To develop, implement and evaluate an integrated care pathway for patients presenting with pneumothorax.

BACKGROUND AND PURPOSE: Pneumothorax is a common presentation to acute healthcare services in Ireland, however there is wide variation in management approaches between centres. There is robust evidence to demonstrate that ambulatory management of pneumothorax is feasible and safe. The purpose of this study was to evaluate whether the implementation of an integrated care pathway (ICP) for pneumothorax patients with a focus on ambulatory care would be economically beneficial for the healthcare system. METHODS: This study developed, implemented and evaluated an ICP for all patients presenting with pneumothorax, with a specific focus on ambulatory management for suitable patients. The ICP was designed to be utilised in the Irish healthcare setting, and was evaluated using a prospective multi-centre observational study, with a rigorous economic analysis at the centre of study design. MAIN FINDINGS: Implementation of the ICP resulted in a statistically significant reduction in inpatient length of stay of 2.84 days from 7.4 to 4.56 days (p = 0.001). The incremental per patient cost reduction of treating a patient according to the pneumothorax ICP was 2314 euro. There were no adverse events related to drain insertion at the study sites. CONCLUSIONS: This study demonstrates therefore that standardisation of care for pneumothorax patients with a focus on ambulatory management are economically beneficial for the publicly-funded healthcare service. It is envisaged that this work will be used to inform healthcare policy at a national level across Ireland.

Implementation of a chest injury pathway in the emergency department.

Rib fractures represent a substantial health burden. Chest injuries contribute to 25% of deaths after trauma and survivors can experience long-standing consequences, such as reduced functional capabilities and loss of employment. Over recent years, there has been an increase in the awareness of the importance of early identification, aggressive pain management and adequate safety netting for patients with chest injuries. Substandard management leads to increased rates of morbidity and mortality. The development of protocols in the emergency department (ED) for management of patients with chest wall injuries has demonstrated reduction of complication rates.Our aim was to develop an evidence-based, multidisciplinary chest injury pathway for the management of patients presenting with rib injury to our ED.Prior to implementation of the pathway in our department, only 39% of patients were documented as having received analgesia and only 7% of discharged patients had documented written verbal advice. There was no standardised method to perform regional anaesthetic blocks. Using quality improvement methods, we standardised imaging modality, risk stratification with a scoring system, analgesia with emphasis on regional anaesthesia blocks and disposition with information leaflets for those discharged.Implementation of the pathway increased rates of documented analgesia received from 39% to 70%. The number of regional anaesthetic blocks performed went from 0% to 60% and the number of patients receiving discharge advice went from 7% to 70%. Compliance of doctors and nurses with the pathway was 63%.Our previous audits showed substandard management of patients with chest injuries in our department. Through this quality improvement project, we were able to improve the quality of care provided to patients attending with rib fractures by increasing rate of analgesia received, regional blocks performed and discharge advice given.

National Emergency Resuscitation Airway Audit (NERAA): a pilot multicentre analysis of emergency intubations in Irish emergency departments.

BACKGROUND: There is paucity of literature on why and how patients are intubated, and by whom, in Irish Emergency Departments (EDs). The aim of this pilot study was to characterise emergency airway management (EAM) of critically unwell patients presenting to Irish EDs. METHODS: A multisite prospective pilot study was undertaken from February 10 to May 10, 2020. This project was facilitated through the Irish Trainee Emergency Research Network (ITERN). All patients over 16 years of age requiring EAM were included. Eleven EDs participated in the project. Data recorded included patients' demographics, indication for intubation, technique of airway management, medications used to facilitate intubation, level of training and specialty of the intubating clinician, number of attempts, success/complications rates and variation across centres. RESULTS: Over a 3-month period, 118 patients underwent 131 intubation attempts across 11 EDs. The median age was 57 years (IQR: 40-70). Medical indications were reported in 83% of patients compared to 17% for trauma. Of the 118 patients intubated, Emergency Medicine (EM) doctors performed 54% of initial intubations, while anaesthesiology/intensive care medicine (ICM) doctors performed 46%. The majority (90%) of intubating clinicians were at registrar level. Emergency intubation check lists, video laryngoscopy and bougie were used in 55, 53 and 64% of first attempts, respectively. The first pass success rate was 89%. Intubation complications occurred in 19% of patients. EM doctors undertook a greater proportion of intubations in EDs with > 50,000 attendance (65%) compared to EDs with < 50,000 attendances (16%) (p < 0.000). CONCLUSION: This is the first study to describe EAM in Irish EDs, and demonstrates comparable first pass success and complication rates to international studies. This study highlights the need for continuous EAM surveillance and could provide a vector for developing national standards for EAM and EAM training in Irish EDs.

Tranexamic acid for major trauma patients in Ireland.

BACKGROUND: The Clinical Randomisation of an Anti-fibrinolytic in Significant Hemorrhage-2 (CRASH-2) is the largest randomized control trial (RCT) examining circulatory resuscitation for trauma patients to date and concluded a statistically significant reduction in all-cause mortality in patients administered tranexamic acid (TXA) within 3 hours of injury. Since the publication of CRASH-2, significant geographical variance in the use of TXA for trauma patients exists. This study aims to assess TXA use for major trauma patients with hemorrhagic shock in Ireland after the publication of CRASH-2. METHODS: A retrospective cohort study was conducted using data derived from the Trauma Audit and Research Network (TARN). All injured patients in Ireland between January 2013 and December 2018 who had evidence of hemorrhagic shock on presentation (as defined by systolic blood pressure [SBP] <100 mmHg [1 mmHg=0.133 kPa] and administration of blood products) were eligible for inclusion. Death at hospital discharge was the primary outcome. RESULTS: During the study period, a total of 234 patients met the inclusion criteria. Among injured patients presenting with hemorrhagic shock, 133 (56.8%; 95% confidence interval [CI] 50.2%-63.3%) received TXA. Of patients that received TXA, a higher proportion of patients presented with shock index >1 (70.68% vs.57.43%) and higher Injury Severity Score (ISS >25; 49.62% vs. 23.76%). Administration of TXA was not associated with mortality at hospital discharge (odds ratio [OR] 0.86, 95% CI 0.31-2.38). CONCLUSIONS: Among injured Irish patients presenting with hemorrhagic shock, TXA was administered to 56.8% of patients. Patients administered with TXA were on average more severely injured. However, a mortality benefit could not be demonstrated.

Orbital decompression.

A trauma patient with orbital compartment syndrome may lose vision within hours of the injury. This article describes an approach to decompressing the orbit which may be sight-saving.

Diagnosing death 50 years after the Harvard brain death report.

More than 50 years after the publication of the Harvard Committee Report that sought to define death according to whole-brain function criteria, this document continues to generate a diversity of opinions regarding how death should be defined. The various perspectives show that doubts linger regarding when brain death should be diagnosed, the criteria to pinpoint the occurrence of death, and the alignment of medical practices seeking to establish human death with these criteria. This study reviews and assesses three perspectives that have made significant contributions to the debate. Attention is also given to definitions of death that depart from the recommendations of the Harvard Report. Appraisals of various arguments lead to the conclusion that changes in the definition of death have resulted from advances in knowledge of human biology, medical technology and diagnostic techniques. A commentary is included on expediting the time of death with the view of organ donation.

Resuscitative thoracotomy.

A trauma patient with cardiac tamponade may not survive transfer to the operating theatre for pericardial decompression. This article describes an approach to a resuscitative thoracotomy in the ED, which may be life-saving in these patients when a cardiothoracic surgeon is not immediately available.

Decompressive craniotomy.

An unconscious patient with an extra-dural haematoma may not survive transfer to a neurosurgical centre for definitive care. This article describes a simple approach to a decompressive craniotomy which may be life-saving in these patients when a neurosurgeon is not available.

Geographical Variance in the Use of Tranexamic Acid for Major Trauma Patients.

Background and Objectives: The CRASH-2 trial is the largest randomised control trial examining tranexamic acid (TXA) for injured patients. Since its publication, debate has arisen around whether results could be applied to mature trauma systems in developed nations, with global opinion divided. The aim of this study was to determine if, among trauma patients in or at significant risk of major haemorrhages, there is an association of geographic region with the proportion of patients that received tranexamic acid. Materials and Methods: We conducted a systematic review of the literature. Potentially eligible papers were first screened via title and abstract screening. A full copy of the remaining papers was then obtained and screened for final inclusion. The Newcastle-Ottawa Scale for non-randomised control trials was used for quality assessment of the final studies included. A meta-analysis was conducted using a random-effects model, reporting variation in use sub-grouped by geographical location. Results: There were 727 papers identified through database searching and 23 manuscripts met the criteria for final inclusion in this review. There was a statistically significant variation in the use of TXA for included patients. Europe and Oceania had higher usage rates of TXA compared to other continents. Use of TXA in Asia and Africa was significantly less than other continents and varied use was observed in North America. Conclusions: A large geographical variance in the use of TXA for trauma patients in or at significant risk of major haemorrhage currently exists. The populations in Asia and Africa, where the results of CRASH-2 could be most readily generalised to, reported low rates of use. The reason why remains unclear and further research is required to standardise the use of TXA for trauma resuscitation.

The World Health Organization trauma checklist versus Trauma Team Time-out: A perspective.

Time-out protocols have reportedly improved team dynamics and patients' safety in various clinical settings - particularly in the operating room. In 2016, the World Health Organization (WHO) introduced a Trauma Care checklist, which outlines steps to follow immediately after the primary and secondary surveys and prior to the team leaving the patient. The WHO Trauma Care checklist's main perceived benefit is the prompting of clinicians to complete trauma admissions as per evidence-based guidelines. The WHO Trauma Care checklist, while likely to be successful in reducing errors of omission related to hospital admission, may be limited in its ability to reduce errors that occur in the initial 30 min of trauma reception - when most of the life-saving decisions are made. To address this limitation a Trauma Team Time-out protocol is proposed for initial trauma resuscitation, targeting the critical first 30 min of hospital reception.

Straight leg elevation to rule out pelvic injury.

OBJECTIVE: Pelvic x-ray is frequently used as a screening tool during initial assessment of injured patients. However routine use in the awake and alert blunt trauma patient may be questioned due to low yield. We propose a clinical tool that may avoid unnecessary imaging by examining whether the ability to straight leg raise, without pain, can rule out pelvic injury. METHODS: We conducted a prospective cohort study with the exposure variables of ability to straight leg raise and presence of pain on doing so, and presence of pelvic fracture on x-ray as the primary outcome variable. RESULTS: Of the 328 participants, 35 had pelvic fractures, and of these 32 were either unable to straight leg raise, or had pain on doing so, with a sensitivity of 91.43% (95% CI: 76.94-98.2%) and a negative predictive value of 98.57% (95% CI: 95.88-99.70%). The 3 participants with a pelvic fracture who could straight leg raise with no pain, all had a GCS of less than 15, and therefore, among the sub-group of patients with GCS15, a 100% sensitivity and 100% negative predictive value for straight leg raise with no pain to rule out pelvic fracture was demonstrated. CONCLUSION: Among awake, alert patients, painless straight leg raise can exclude pelvic fractures and be incorporated into initial examination during reception and resuscitation of injured patients.