BET 2: Tubular bandage, plaster or aircast boot for avulsion fractures of the base of the fifth metatarsal?

A shortcut review was carried out to investigate whether avulsion fractures of the base of the fifth metatarsal were best treated with tubular bandage, a walking boot or a short leg plaster cast. One paper presented the only evidence to answer one of the clinical questions (plaster cast or walking boot) but no evidence was found comparing tubular bandage and a walking boot. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of this paper are tabulated. It is concluded that while the only evidence available shows marginal benefit of walking boot over short plaster cast during recovery, there is no benefit to final outcome. Further research comparing tubular bandage and walking boot is required.

Evidence-based medicine and COVID-19: what to believe and when to change.

The COVID-19 pandemic has led to a surge of information being presented to clinicians regarding this novel and deadly disease. There is a clear urgency to collate, review, appraise and act on this information if we are to do the best for clinicians and patients. However, the speed of the pandemic is a threat to traditional models of knowledge translation and practice change. In this concepts paper, we argue that clinicians need to be agile in their thinking and practice in order to find the right time to change. Adoption of new methods should be based on clinical judgement, the weight of evidence and the balance of probabilities that any new technique, test or treatment might work. The pandemic requires all of us to reach a new level of evidence-based medicine characterised by scepticism, thoughtfulness, responsiveness and clinically agility in practice.

An Expert Delphi study to derive a tool for mental health triage in emergency departments.

OBJECTIVE: This study aimed to investigate and collate the opinions of experts regarding the triage of patients in mental health crisis presenting to EDs. DESIGN: A three-round e-Delphi study was conducted between November 2017 and April 2018. The panel of 28 representative experts were drawn from six stakeholder groups. 23 of the panel were clinicians working in England, while 5 were international triage experts. RESULTS: Experts generated 173 statements in six topic areas in the first round. 32 of these statements reached consensus in round 2. A further 20 statements reached consensus in round 3, leaving 121 statements that did not reach consensus. The consensus statements were used to develop a structured five-level triage tool where the highest level of priority was assigned to patients exhibiting extreme aggression or agitation, those requiring restraint, those at immediate risk of leaving before assessment and those who presented a high risk of self-harm or harm to others. At lower triage priorities, other factors, such as items of psychiatric history, collateral history, observations and judgements, have been identified. CONCLUSIONS: A broadly based, multispecialty, multiprofessional expert Delphi panel has reached consensus on 52 statements concerning the triage of patients presenting in mental health crisis to EDs. The triage tool derived from this work can be used to inform the design of triage instruments employed to prioritise patients with physical and mental health problems equitably.

Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid: single biomarker re-derivation and external validation in three cohorts.

BACKGROUND: The original Manchester Acute Coronary Syndromes model (MACS) 'rules in' and 'rules out' acute coronary syndromes (ACS) using high sensitivity cardiac troponin T (hs-cTnT) and heart-type fatty acid binding protein (H-FABP) measured at admission. The latter is not always available. We aimed to refine and validate MACS as Troponin-only Manchester Acute Coronary Syndromes (T-MACS), cutting down the biomarkers to just hs-cTnT. METHODS: We present secondary analyses from four prospective diagnostic cohort studies including patients presenting to the ED with suspected ACS. Data were collected and hs-cTnT measured on arrival. The primary outcome was ACS, defined as prevalent acute myocardial infarction (AMI) or incident death, AMI or coronary revascularisation within 30 days. T-MACS was built in one cohort (derivation set) and validated in three external cohorts (validation set). RESULTS: At the 'rule out' threshold, in the derivation set (n=703), T-MACS had 99.3% (95% CI 97.3% to 99.9%) negative predictive value (NPV) and 98.7% (95.3%-99.8%) sensitivity for ACS, 'ruling out' 37.7% patients (specificity 47.6%, positive predictive value (PPV) 34.0%). In the validation set (n=1459), T-MACS had 99.3% (98.3%-99.8%) NPV and 98.1% (95.2%-99.5%) sensitivity, 'ruling out' 40.4% (n=590) patients (specificity 47.0%, PPV 23.9%). T-MACS would 'rule in' 10.1% and 4.7% patients in the respective sets, of which 100.0% and 91.3% had ACS. C-statistics for the original and refined rules were similar (T-MACS 0.91 vs MACS 0.90 on validation). CONCLUSIONS: T-MACS could 'rule out' ACS in 40% of patients, while 'ruling in' 5% at highest risk using a single hs-cTnT measurement on arrival. As a clinical decision aid, T-MACS could therefore help to conserve healthcare resources.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: Should bite guards be used with laryngeal mask airways in adults?

A shortcut review was carried out to establish whether bite blocks should be used when a laryngeal mask airway is used in the emergency department. Eighteen papers were found using the reported searches and a further eight were found by scanning the reference lists. Ten presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that bite guards should be used when laryngeal mask airways are employed in the emergency department.

Single whole-leg compression ultrasound for exclusion of deep vein thrombosis in symptomatic ambulatory patients: a prospective observational cohort study.

International guidance has recently recommended serial proximal compression ultrasound (CUS) as first line imaging for suspected deep vein thrombosis (DVT). Single whole-leg CUS is a routine alternative diagnostic strategy that can reduce repeated attendances and identify alternative pathology. We conducted a prospective observational cohort study. Consecutive ambulatory, adult patients with suspected DVT and negative or inconclusive whole-leg CUS had anticoagulation withheld and were followed for 3 months. The primary outcome was a predefined clinically relevant adverse event rate. Secondary outcomes included technical failure, alternative diagnoses and all cause mortality. 212 patients agreed to participate and completed follow up. One patient was subsequently diagnosed with an isolated distal DVT. The adverse event rate was thus 1/212, 0·47% (95% confidence interval [CI] 0·08-2·62). Technical imaging failure occurred in 11·3% of cases (95% CI 7·7-16·3). Several potential predictors of an inconclusive result were identified on multivariate analysis. 150 (70·8%) patients were provided with a documented alternative diagnosis. Patients who have anticoagulation withheld following a negative or inconclusive whole-leg CUS for suspected DVT have a low rate of adverse events. Technical failure remains an issue: several factors were significantly associated with inconclusive results and may warrant an alternative diagnostic approach.

Clinical navigation for beginners: the clinical utility and safety of the Paramedic Pathfinder.

BACKGROUND: English Ambulance Services are faced with annual increases in emergency demand. Addressing the demand for low acuity emergency calls relies upon the ability of ambulance clinicians to accurately identify the most appropriate destination or referral pathway. Given the risk of undertriage, the challenge is to develop processes that can safely determine patient dispositions, thereby increasing the number of patients receiving care closer to home. AIMS: The aim of the study was to evaluate the clinical utility and safety of triage support tools (Paramedic Pathfinders). METHODS: Two triage filters (Pathfinders) were developed (one medical, one trauma). These were applied by ambulance clinicians to 481 patients who had been transported to emergency departments (EDs). Preferred (gold standard) patient dispositions were established by senior medical practitioners using both ambulance and ED clinical records. The clinical utility of ambulance clinicians using Pathfinders was evaluated against this gold standard. RESULTS: The Medical Pathfinder was applied to 367 patients (76.3%) and the Trauma Pathfinder to 114 (23.7%). Agreement between ambulance clinician and gold standard was achieved in 387 cases (80.5%) giving the tools a combined sensitivity of 94.83% and specificity of 57.9%. 20.9% of medical patients and 30.7% of trauma patients who had been transported to hospital could have been safely cared for elsewhere. CONCLUSIONS: Ambulance clinicians using Pathfinders have demonstrated acceptable levels of sensitivity in identifying patients who require ED care. The actual impact of the tools in clinical practice will be dependent on the provision of suitable alternatives to ED.

Guidelines in Emergency Medicine Network (GEMNet): guideline for the use of thromboprophylaxis in ambulatory trauma patients requiring temporary limb immobilisation.

The Guidelines in Emergency Medicine Network (GEMNet) has been created to promote best medical practice in a range of conditions presenting to emergency departments (EDs) in the UK. This guideline presents a summary of the best available evidence to guide the use of thromboprophylaxis in adult ambulatory outpatients who present to the ED following acute limb trauma and require temporary immobilisation. The document has been developed following discussion among emergency physicians and collegiate fellows to decide which topics would benefit from the development of clinical guidelines. The document is intended as a guideline for use in the ED by emergency physicians and is based on the review of the best existing evidence for treatments used in this setting. The document is summarised as a Clinical Decision Support Guideline that has been presented as an easy to follow algorithm. The intention is for each guideline to be updated and reviewed as further evidence becomes available. The formal revision date has been set at 5 years from publication, though the guideline is subject to continuous informal review.

Making more nurses, one minute at a time: an efficiency and quality improvement project in emergency triage.

Emergency triage is a short-duration, high-volume process so small reductions in the time taken to triage one patient can have large repercussions on the total amount of triage time. At the emergency department of a large inner-city hospital, an efficiency and quality improvement project was undertaken to reduce the time taken to safely triage patients and optimise the use of triage nurses' time. The project involved removing processes that did not contribute to the primary aim of triage, supporting individual triage nurses to improve their performance where needed, and optimising the triage process. A 44% reduction in mean triage episode time was seen, equating to 18,000 minutes of triage nurses' time saved every month. This near doubling of triage capacity was associated with an improvement in triage accuracy. The article describes the project, which used lean management principles and statistical process control methods, and discusses its implications for emergency triage.

An international expert Delphi study to determine research needs in major incident management.

OBJECTIVE: To collate the opinions of experts and to reach consensus about the research priorities in the management of major incidents. DESIGN: A three-round e-Delphi study was conducted using an international panel of experts drawn from active researchers and active educators in major incident management. General areas for consideration were derived from the literature analysis undertaken as part of the overall project. RESULTS: Experts generated 221 statements in 11 topic areas in the first round. Fifty-one of these statements reached consensus in Round 2. A further 23 statements reached consensus in Round 3, leaving 147 statements that did not reach consensus. CONCLUSIONS: An international expert panel reached consensus on 74 topics of research priority in major incidents management. The strongest themes within these topics were education and training, planning, and communication.

Diagnosing pulmonary embolism: a comparison of clinical probability scores.

Pulmonary embolism (PE) is a major cause of community and in-hospital mortality. This study aimed to compare the performance of the British Thoracic Society (BTS) score to the Wells' score in diagnosing PE. Data from two separate prospective diagnostic PE studies were analysed. All patients underwent gold standard investigation to determine the presence or absence of PE, together with a 3-month follow-up. The posttest prevalence of PE was compared using both scores and the receiver operating characteristic (ROC) curves. Seven hundred and seventy-nine patients were consented and investigated for PE. In patients with pleuritic chest pain, respiratory rate <20 breaths/min and absence of dyspnoea, 4·0% [95% confidence interval (CI) 1·9-7·9%] had PE. The BTS score allocated 463/779 patients as low probability, compared to 565/779 according to the Wells' score. Both scores identified a low risk group in the Manchester Investigation of Pulmonary Embolism Diagnosis cohort, however the BTS low probability group in the Thromboembolism Assessment and Diagnosis study had a prevalence of 9·7% (95% CI 5·8-15·9%). For the BTS score, the areas under the ROC curves were 0·67 (95% CI 0·61-0·72) and 0·71 (95% CI 0·61-0·75). For the Wells' score these were 0·76 (95%CI 0·71-0·81) and 0·68 (95%CI 0·64-0·73). Given the lack of BTS validation studies to date, the Wells' score appears to be the safer assessment option.

Guidelines in Emergency Medicine Network (GEMNet): guideline for the management of tricyclic antidepressant overdose.

The Guidelines in Emergency Medicine Network (GEMNet) has been created to promote best medical practice in a range of conditions presenting to emergency departments (EDs) in the UK. This guideline presents a summary of the best available evidence to guide the management of adult patients who present to the ED following an overdose of tricyclic antidepressant agents (TCA). The document has been developed following discussion among emergency physicians to decide which topics would benefit from the development of clinical guidelines. The document is intended as a guideline for use in the ED by emergency physicians and is based on the review of the best existing evidence for the diagnostic tools and treatments used in this setting. The document is summarised as a clinical decision support guideline that has been presented as an easy to follow algorithm. The intention is for each guideline to be updated and reviewed as further evidence becomes available. The formal revision date has been set at 5 years from publication, although the guideline is subject to continuous informal review.

Decision Support Framework for Deployment of Emergency Medical Teams After Earthquakes.

OBJECTIVE: The effectiveness of Emergency Medical Teams (EMTs) is strongly related to their time of arrival, and usually only few teams arrive within 24-48 h postdisaster. The decision to deploy and the scale of deployment rely heavily on context and nature of the event and consequently a rapid assessment of needs/gaps is critical to an appropriate and customized response. METHODS: In this study, we describe a desk-based study that provides: (1) knowledge about the medical needs that can be anticipated according to the phases of the disaster that is not rich in literature; and (2) a decision support framework for the deployment of EMTs to earthquakes that combines the results of a literature research and a Delphi study involving the opinion of 12 experts in the field. RESULTS: The resulting framework is a tool that will help better mapping the configuration to the needs on the ground at the time the team becomes operational in the field and will assist those responsible for deploying and/or accepting EMTs in making informed decisions on deployment after an earthquake. CONCLUSIONS: With additional research the framework approach may be adapted to other types of international relief such as to deploy a Search And Rescue (SAR) team.

Diagnosing acute myocardial infarction with troponins: how low can you go?

BACKGROUND: Recent consensus guidelines state that acute myocardial infarction (AMI) may be diagnosed in the context of a troponin rise above the 99th percentile of the upper reference limit (URL) with the optimal imprecision of the assay (coefficient of variation, CV) being

Enhanced triage for patients with suspected cardiac chest pain: the History and Electrocardiogram-only Manchester Acute Coronary Syndromes decision aid.

OBJECTIVES: Several decision aids can 'rule in' and 'rule out' acute coronary syndromes (ACS) in the Emergency Department (ED) but all require measurement of blood biomarkers. A decision aid that does not require biomarker measurement could enhance risk stratification at triage and could be used in the prehospital environment. We aimed to derive and validate the History and ECG-only Manchester ACS (HE-MACS) decision aid using only the history, physical examination and ECG. METHODS: We undertook secondary analyses in three prospective diagnostic accuracy studies that included patients presenting to the ED with suspected cardiac chest pain. Clinicians recorded clinical features at the time of arrival using a bespoke form. Patients underwent serial troponin sampling and 30-day follow-up for the primary outcome of ACS. The model was derived by logistic regression in one cohort and validated in two similar prospective studies. RESULTS: The HE-MACS model was derived in 796 patients and validated in cohorts of 474 and 659 patients. HE-MACS incorporated age, sex, systolic blood pressure plus five historical variables to stratify patients into four risk groups. On validation, 5.5 and 12.1% (pooled total 9.4%) patients were identified as 'very low risk' (potential immediate rule out) with a pooled sensitivity of 99.5% (95% confidence interval: 97.1-100.0%). CONCLUSION: Using only the patient's history and ECG, HE-MACS could 'rule out' ACS in 9.4% of patients while effectively risk stratifying remaining patients. This is a very promising tool for triage in both the prehospital environment and ED. Its impact should be prospectively evaluated in those settings.

Performance of triage systems in emergency care: a systematic review and meta-analysis.

OBJECTIVE: To assess and compare the performance of triage systems for identifying high and low-urgency patients in the emergency department (ED). DESIGN: Systematic review and meta-analysis. DATA SOURCES: EMBASE, Medline OvidSP, Cochrane central, Web of science and CINAHL databases from 1980 to 2016 with the final update in December 2018. ELIGIBILITY CRITERIA: Studies that evaluated an emergency medical triage system, assessed validity using any reference standard as proxy for true patient urgency and were written in English. Studies conducted in low(er) income countries, based on case scenarios or involving less than 100 patients were excluded. REVIEW METHODS: Reviewers identified studies, extracted data and assessed the quality of the evidence independently and in duplicate. The Quality Assessment of studies of Diagnostic Accuracy included in Systematic Reviews -2 checklist was used to assess risk of bias. Raw data were extracted to create 2×2 tables and calculate sensitivity and specificity. ED patient volume and casemix severity of illness were investigated as determinants of triage systems' performance. RESULTS: Sixty-six eligible studies evaluated 33 different triage systems. Comparisons were restricted to the three triage systems that had at least multiple evaluations using the same reference standard (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System). Overall, validity of each triage system to identify high and low-urgency patients was moderate to good, but performance was highly variable. In a subgroup analysis, no clear association was found between ED patient volume or casemix severity of illness and triage systems' performance. CONCLUSIONS: Established triage systems show a reasonable validity for the triage of patients at the ED, but performance varies considerably. Important research questions that remain are what determinants influence triage systems' performance and how the performance of existing triage systems can be improved.

Management of patients with an advance decision and suicidal behaviour: a systematic review.

BACKGROUND: The use of advance care planning and advance decisions for psychiatric care is growing. However, there is limited guidance on clinical management when a patient presents with suicidal behaviour and an advance decision and no systematic reviews of the extant literature. OBJECTIVES: To synthesise existing literature on the management of advance decisions and suicidal behaviour. DESIGN: A systematic search of seven bibliographic databases was conducted to identify studies relating to advance decisions and suicidal behaviour. Studies on terminal illness or end-of-life care were excluded to focus on the use of advance decisions in the context of suicidal behaviour. A textual synthesis of data was conducted, and themes were identified by using an adapted thematic framework analysis approach. RESULTS: Overall 634 articles were identified, of which 35 were retained for full text screening. Fifteen relevant articles were identified following screening. Those articles pertained to actual clinical cases or fictional scenarios. Clinical practice and rationale for management decisions varied. Five themes were identified: (1) tension between patient autonomy and protecting a vulnerable person, (2) appropriateness of advance decisions for suicidal behaviour, (3) uncertainty about the application of legislation, (4) the length of time needed to consider all the evidence versus rapid decision-making for treatment and (5) importance of seeking support and sharing decision-making. CONCLUSIONS: Advance decisions present particular challenges for clinicians when associated with suicidal behaviour. Recommendations for practice and supervision for clinicians may help to reduce the variation in clinical practice.

Advance decisions to refuse treatment and suicidal behaviour in emergency care: 'it's very much a step into the unknown'.

BACKGROUND: Complex challenges may arise when patients present to emergency services with an advance decision to refuse life-saving treatment following suicidal behaviour. AIMS: To investigate the use of advance decisions to refuse treatment in the context of suicidal behaviour from the perspective of clinicians and people with lived experience of self-harm and/or psychiatric services. METHOD: Forty-one participants aged 18 or over from hospital services (emergency departments, liaison psychiatry and ambulance services) and groups of individuals with experience of psychiatric services and/or self-harm were recruited to six focus groups in a multisite study in England. Data were collected in 2016 using a structured topic guide and included a fictional vignette. They were analysed using thematic framework analysis. RESULTS: Advance decisions to refuse treatment for suicidal behaviour were contentious across groups. Three main themes emerged from the data: (a) they may enhance patient autonomy and aid clarity in acute emergencies, but also create legal and ethical uncertainty over treatment following self-harm; (b) they are anxiety provoking for clinicians; and (c) in practice, there are challenges in validation (for example, validating the patient's mental capacity at the time of writing), time constraints and significant legal/ethical complexities. CONCLUSIONS: The potential for patients to refuse life-saving treatment following suicidal behaviour in a legal document was challenging and anxiety provoking for participants. Clinicians should act with caution given the potential for recovery and fluctuations in suicidal ideation. Currently, advance decisions to refuse treatment have questionable use in the context of suicidal behaviour given the challenges in validation. Discussion and further patient research are needed in this area. DECLARATION OF INTEREST: D.G., K.H. and N.K. are members of the Department of Health's (England) National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group (which developed the quality standards for self-harm services). He is currently chair of the updated NICE guideline for Depression. K.H. and D.G. are NIHR Senior Investigators. K.H. is also supported by the Oxford Health NHS Foundation Trust and N.K. by the Greater Manchester Mental Health NHS Foundation Trust.

Do risk factors for chronic coronary heart disease help diagnose acute myocardial infarction in the Emergency Department?

BACKGROUND: Hypertension, hyperlipidaemia, diabetes mellitus, tobacco smoking and a family history of premature coronary artery disease are known to be risk factors for the development of coronary artery disease. We sought to determine whether these traditional risk factors aid the diagnosis of acute myocardial infarction (AMI) in the Emergency Department (ED). METHODS: We performed a prospective diagnostic cohort study within the ED at Manchester Royal Infirmary, a university-affiliated teaching hospital with an annual ED census of approximately 145,000 patients. We recruited 804 patients who had presented to the ED with suspected cardiac chest pain. All patients had the presence or absence of traditional cardiac risk factors documented at the time of presentation using a custom-designed clinical report form. All patients subsequently underwent 12-h troponin T testing to provide a robust gold standard for the diagnosis of AMI according to revised World Health Organisation criteria. RESULTS: The absence of any traditional cardiac risk factors carried a negative likelihood ratio of 0.61 for the diagnosis of AMI. 12.2% of patients with no cardiac risk factors had AMI, compared with 21.3% of patients with four or five risk factors. The area under the receiver-operating characteristic curve was 0.49. CONCLUSIONS: Traditional cardiac risk factors are not helpful for the confirmation or exclusion of AMI within the ED. Future Emergency Medicine research should focus on those clinical and diagnostic features that are likely to alter during the acute phase of illness.

Management of coagulopathy in the patients with multiple injuries: results from an international survey of clinical practice.

BACKGROUND: Bleeding is one of the leading causes of preventable death after traumatic injury. Trauma-associated coagulopathy complicates the control of bleeding. The published approaches on the management of this coagulopathy differ significantly. METHODS: A qualitative international survey of clinical practice among senior physicians responsible for the treatment of patients with multiple injuries (Injury Severity Score > or = 16) was conducted to document common practices, highlight the variabilities, and profile the rationale behind existing clinical practices around the world. RESULTS: Survey results are based on 80 (32%) completed returns, representing 25 countries with 93% of respondents employed by trauma centers and a mean of 20 years clinical experience. There are regional differences in the clinical specialty of physicians responsible for trauma management decisions. Blood loss, temperature, pH, platelets, prothrombin time/INR/activated partial thromboplastin time, and overall clinical assessment, were the most common criteria used to assess coagulopathy. Forty-five percent of respondents claimed to follow a massive transfusion protocol in their institution, 19% reported inconsistent protocol use and 34% do not use a protocol. The management of hypothermia, acidosis, blood products, and adjuvant therapy showed regional as well as institutional variability, and surprisingly few massive transfusion protocols specifically address these issues. CONCLUSIONS: The results of this survey may serve to draw attention to the need for a common definition of coagulopathy and standardized clinical protocols to ensure optimal patient care.