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.

Impact of emergency physician experience on decision-making in patients with suspected community-acquired pneumonia and undergoing systematic thoracic CT scan.

OBJECTIVES: To determine whether the impact of a thoracic CT scan on community-acquired pneumonia (CAP) diagnosis and patient management varies according to emergency physician's experience (≤10 vs >10 years). METHODS: Early thoracic CT Scan for Community-Acquired Pneumonia at the Emergency Department is an interventional study conducted from November 2011 to January 2013 in four French emergency departments, and included suspected patients with CAP. We analysed changes in emergency physician CAP diagnosis classification levels before and after CT scan; and their agreement with an adjudication committee. We performed univariate analysis to determine the factors associated with modifying the diagnosis classification level to be consistent with the radiologist's CT scan interpretation. RESULTS: 319 suspected patients with CAP and 136 emergency physicians (75% less experienced with ≤10 years, 25% with >10 years of experience) were included. The percentage of patients whose classification was modified to become consistent with CT scan radiologist's interpretation was higher among less-experienced than experienced emergency physicians (54.2% vs 40.2%; p=0.02). In univariate analysis, less emergency physician experience was the only factor associated with changing a classification to be consistent with the CT scan radiologist's interpretation (OR 1.77, 95% CI 1.01 to 3.10, p=0.04). After CT scan, the agreement between emergency physicians and adjudication committee was moderate for less-experienced emergency physicians and slight for experienced emergency physicians (k=0.457 and k=0.196, respectively). After CT scan, less-experienced emergency physicians modified patient management significantly more than experienced emergency physicians (36.1% vs 21.7%, p=0.01). CONCLUSIONS: In clinical practice, less-experienced emergency physicians were more likely to accurately modify their CAP diagnosis and patient management based on thoracic CT scan than more experienced emergency physicians. TRIAL REGISTRATION NUMBER: NCT01574066.

A traumatic tale of two cities: does EMS level of care and transportation model affect survival in patients with trauma at level 1 trauma centres in two neighbouring Canadian provinces?

BACKGROUND: Two distinct Emergency Medical Services (EMS) systems exist in Atlantic Canada. Nova Scotia operates an Advanced Emergency Medical System (AEMS) and New Brunswick operates a Basic Emergency Medical System (BEMS). We sought to determine if survival rates differed between the two systems. METHODS: This study examined patients with trauma who were transported directly to a level 1 trauma centre in New Brunswick or Nova Scotia between 1 April 2011 and 31 March 2013. Data were extracted from the respective provincial trauma registries; the lowest common Injury Severity Score (ISS) collected by both registries was ISS≥13. Survival to hospital and survival to discharge or 30 days were the primary endpoints. A separate analysis was performed on severely injured patients. Hypothesis testing was conducted using Fisher's exact test and the Student's t-test. RESULTS: 101 cases met inclusion criteria in New Brunswick and were compared with 251 cases in Nova Scotia. Overall mortality was low with 93% of patients surviving to hospital and 80% of patients surviving to discharge or 30 days. There was no difference in survival to hospital between the AEMS (232/251, 92%) and BEMS (97/101, 96%; OR 1.98, 95% CI 0.66 to 5.99; p=0.34) groups. Furthermore, when comparing patients with more severe injuries (ISS>24) there was no significant difference in survival (71/80, 89% vs 31/33, 94%; OR 1.96, 95% CI 0.40 to 9.63; p=0.50). CONCLUSION: Overall survival to hospital was the same between advanced and basic Canadian EMS systems. As numbers included are low, individual case benefit cannot be excluded.

A comparison of three supraglottic airway devices used by healthcare professionals during paediatric resuscitation simulation.

OBJECTIVE: The aim of this study was to determine the best airway device among the laryngeal mask, I-gel and the laryngeal tube used by healthcare professional groups with different levels of experience with paediatric airway management. METHOD: Three groups of healthcare professionals were separately provided with brief supervised training in using the three devices. Afterwards the participants were asked to place the airway device. For every participant, the positioning of each device was recorded. The success rate and timing of insertion were measured. Furthermore, each insertion was scored for the ease of insertion, clinical and fibreoptic verification of the position and successful ventilation. RESULTS: A total of 66 healthcare providers (22 paramedics, 22 nurse anaesthetists and 22 anaesthesia residents) participated in the study. The median time of insertion of both the laryngeal mask and the tube was significantly longer than for the I-gel for all professional groups (p<0.001). The success rate with the I-gel was higher than that with the laryngeal mask or tube (p<0.001). Except for the laryngeal mask, there were no differences among the professional groups regarding the fibreoptic evaluation. CONCLUSIONS: In terms of both the time required for successful placement and the rate of successful placement, the I-gel is superior to the laryngeal mask and tube in paediatric resuscitation simulations by healthcare professional groups with different levels of experience with paediatric airway management.