, 95% CI 1.21-3.00) were predictors for spinal cord injury. Multilevel injury was found in 10.4% of fractures/dislocations and in 1.3% of cord injury patients. As spinal trauma occurred in >10% of major trauma patients, aggressive evaluation of the spine is warranted, especially, in males, patients <45 years, with a GCS <15, concomitant chest injury and/or dangerous injury mechanisms (falls >2 m, sports injuries, RTCs and shooting). Diagnostic imaging of the whole spine and a diligent search for associated injuries are substantial.

Do chronic heart failure symptoms interact with burden of treatment? Qualitative literature systematic review.

OBJECTIVE: Explore the interaction between patient experienced symptoms and burden of treatment (BoT) theory in chronic heart failure (CHF). BoT explains how dynamic patient workload (self-care) and their capacity (elements influencing capability), impacts on patients' experience of illness. DESIGN: Review of qualitative research studies. DATA SOURCES: CINAHL, EMBASE, MEDLINE, PsycINFO, Scopus and Web of Science were searched between January 2007 and 2020. ELIGIBILITY CRITERIA: Journal articles in English, reporting qualitative studies on lived experience of CHF. RESULTS: 35 articles identified related to the lived experience of 720 patients with CHF. Symptoms with physical and emotional characteristics were identified with breathlessness, weakness, despair and anxiety most prevalent. Identifying symptoms' interaction with BoT framework identified three themes: (1) Symptoms appear to infrequently drive patients to engage in self-care (9.2% of codes), (2) symptoms appear to impede (70.5% of codes) and (3) symptoms form barriers to self-care engagement (20.3% of codes). Symptoms increase illness workload, making completing tasks more difficult; simultaneously, symptoms alter a patient's capacity, through a reduction in their individual capabilities and willingness to access external resources (ie, hospitals) often with devasting impact on patients' lives. CONCLUSIONS: Symptoms appear to be integral in the patient experience of CHF and BoT, predominately acting to impede patients' efforts to engage in self-care. Symptoms alter illness workload, increasing complexity and hardship. Patients' capacity is reduced by symptoms, in what they can do and their willingness to ask for help. Symptoms can lower their perceived self-value and roles within society. Symptoms appear to erode a patient's agency, decreasing self-value and generalised physical deconditioning leading to affective paralysis towards self-care regimens. Together describing a state of overwhelming BoT which is thought to be a contributor to poor engagement in self-care and may provide new insights into the perceived poor adherence to self-care in the CHF population. PROSPERO REGISTRATION NUMBER: CRD42017077487.

Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services national health policy.

BACKGROUND: In 2013, the English National Health Service launched the policy of 7-day services to improve care quality and outcomes for weekend emergency admissions. AIMS: To determine whether the quality of care of emergency medical admissions is worse at weekends, and whether this has changed during implementation of 7-day services. METHODS: Using data from 20 acute hospital Trusts in England, we performed randomly selected structured case record reviews of patients admitted to hospital as emergencies at weekends and on weekdays between financial years 2012-2013 and 2016-2017. Senior doctor ('specialist') involvement was determined from annual point prevalence surveys. The primary outcome was the rate of clinical errors. Secondary outcomes included error-related adverse event rates, global quality of care and four indicators of good practice. RESULTS: Seventy-nine clinical reviewers reviewed 4000 admissions, 800 in duplicate. Errors, adverse events and care quality were not significantly different between weekend and weekday admissions, but all improved significantly between epochs, particularly errors most likely influenced by doctors (clinical assessment, diagnosis, treatment, prescribing and communication): error rate OR 0.78; 95% CI 0.70 to 0.87; adverse event OR 0.48, 95% CI 0.33 to 0.69; care quality OR 0.78, 95% CI 0.70 to 0.87; all adjusted for age, sex and ethnicity. Postadmission in-hospital care processes improved between epochs and were better for weekend admissions (vital signs with National Early Warning Score and timely specialist review). Preadmission processes in the community were suboptimal at weekends and deteriorated between epochs (fewer family doctor referrals, more patients with chronic disease or palliative care designation). CONCLUSIONS AND IMPLICATIONS: Hospital care quality of emergency medical admissions is not worse at weekends and has improved during implementation of the 7-day services policy. Causal pathways for the weekend effect may extend into the prehospital setting.

Digital anaesthesia: one injection or two?

BACKGROUND: Digital nerve blocks (DNB) are performed frequently in the Emergency Department (ED). The aim of this study was to establish whether single injection subcutaneous digital nerve block (SDNB) is as effective as the traditional (two injection) digital nerve block (TDNB) for digital anaesthesia. METHOD: Single blinded, prospective, randomised-controlled multicentre trial within Hampshire EDs. Patients > or = 16 years attending the ED with fingertip injuries/infections (distal to the distal-interphalangeal joint) requiring a DNB were randomised to SDNB/TDNB groups. Outcome measures were: primary - successful anaesthesia; secondary - patient distress, clinician satisfaction (CS), complications. RESULTS: 76 patients were randomised. (37 received SDNB). At 5 min, more patients in the SDNB group (28/37, 76%) were adequately anaesthetised than in the TDNB group, (22/34, 65%). At 10 min, 33/37 (89%) of the SDNB group compared to 28/34 (82%) of the TDNB group were adequately anaesthetised. The mean (SD) of self-reported distress scores for the SDNB group were lower than those reported for the TDNB group, whereas the mean (SD) of CS scores for SDNB were higher than those reported for TDNB. Neither group reported complications from anaesthesia. CONCLUSIONS: SDNB is as effective as TDNB. Outcome measures favoured SDNB, but only CS scores achieved statistical significance. Trial recruitment is much slower than anticipated. However, clinical practice has demonstrated that SDNB works and practice is already changing within the Hampshire region, with some departments adopting SDNB as standard practice. Therefore, the results are being presented now to allow clinicians to make an informed choice. Our results may also contribute to future metanalyses.

The College of Emergency Medicine curriculum: is the specialty-specific knowledge section fit for purpose?

OBJECTIVE: To determine whether the knowledge specified in the specialty-specific section of the College of Emergency Medicine curriculum covered the diagnoses presenting to a UK teaching hospital emergency department. METHOD: An audit of 1000 sets of notes was undertaken, the diagnosis abstracted and mapped to the curriculum. RESULTS: 1076 diagnoses were derived and all were covered by the curriculum. The three most common diagnostic categories were musculoskeletal, wound management and cardiology. CONCLUSION: The curriculum covered all the diagnoses in this sample. Knowing the frequency of a diagnosis could be used to inform training and assessment.

Two-epoch cross-sectional case record review protocol comparing quality of care of hospital emergency admissions at weekends versus weekdays.

INTRODUCTION: The mortality associated with weekend admission to hospital (the 'weekend effect') has for many years been attributed to deficiencies in quality of hospital care, often assumed to be due to suboptimal senior medical staffing at weekends. This protocol describes a case note review to determine whether there are differences in care quality for emergency admissions (EAs) to hospital at weekends compared with weekdays, and whether the difference has reduced over time as health policies have changed to promote 7-day services. METHODS AND ANALYSIS: Cross-sectional two-epoch case record review of 20 acute hospital Trusts in England. Anonymised case records of 4000 EAs to hospital, 2000 at weekends and 2000 on weekdays, covering two epochs (financial years 2012-2013 and 2016-2017). Admissions will be randomly selected across the whole of each epoch from Trust electronic patient records. Following training, structured implicit case reviews will be conducted by consultants or senior registrars (senior residents) in acute medical specialities (60 case records per reviewer), and limited to the first 7 days following hospital admission. The co-primary outcomes are the weekend:weekday admission ratio of errors per case record, and a global assessment of care quality on a Likert scale. Error rates will be analysed using mixed effects logistic regression models, and care quality using ordinal regression methods. Secondary outcomes include error typology, error-related adverse events and any correlation between error rates and staffing. The data will also be used to inform a parallel health economics analysis. ETHICS AND DISSEMINATION: The project has received ethics approval from the South West Wales Research Ethics Committee (REC): reference 13/WA/0372. Informed consent is not required for accessing anonymised patient case records from which patient identifiers had been removed. The findings will be disseminated through peer-reviewed publications in high-quality journals and through local High-intensity Specialist-Led Acute Care (HiSLAC) leads at the 121 hospitals that make up the HiSLAC Collaborative.

Physiological observations of patients admitted from A&E.

BACKGROUND: A&E department records were collected over a four-week period for all patients admitted to hospital via A&E. Timing and values of recorded observations were collected, as was the length of time spent in the department. During the study period, 739 patients were admitted. Observation charts were available for 728. Those having some observations within 15 minutes of arrival totalled 640 (88 per cent); 378 (52 per cent) had temperature, heart rate, respiratory rate and blood pressure recorded; and 265 (36 per cent) had repeat observations while waiting for admission. The mean time in the department was three hours 43 minutes. CONCLUSION: Recorded patient observations are carried out in an inconsistent pattern in this A&E department and standards should be set. Patients at risk of deterioration must be identified early. Complete observations should be carried out so that patients with abnormal physiology can be prioritized for treatment and repeated observation can be instituted to monitor response to interventions. Further work is needed to determine variables that provide the best prediction of outcome and whether increasing observation frequency and earlier activation improves outcome.

Epidemiology and predictors of cervical spine injury in adult major trauma patients: a multicenter cohort study.

BACKGROUND: Patients with cervical spine injuries are a high-risk group, with the highest reported early mortality rate in spinal trauma. METHODS: This cohort study investigated predictors for cervical spine injury in adult (≥ 16 years) major trauma patients using prospectively collected data of the Trauma Audit and Research Network from 1988 to 2009. Univariate and multivariate logistic regression analyses were used to determine predictors for cervical fractures/dislocations or cord injury. RESULTS: A total of 250,584 patients were analyzed. Median age was 47.2 years (interquartile range, 29.8-66.0) and Injury Severity Score 9 (interquartile range, 4-11); 60.2% were male. Six thousand eight hundred two patients (2.3%) sustained cervical fractures/dislocations alone. Two thousand sixty-nine (0.8%) sustained cervical cord injury with/without fractures/dislocations; 39.9% of fracture/dislocation and 25.8% of cord injury patients suffered injuries to other body regions. Age ≥ 65 years (odds ratio [OR], 1.45-1.92), males (females OR, 0.91; 95% CI, 0.86-0.96), Glasgow Coma Scale (GCS) score <15 (OR, 1.26-1.30), LeFort facial fractures (OR, 1.29; 95% confidence interval [CI], 1.05-1.59), sports injuries (OR, 3.51; 95% CI, 2.87-4.31), road traffic collisions (OR, 3.24; 95% CI, 3.01-3.49), and falls >2 m (OR, 2.74; 95% CI, 2.53-2.97) were predictive for fractures/dislocations. Age <35 years (OR, 1.25-1.72), males (females OR, 0.59; 95% CI, 0.53-0.65), GCS score <15 (OR, 1.35-1.85), systolic blood pressure <110 mm Hg (OR, 1.16; 95% CI, 1.02-1.31), sports injuries (OR, 4.42; 95% CI, 3.28-5.95), road traffic collisions (OR, 2.58; 95% CI, 2.26-2.94), and falls >2 m (OR, 2.24; 95% CI, 1.94-2.58) were predictors for cord injury. CONCLUSIONS: 3.5% of patients suffered cervical spine injury. Patients with a lowered GCS or systolic blood pressure, severe facial fractures, dangerous injury mechanism, male gender, and/or age ≥ 35 years are at increased risk. Contrary to common belief, head injury was not predictive for cervical spine involvement.

The effectiveness of implementing a care pathway for femoral neck fracture in older people: a prospective controlled before and after study.

OBJECTIVES: To investigate whether a care pathway for older hip fracture patients can reduce length of stay while maintaining the quality of clinical care. DESIGN: Prospective study of patients admitted 12 months before and after implementation of a care pathway for the management of femoral neck fracture. Audit data for corresponding time periods from nearby orthopaedic units was used to control for secular trends. SETTING: Teaching hospital. SUBJECTS: Patients aged 65 years and over with a femoral neck fracture. EXCLUSION CRITERIA: multiple fractures, fractures due to malignancy, re-fracture, total hip replacement, previously entered into the study, operation performed elsewhere. Three-hundred and ninety-five (99%) and 369 (97%) case records were available for full analysis. MAIN OUTCOME MEASURES: primary outcome: length of stay on the orthopaedic unit. SECONDARY OUTCOMES: ambulation at discharge, discharge destination, in-hospital complications, 30 day mortality, readmission within 30 days of discharge, post-operative days the patient first sat out of bed and walked. RESULTS: Mean length of stay increased by 6.5 days (95% confidence interval 3.5-9.5 days, P < 0.0005) in the second period with a significant improvement in ambulation on discharge (odds ratio 1.6, 95% confidence interval 1.0-2.6, P = 0.033) and a trend towards reduction in admission to long term care (odds ratio 0.6, 95% confidence interval 0.3-1.0, P = 0.058). CONCLUSIONS: This care pathway was associated with longer hospital stay and improved clinical outcomes. Care pathways for hip fracture patients can be a useful tool for raising care standards but may require additional resources.