Predictors of massive blood transfusion: a Delphi Study to examine the views of experts.

BACKGROUND: Trauma patients requiring massive blood transfusion (MBT) have high morbidity and mortality: early and aggressive use of blood products during immediate resuscitation may improve survival. There is currently a lack of evidence to guide initial identification of these patients which is especially important in areas where plasma may need to be thawed. In the absence of this evidence, this study aimed to robustly evaluate expert opinion by using a Delphi process to identify predictors of massive transfusion. This process can be used to ensure that decision rules include variables that have clinical validity, which may improve translation of rules into clinical practice. METHODS: An international panel of 35 experts was identified through expert advice against specific criteria. Military and civilian experts from the fields of emergency medicine, critical care, anaesthesia, prehospital care, haematology and general/trauma surgery were included. The Delphi Study was carried out over three rounds. Consensus level was predefined at 80%. RESULTS: 195 statements were generated by the panel of which 97 (49.7%) achieved consensus at the 80% level by the end of round 3. Strikingly no clinical observations reached consensus individually. Metabolic acidosis of a base excess of -5.0 or worse, lactate >5 mmol/L and a low haematocrit on arrival were all considered predictive. Some patterns of injury, but few mechanisms of injury, were considered highly predictive of the need of MBT. CONCLUSIONS: This Delphi process has produced a list of parameters that expert clinicians felt were predictive for MBT. This list can be used to inform the generation of decision rules. It is of note that many factors used in current decision rules were not valued by clinical experts-this may be a cause for poor uptake of those rules.

Initial experience with a rapid access blackouts triage clinic.

Transient loss of consciousness (T-LOC), or blackout, is common in acute medicine. Clinical skills are not done well, with at least 74,000 patients misdiagnosed and mistreated for epilepsy in England alone. The aim of this study was to provide a rapid, structured assessment and an electrocardiogram (ECG) for patients with blackouts, aiming to identify high risk, reduce misdiagnoses, reduce hospital admission rates for low-risk patients, diagnose and treat where appropriate, and also provide onward specialist referral. The majority of patients had syncope, and very few had epilepsy. A high proportion had an abnormal ECG. A specialist-nurse-led rapid access blackouts triage clinic (RABTC) provided rapid effective triage for risk, a comprehensive assessment format, direct treatment for many patients, and otherwise a prompt appropriate onward referral. Rapid assessment through a RABTC reduced re-admissions with blackouts. Widespread use of the web-based blackouts tool could provide the NHS with a performance map. The U.K. has low rates of pacing compared to Western Europe, which RABTCs might help correct. The RABTC sits between first responders and specialist referral, providing clinical assessment and ECG in all cases, and referral where appropriate.

Can a modified thrombolysis in myocardial infarction risk score outperform the original for risk stratifying emergency department patients with chest pain?

BACKGROUND: The thrombolysis in myocardial infarction (TIMI) risk score has been shown to risk stratify patients with suspected acute coronary syndromes (ACS) effectively in the emergency department (ED) but cannot be used to guide patient disposition. We aimed to evaluate whether modifying the TIMI risk score to give greater weighting to ischaemic ECG changes and troponin elevations would enhance its risk stratification and thus potentially facilitate safe patient discharge after 12-h troponin testing. METHODS: A prospective diagnostic cohort study was performed within the ED at Manchester Royal Infirmary, a university-affiliated teaching hospital with an annual ED census of approximately 145,000 patients. 804 patients who had presented to the ED with suspected cardiac chest pain were recruited. All patients underwent 12-h troponin T testing and were followed up by telephone and chart review after 30 days for the composite primary outcome of death, acute myocardial infarction (AMI) or urgent coronary revascularisation. RESULTS: The modified TIMI risk score outperformed the original (area under the receiver operator characteristic curve 0.87 versus 0.77, p<0.001). Using a cut-off of more than 2 points the score had a sensitivity of 96.4% for the prediction of 30-day events. The specificity of the score was only 51.0%, suggesting that in practice over 40% of patients would be ineligible for discharge even after troponin testing. CONCLUSIONS: Modifications to the TIMI risk score can improve its performance in the risk stratification of patients presenting to the ED with chest pain. However, a lack of specificity may still limit its use for guiding patient disposition after troponin testing.

Incidence and causes of critical incidents in emergency departments: a comparison and root cause analysis.

OBJECTIVES: To investigate the incidence of critical incidents in UK emergency departments (EDs) and to compare the root causes of such incidents between different EDs. METHODS: An observational study with semi-structured interviews and root cause analysis was conducted over a 12-month period. It was set in EDs in two teaching hospitals and two district general hospitals in the north-west of England. A single investigator identified critical incidents by a variety of means and conducted interviews with involved members of staff. The main outcome measures were rates of occurrence of critical incidents per 1000 new patients in each ED and root cause analysis of identified critical incidents according to a predetermined system. RESULTS: 443 critical incidents were identified. The rate of occurrence ranged from 11.1 to 15.9 per 1000 new patients. The most common root causes underlying these critical incidents related to organisational issues outside the EDs; internal management issues; human errors relating to knowledge or task verification and execution; and issues related to patient behaviours. By contrast, technical root causes occurred infrequently. Significant differences were shown between the EDs for three types of root cause relating to organisational issues outside the EDs and internal protocol and collective behaviour issues. CONCLUSION: Critical incidents occur frequently in EDs. There are significant differences, as well as common themes, in the causes of these critical incidents between different EDs.

Who's who at a major incident: standardising role titles for emergency planners.

OBJECTIVE: To standardise the names for key roles in a major incident. METHODS: A Delphi study using experts in major incident planning. RESULTS: There is clear consensus regarding the need for standard nomenclature. The expert group identified 28 roles, and 184 different names were initially given by group members for the 28 roles. Agreement on a common nomenclature was achieved in only 12/28 roles. CONCLUSION: There is agreement for a standardised nomenclature for major incident roles. However, consensus may be difficult to achieve from within an expert group.

Investigating pulmonary embolism in the emergency department with lower limb plethysmography: the Manchester Investigation of Pulmonary Embolism Diagnosis (MIOPED) study.

OBJECTIVES: To measure the diagnostic accuracy of computerised strain gauge plethysmography in the diagnosis of pulmonary embolism (PE). METHODS: Two researchers prospectively recruited 425 patients with pleuritic chest pain presenting to the emergency department (ED). Lower limb computerised strain gauge plethysmography was performed in the ED. All patients underwent an independent reference standard diagnostic algorithm to establish the presence or absence of PE. A low modified Wells' clinical probability combined with a normal D-dimer excluded PE. All others required diagnostic imaging with PIOPED interpreted ventilation perfusion scanning and/or computerised tomography (CT) pulmonary angiography. Patients with a nondiagnostic CT had digital subtraction pulmonary angiography. All patients were followed up clinically for 3 months. RESULTS: The sensitivity of computerised strain gauge plethysmography was 33.3% (95% confidence interval (CI) 16.3 to 56.2%) and specificity 64.1% (95% CI 59.0 to 68.8%). The negative likelihood ratio was 1.04 (95% CI 0.68 to 1.33) and positive likelihood ratio 0.93 (95% CI 0.45 to 1.60). CONCLUSIONS: Lower limb computerised strain gauge plethysmography does not aid in the diagnosis of PE.

Outpatient diagnosis of pulmonary embolism: the MIOPED (Manchester Investigation Of Pulmonary Embolism Diagnosis) study.

BACKGROUND AND OBJECTIVES: Pleuritic chest pain, a symptom of pulmonary embolism, is a common presenting symptom in the emergency department. The aim of this study was to validate an algorithm for the diagnosis of pulmonary embolism in emergency department patients with pleuritic chest pain. METHODS: This was a prospective, diagnostic cohort study conducted in a large UK city centre emergency department. A total of 425 patients with pleuritic chest pain presenting to the emergency department between February 2002 and June 2003 were recruited. Patients scoring a low modified Wells clinical probability of pulmonary embolism, who had a normal latex agglutination D-dimer, were discharged. All others followed a diagnostic imaging protocol to exclude and diagnose pulmonary embolism using PIOPED interpreted ventilation-perfusion scanning, CT pulmonary angiography, and digital subtraction pulmonary angiography. All patients were followed up for three months for evidence of pulmonary embolism or deep vein thrombosis. An independent adjudication committee reviewed all deaths. RESULTS: A total of 408 patients completed the diagnostic algorithm; 86.5% (353/408) were investigated as outpatients, 5.4% (22/408) were diagnosed as having pulmonary embolism, and 98.8% (403/408) were followed up for three months. Of the 381 patients without pulmonary embolism who completed follow up, the incidence of thromboembolic disease was 0.8% (95% CI 0.3% to 2.3%): two patients had pulmonary embolism and one had a deep vein thrombosis. CONCLUSIONS: The MIOPED (Manchester Investigation Of Pulmonary Embolism Diagnosis) diagnostic protocol can safely exclude pulmonary embolism in outpatients with pleuritic chest pain.

Diagnosis of pulmonary embolism with CT pulmonary angiography: a systematic review.

OBJECTIVE: To appraise the evidence on the diagnostic accuracy of CT pulmonary angiography and the prognostic value of a negative CT pulmonary angiogram in the diagnosis of pulmonary embolism. METHODS: Medline, EMBASE, and grey literature were systematically searched by two researchers. Any study which compared CT pulmonary angiography to an acceptable reference standard or prospectively followed up a cohort of patients with a normal CT pulmonary angiogram was included. Study methods were appraised independently by two researchers, and data were extracted independently by three researchers. RESULTS: Thirteen diagnostic and 11 follow up studies were identified. Studies varied in prevalence of pulmonary embolism (19-79%), patient groups, and method quality. Few studies recruited unselected emergency department patients. There was heterogeneity in the analysis of sensitivity (53 to 100%), specificity (79 to 100%), and false negative rate (1.0 to 10.7%). The pooled false negative rate of combined negative CT pulmonary angiography and negative deep vein thrombosis testing was 1.5% (95% CI 1.0 to 1.9%). CONCLUSION: Diagnostic studies give conflicting results for the diagnostic accuracy of CT pulmonary angiography. Follow up studies show that CT pulmonary angiography can be used in combination with investigation for deep vein thrombosis to exclude pulmonary embolism.

Self-poisoning suicides in England: a multicentre study.

BACKGROUND: Suicide by self-poisoning is an important cause of death worldwide. A substantial proportion of those with a fatal outcome may come into contact with medical services before they die. AIM: To estimate the proportion of self-poisoning suicides who reached hospital alive; to compare those who reached hospital alive with those who did not; to describe in detail the clinical characteristics and medical management of those dying in hospital. DESIGN: Retrospective audit. METHODS: We studied 24 coroners' jurisdictions across England, reviewing coroners' files and identifying all suicides by self-poisoning (drugs and other ingestible poisons) from 1 January 2001 to 31 December 2001. RESULTS: Of the 214 individuals who completed suicide by self-poisoning during the study period, 49 (23%) reached hospital alive. Those reaching hospital were more likely to be female, more likely to have ingested paracetamol and less likely to have ingested co-proxamol. In the hospital sample, the commonest causes of death were respiratory (n = 10), hepatic or hepatorenal (n = 8), cardiac (n = 5), or a result of hypoxic brain injury (n = 5). Only 18% of in-hospital deaths occurred within 24 h of the overdose. DISCUSSION: Extrapolating to England as a whole, we might expect 300 self-poisoning suicides per year to reach hospital alive (6% of all suicides). Improved medical management might produce a small but significant reduction in the rate of suicide. Such interventions should not be restricted to the emergency care domain. Further research will help to clarify the likely contribution of improved medical management to suicide prevention.

A maximally sensitive clinical decision rule to reduce the need for radiography in mandibular trauma.

INTRODUCTION: To identify clinical symptoms and signs that exclude the presence of mandibular fracture in patients presenting with mandibular trauma and thus devise a clinical decision rule that will rule out the need for radiography in some patients. PATIENTS AND METHODS: A prospective study was conducted of consecutive patients with a possible diagnosis of mandibular fracture who attended a city-centre emergency department between July 2000 and December 2001. Clinical symptoms and signs were recorded for each patient using a predesigned proforma. Radiographic evaluation of a suspected mandibular fracture consisted of lateral-oblique and postero-anterior mandibular views. The presence of a fracture was based on the interpretation of the X-rays by a radiologist who was blinded to the clinical probability of a fracture. Data were initially analysed using the chi-square test. Recursive partitioning was then performed to create a maximally sensitive decision tree. RESULTS: 280 patients were included in the study, 65 of whom had a mandibular fracture. A maximally sensitive decision rule was found that identified 5 parameters (malocclusion, trismus, broken teeth, pain with mouth closed, step deformity) whose absence excluded mandibular fracture. This rule has a sensitivity of 100% and specificity of 39% in identifying patients with mandibular fracture. If applied to our patient cohort, this rule would have saved 83 radiographs without missing any fractures. CONCLUSIONS: A simple decision rule is presented that can be used to exclude the need for radiography in a subset of patients with mandibular trauma.

Prophylactic aluminium hydroxide and hyperaluminaemia in intensive care.

Prophylactic antacid therapy is widely used in intensive care units. We show that significant hyperaluminaemia may occur during the course of prophylaxis with aluminium hydroxide in patients with compromised renal function. Since a significant proportion of patients in intensive care have, or are at risk of developing, renal failure we suggest that the routine use of aluminium hydroxide should be avoided.

Major incidents in Britain over the past 28 years: the case for the centralised reporting of major incidents.

STUDY OBJECTIVES: To describe the incidence and epidemiology of major incidents occurring in Britain over the past 28 years. METHODS: Major incidents were identified through a MEDLINE search, a hand search of journals and government reports at the Home Office Emergency Planning College, newspaper reports, a postal survey of ambulance emergency planning officers, and through requests for information posted on the internet. MAIN RESULTS: Brief incidents profiles from 108 British major incidents are presented. Most major incidents pass unreported in the medical literature. On average three to four major incidents occur in Britain each year (range 0-11). Sixty three of 108 (59.2%) of incidents involve public transportation. The next two largest groups are civil disturbance 22 of 108 (20.3%) and industrial accidents 16 of 108 (14.8%). Although incidents at sports stadiums are rare they produce large numbers of casualties. The data currently available on major incidents are difficult to find and of questionable accuracy. CONCLUSIONS: The lack of data makes planning for major incidents and exercising major incident plans difficult. Casualty incident profiles (CIPs) may assist major incidents exercises and planning. CIPs from future major incidents should be collated and made available to all major incident planners.

The European Resuscitation Council's paediatric life support course 'Advanced Paediatric Life Support'.

The poor outcome for resuscitation from cardiopulmonary arrest in childhood is widely recognised. The European Resuscitation Council has adopted the Advanced Paediatric Life Support course (originating in the UK and now available in a number of countries) as its course for providers caring for children. This paper outlines the course content and explains its remit, which is to reduce avoidable deaths in childhood by not only resuscitation from cardiac arrest but, more effectively, by recognising and treating in a timely and effective fashion life-threatening illness and injury in infants and children. Two related courses Paediatric Life Support, a less intense course for less advanced providers, and Pre-Hospital Paediatric Life Support for immediate care providers are also described.

Clinical risk and collective competence in the hospital emergency department in the UK.

The hospital emergency department (ED) is a risky environment, often subject to litigation for negligence. Risk is defined as an avoidable increase in the probability of an adverse outcome for a patient. With the aim of identifying the sources of risk, this study carried out participant observation and collected critical incidents in two EDs in the UK for a period of 30 months. Active failures included delay in beginning investigations or treatment, failure to obtain diagnostic information, misinterpretation of diagnostic information and the administration of inappropriate treatment. Three latent conditions underlay these failures: patients' unrestricted access to the ED, cognitive errors by individual members of staff and a strict horizontal and vertical division of labour. An analysis of the incidents resulting from the third latent condition identified a contradiction between the division of labour and working conditions in the ED. The paradigm circumstances under which this contradiction can result in active failures are described. The management of risks arising in this way could be improved by developing a workplace culture in which 'sapiential authority'--authority derived from experience, special access to information or being at hand in an emergency--is recognised in addition to authority derived from a formal status. However, as long the contradictions between the division of labour and working conditions remain, accidents should be considered normal events.

Psychiatric status, somatisation, and health care utilization of frequent attenders at the emergency department: a comparison with routine attenders.

Seventy-seven frequent attenders at an emergency department (ED) in an inner-city hospital in the UK (defined as seven or more visits in the previous 12 months) were compared with 182 patients who were attending the same department on a routine basis. Patients completed the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and the Short Form (SF)-36. Information was obtained on 64% of the frequent attenders and 45% underwent a detailed psychiatric assessment. Of the frequent attenders, 45% had psychiatric disorder and 49% had some form of an alcohol-related disorder. Compared with routine attenders, frequent attenders reported lower health status, had more psychiatric disorder (odds ratio: OR=8.2, 95% confidence interval: CI=3.8--18.1), had more general hospital admissions (OR=19.9, 95% CI=8.3--47.8), more psychiatric admissions (OR=167.5, 95% CI=9.5--2959.0), and more GP visits (95% CI for difference=-10.2 to -5.7). There was no evidence that frequent attenders had more somatisation than routine attenders. Specific treatment and management strategies need to be developed for this group of patients, although a substantial proportion may be difficult to engage in the treatment process.

Emergency unit care of sexually transmitted infections.

The aim of the study was to assess provisions for management of sexually transmitted infections (STIs), emergency contraception and pregnancy test in UK emergency departments. Postal questionnaires were sent to all consultant-led emergency departments in the UK in January 1996. The response rate was 64%. Most departments made direct referrals to genitourinary medicine (GUM) clinics and most had access to appropriate clinics. While 55% had facilities for diagnosis of at least one of the 3 common STIs (Chlamydia trachomatis, Neisseria gonorrhoeae and herpes simplex), only 6.25% had facilities for all 3. A minority of units provided training in the management of STIs. Emergency physicians should be trained in the early management of STIs and a coordinated working relationship should be developed between emergency and GUM departments to provide optimal sexual health care.

A Delphi study to identify performance indicators for emergency medicine.

OBJECTIVES: The aim of this study was to identify performance indicators thought to reflect the quality of patient care in the emergency department. METHODS: A three round accelerated Expert Delphi study was conducted by email or fax. A panel of 33 experts drawn from the fields of emergency medicine, emergency nursing, professional service users, and patients were consulted. Participants were initially asked to propose performance indicators that reflected the quality of care given in the emergency department setting in the United Kingdom. In the second round these proposals were collated and scored using a 9 point Likert scale; those that had not reached consensus were returned for reconsideration in the light of group opinion. Those statements reaching a pre-defined consensus were identified. RESULTS: 224 performance indicators were proposed. Altogether 36 indicators reached consensus reflecting good departmental performance after round three; 24 of these were process measures. CONCLUSIONS: 36 potential indicators of good quality of care in the emergency department in the UK have been identified.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Buscopan (hyoscine butylbromide) in abdominal colic.

A short cut review was carried out to establish whether buscopan (hyoscine butylbromide) is better than analgesics at controlling pain in abdominal colic. A total of 31 papers were found using the reported search, of which none presented any evidence to answer the clinical question. It is concluded that there is no evidence available to answer this question. Further research is needed.

Derivation of a typology for the classification of risks in emergency medicine.

OBJECTIVES: To develop a graded classification system for risks in emergency medicine. To test the inter-user reliability of this classification system. DESIGN: Prospective collection of data involving emergency department (ED) critical incidents. Derivation of classification system using the collected critical incidents. Comparison of results of classification of a sample of the critical incidents between different users of the system. SETTING: EDs in two teaching hospitals and two district general hospitals (DGHs) in the north west of England. INTERVENTIONS: Observational study. MAIN OUTCOMES: Classification system itself. Results of classification of same critical incidents by different users. RESULTS: 816 critical incidents were identified and used to derive a typology. This typology was found to have inter-user reliability score of 86% (95% confidence intervals 76.4% to 95.6%). CONCLUSIONS: The typology that has been derived is a reliable tool for the classification of risks in emergency medicine.

Identifying and comparing risks in emergency medicine.

OBJECTIVES: To identify common risk types occurring in emergency departments (EDs). To compare the risks occurring between different emergency departments. DESIGN: Application of a typology of risks to a database of critical incidents. Comparison of results of applying typology to group of critical incidents collected in a uniform manner in four different EDs. SETTING: EDs in two teaching hospitals and two district general hospitals in the north west of England. INTERVENTIONS: Observational study. MAIN OUTCOME MEASURES: Types of critical incidents identified. Statistical comparisons between EDs. RESULTS: 816 critical incidents were classified. Patient assessment omission failures were the commonest type of failure, accounting for 291 (35.6%) of the critical incidents. Level 1 and level 2 failures accounted for 254 (31.1%) of critical incidents. Significant differences (p = 0.009) were shown between EDs when the categories of critical incidents occurring were compared. No significant differences (p = 0.336) were shown between EDs when the levels of severity of critical incidents occurring were compared. CONCLUSIONS: Large numbers of critical incidents with potentially fatal consequences occur. The types of risks differ significantly between different EDs.