Impact of Emergency Medicine Consultants and Clinical Advisors on a NHS 111 Clinical Assessment Service.

OBJECTIVE: To compare outcome of clinical advice given by emergency physicians (EPs) versus non-physician clinical advisors (NPCAs) on a UK National Health Service 111 centre. METHOD: This was a prospective study conducted between July 2016 and February 2017. We targeted calls in which call handlers using standard NHS 111 clinical decision support software would have advised the caller to attend a hospital ED. These calls were passed to a clinical assessment service (CAS) and reviewed by either an EP (July to November 2016) or an NPCA (December 2016 to February 2017). RESULTS: During the preintervention year, 80.2% of callers were advised to attend the ED within 1 or 4 hours, 1.2% were referred to out of hours (OOH) primary care and 0.3% to self-care. During the study, call handlers designated 2606 calls as needing to attend the ED in 1 or 4 hours and passed these on to the clinical advisors. There was a reduction of 75%-81% in cases advised to attend the ED in both intervention groups; EPs advised 396 of 1558 callers (25.4%) to attend ED; NPCAs advised 194 of 1048 callers (18.5%) to attend ED. For calls not requiring the ED, EPs recommended self/home care management in 38.1% of these calls, NPCAs recommended self-care for 15.7% (difference=22.4%; 95% CI 19.0% to 25.7%). EPs recommended 4.5% to attend OOH primary care, while NPCAs recommended OOH primary care for 42.1% (difference=37.6%, 95% CI 34.3% to 40.8%). CONCLUSIONS: A CAS within NHS 111 using clinicians decreases referrals to the ED. EPs use fewer services and resources. Further work needs to be undertaken to determine the workforce skill mix for an NHS 111 CAS.

Does the introduction of a COPD pro-forma improve the standards of care delivered by junior doctors in the emergency department.

AIM: To determine if pro-forma based management improves standards of care delivered by junior doctors in chronic obstructive pulmonary disease (COPD) patients in the Emergency Department (ED). INTRODUCTION: National COPD audits have found large variations in ED standards of care compared to guidelines. They concluded that the publication of guidelines itself does not translate to an improvement in care. METHOD: A pro-forma based on the British Thoracic Society Guidelines on COPD, 1997, NICE Guidelines CG12, 2004 and Non Invasive Ventilation (NIV), 2002 was devised and implemented following targeted education. Data were collected pre and post pro-forma implementation and analysed. The primary end point was categorisation of respiratory failure as it was felt that this concept was fundamental in COPD management. Secondary endpoints included the administration of controlled oxygen, repeat blood gases and appropriate referral for NIV. RESULTS: There were a total of 55 patients in each group. The correct categorisation of respiratory failure improved significantly from 4% in the pre- compared to 89% (p < 0.0001) in the post-intervention group. Similarly the administration of controlled oxygen (47% compared to 92%, p < 0.0001), repeat arterial blood gases (50% compared to 83%, p = 0.0098), and appropriate referral for NIV (33% compared to 100%, p = 0.0023) showed significant improvement after the pro-forma was introduced. CONCLUSION: Pro-forma aided management significantly improves the standards of care in COPD patients in the ED.

Comparison of D-dimer point of care test (POCT) against current laboratory test in patients with suspected venous thromboembolism (VTE) presenting to the emergency department (ED).

AIMS: To compare quantitative point of care (POC) with laboratory d-dimer testing in patients with suspected venous thromboembolism (VTE) presenting to the emergency department. METHODS: A prospective single centre diagnostic study in adults presenting with suspected VTE (pleuritic chest pain or leg swelling) RESULTS: Main outcome measures were the statistical correlation of the two methods. Secondary outcome measures were: test turnaround times, correlation between D-dimer levels, Wells score and final diagnosis. The results showed that there was strong evidence of POC D-dimer being sufficiently accurate to be used as a screening device. The correlation between the two logged assay scores was good. Both logged scores correlated similarly with the Wells score. Once an equivalent cut-off value for POC D-dimer (412 ng/mL) was established, there were only 4 of 100 cases all of which were extremely close to the cut-off. D-dimer turnaround time decreased by 83%. A further recent analysis of laboratory times done in 2013 demonstrates that POC D-dimer results remain 62% quicker. Based on the D-dimer results 27 patients were scanned. The median Wells score in this group was 3.0 (range 2-10) median POC D-dimer levels of 2590 (412-5000) and median lab D-dimer levels of 864 (230-13 000) showing good correlation between D-dimer positive patients and the Wells score. Seven patients had positive scans. There was a significant difference in both logged D-dimer scores between the negative and positive groups indicating that raised D-dimer levels correlate well with final diagnosis. CONCLUSIONS: The POC device was comparable with the laboratory device and was sufficiently accurate to be used as a screening tool in the emergency department setting.