National early warning score at Emergency Department triage may allow earlier identification of patients with severe sepsis and septic shock: a retrospective observational study.

INTRODUCTION: Severe sepsis and septic shock (SS) are time-critical medical emergencies that affect millions of people in the world. Earlier administration of antibiotics has been shown to reduce mortality from SS; however, the initiation of early resuscitation requires recognition that a patient may have sepsis. Early warning scores (EWS) are broadly used to detect patient deterioration, but to date have not been evaluated to detect patients at risk for SS. The purpose of our study was to look at the relationship between the initial national EWS (NEWS) in the emergency department (ED) and the diagnosis of SS. METHODS: We performed a retrospective, single-centre, observational study in the ED of an urban university hospital with an annual attendance of 140,000 patients. We aimed to include 500 consecutive non-trauma adult patients presenting to the ED with Manchester Triage System (MTS) category 1-3. The final diagnosis was taken from either the ED medical records or the hospital discharge summary. For all NEWS, the sensitivity and specificity to detect patients with SS was calculated. RESULTS: A total of 500 patients were included, 27 patients (5.4%) met the criteria for SS. The area under the curve (AUC) for NEWS to identify patient at risk for SS is 0.89 (95% CI 0.84 to 0.94). A NEWS of 3 or more at ED triage has a sensitivity of 92.6% (95% CI 74.2% to 98.7%) and a specificity of 77% (95% CI 72.8% to 80.6%) to detect patients at risk for SS at ED triage. CONCLUSIONS: A NEWS of 3 or more at ED triage may be the trigger to systematically screen the patient for SS, which may ultimately lead to early recognition and treatment.

A cross-sectional study of knife injuries at a London major trauma centre.

INTRODUCTION: No national recording systems for knife injuries exist in the UK. Understanding the true size and nature of the problem of knife injuries is the first stage in reducing the burden of this injury. The aim of this study was to survey every knife injury seen in a single inner city emergency department (ED) over a one-year period. METHODS: A cross-sectional observational study was performed of all patients attending with a knife injury to the ED of a London major trauma centre in 2011. Demographic characteristics, patterns of injury, morbidity and mortality data were collected. RESULTS: A total of 938 knife injuries were identified from 127,191 attendances (0.77% of all visits) with a case fatality rate of 0.53%. A quarter (24%) of the major trauma team's caseload was for knife injuries. Overall, 44% of injuries were selfreported as assaults, 49% as accidents and 8% as deliberate self-harm. The highest age specific incident rate occurred in the 16-24 year age category (263/100,000). Multiple injuries were seen in 19% of cases, of which only 81% were recorded as assaults. The mean length of stay for those admitted to hospital was 3.04 days. Intrathoracic injury was seen in 26% of cases of chest trauma and 24% of abdominal injuries had a second additional chest injury. CONCLUSIONS: Violent intentional injuries are a significant contributory factor to the workload of the major trauma team at this centre. This paper contributes to a more comprehensive understanding of the nature of these injuries seen in the ED.

Paranoia and post-traumatic stress disorder in the months after a physical assault: a longitudinal study examining shared and differential predictors.

BACKGROUND: Being physically assaulted is known to increase the risk of the occurrence of post-traumatic stress disorder (PTSD) symptoms but it may also skew judgements about the intentions of other people. The objectives of the study were to assess paranoia and PTSD after an assault and to test whether theory-derived cognitive factors predicted the persistence of these problems. METHOD: At 4 weeks after hospital attendance due to an assault, 106 people were assessed on multiple symptom measures (including virtual reality) and cognitive factors from models of paranoia and PTSD. The symptom measures were repeated 3 and 6 months later. RESULTS: Factor analysis indicated that paranoia and PTSD were distinct experiences, though positively correlated. At 4 weeks, 33% of participants met diagnostic criteria for PTSD, falling to 16% at follow-up. Of the group at the first assessment, 80% reported that since the assault they were excessively fearful of other people, which over time fell to 66%. Almost all the cognitive factors (including information-processing style during the trauma, mental defeat, qualities of unwanted memories, self-blame, negative thoughts about self, worry, safety behaviours, anomalous internal experiences and cognitive inflexibility) predicted later paranoia and PTSD, but there was little evidence of differential prediction. CONCLUSIONS: Paranoia after an assault may be common and distinguishable from PTSD but predicted by a strikingly similar range of factors.

The nature of trauma memories in acute stress disorder in children and adolescents.

BACKGROUND: There is increasing theoretical, clinical and research evidence for the role of trauma memory in the aetiology of acute pathological stress responses in adults. However, research into the phenomenology of trauma memories in young people is currently scarce. METHODS: This study compared the nature of trauma narratives to narratives of unpleasant non-traumatic events in young people (aged 8-17) who sought emergency medical attention following an assault or road traffic accident. Data were collected within 2-4 weeks of the index event. Symptom severity was assessed by child self-report and face-to-face diagnostic interviews. Comparisons of narrative indices were made between those children with acute stress disorder (ASD) and those without ASD. RESULTS: Among participants (n = 50), those with ASD (38%) had significantly elevated levels of disorganisation in their trauma narrative, compared both to trauma-exposed controls and to their unpleasant comparative narrative. This effect was not accounted for by age. Regardless of ASD diagnostic status, trauma narratives had significantly higher sensory content and significantly lower positive emotion content compared to the unpleasant comparative narrative. These effects were not significant when age was included as a covariate. Acute symptom severity was significantly predicted by the level of disorganisation in the trauma narrative and the child's cognitive appraisals of the event. CONCLUSIONS: These data provide the first empirical evidence that disorganisation is not only directly linked to symptom severity, but also specific to the trauma memory. In addition, it provides support for the adaptation of adult cognitive models to acute pathological stress reactions in children and adolescents.

Emergency nurse practitioners and doctors consulting with patients in an emergency department: a comparison of communication skills and satisfaction.

BACKGROUND: Emergency nurse practitioners (ENPs) play an increasingly important role in UK emergency departments (EDs), but there is limited evidence about how this affects patient care and outcome. A study was undertaken to compare the content of, and satisfaction with, consultations made with patients presenting with problems of low acuity to an ED. METHODS: Patients presenting with "primary care" problems were allocated to senior house officers (SHOs, n = 10), specialist registrars/staff grades (n = 7), sessionally-employed general practitioners (GPs, n = 12) or ENPs (n = 6) randomly rostered to work in a consulting room that had a wall-mounted video camera. At the end of each consultation the doctor/ENP and the patient were asked to complete the Physician/Patient Satisfaction Questionnaire. A stratified sample of videotaped consultations (n = 296) was analysed in depth using the Roter Interaction Analysis System. The main outcome measures were length of consultation; numbers of utterances of doctor/ENP and patient talk related to building a relationship, data gathering, activating/partnering, and patient education/counselling; doctor/ENP and patient consultation satisfaction scores. RESULTS: ENPs and GPs focused more on patient education and counselling about the medical condition or therapeutic regimen than did ED doctors. There were no significant differences in consultation length. ENPs had higher levels of overall self-satisfaction with their consultations than ED doctors. Patient satisfaction with how actively they participated in the consultation was significantly associated with the amount of talk relating to building a relationship and activating and partnering, and patient satisfaction with information giving in the consultation was significantly associated with the amount of talk relating to building a relationship. CONCLUSION: These findings suggest differences between ENP and ED doctor consultations which are associated with some aspects of patient satisfaction. In contrast to previous reports, consultation length was not greater for ENPs than for doctors. There is a need for further research to test the generalisability of these findings and their impact on clinical outcome.

Weight-based N-acetylcysteine dosing chart to minimise the risk of calculation errors in prescribing and preparing N-acetylcysteine infusions for adults presenting with paracetamol overdose in the emergency department.

Management of paracetamol overdose (POD) is common in the emergency department (ED) and forms part of the clinical effectiveness audit programme of the British Association for Emergency Medicine. N-acetylcysteine (NAC) infusion regimens for the treatment of POD are complicated and prescribing and administration errors have been well documented. This study assessed the ability of doctors and nurses to calculate correct doses using manual calculation skills and a weight-based NAC dosing chart when prescribing and preparing NAC infusions. With manual calculations, errors were made by doctors and nurses in 26% of cases collectively. No errors were made using the dosing chart. The dosing chart ensured 100% accuracy in dose calculations, which may translate into improved patient safety.

Safety of telephone consultation for "non-serious" emergency ambulance service patients.

OBJECTIVE: To assess the safety of nurses and paramedics offering telephone assessment, triage, and advice as an alternative to immediate ambulance dispatch for emergency ambulance service callers classified by lay call takers as presenting with "non-serious" problems (category C calls). DESIGN: Data for this study were collected as part of a pragmatic randomised controlled trial reported elsewhere. The intervention arm of the trial comprised nurse or paramedic telephone consultation using a computerised decision support system to assess, triage, and advise patients whose calls to the emergency ambulance service had been classified as "non-serious" by call takers applying standard priority dispatch criteria. A multidisciplinary expert clinical panel reviewed data from ambulance service, accident and emergency department, hospital inpatient and general practice records, and call transcripts for patients triaged by nurses and paramedics into categories that indicated that dispatch of an emergency ambulance was unnecessary. All cases for which one or more members of the panel rated that an emergency ambulance should have been dispatched were re-reviewed by the entire panel for an assessment of the "life risk" that might have resulted. SETTING: Ambulance services in London and the West Midlands, UK. STUDY POPULATION: Of 635 category C patients assessed by nurses and paramedics, 330 (52%) cases that had been triaged as not requiring an emergency ambulance were identified. MAIN OUTCOME MEASURES: Assessment of safety of triage decisions. RESULTS: Sufficient data were available from the routine clinical records of 239 (72%) subjects to allow review by the specialist panel. For 231 (96.7%) sets of case notes reviewed, the majority of the panel concurred with the nurses' or paramedics' triage decision. Following secondary review of the records of the remaining eight patients, only two were rated by the majority as having required an emergency ambulance within 14 minutes. For neither of these did a majority of the panel consider that the patient would have been at "life risk" without an emergency ambulance being immediately dispatched. However, the transcripts of these two calls indicated that the correct triage decision had been communicated to the patient, which suggests that the triage decision had been incorrectly entered into the decision support system. CONCLUSIONS: Telephone advice may be a safe method of managing many category C callers to 999 ambulance services. A clinical trial of the full implementation of this intervention is needed, large enough to exclude the possibility of rare adverse events.

Emergency contraception. Has over the counter availability reduced attendances at emergency departments?

Legislation introduced in January 2001 has meant that progestogen only contraception is now available without prescription for women aged 16 years and over. Patient records of two emergency departments in the South East Thames region between 2000 and 2001 were reviewed and it was found that there was a 52% reduction in the number of women attending these emergency departments with requests for emergency contraception. These findings suggest that the legislation has meant that more women are getting their emergency contraception without prescription from pharmacies as compared with emergency departments.

Predictors of falls in a high risk population: results from the prevention of falls in the elderly trial (PROFET).

OBJECTIVES: The prevention of falls in the elderly trial (PROFET) provides evidence of the benefits of structured interdisciplinary assessment of older people presenting to the accident and emergency department with a fall. However, the service implications of implementing this effective intervention are significant. This study therefore examined risk factors from PROFET and used these to devise a practical approach to streamlining referrals from accident and emergency departments to specialist falls services. METHODS: Logistic regression analysis was used in the control group to identify patients with an increased risk of falling in the absence of any intervention. The derived predictors were investigated to see whether they also predicted loss to follow up. A second regression analysis was undertaken to test for interaction with intervention. RESULTS: Significant positive predictors of further falls were; history of falls in the previous year (OR 1.5 (95%CI 1.1 to 1.9)), falling indoors (OR 2.4 (95%CI 1.1 to 5.2)), and inability to get up after a fall (OR 5.5 (95%CI 2.3 to 13.0)). Negative predictors were moderate alcohol consumption (OR 0.55 (95%CI 0.28 to 1.1)), a reduced abbreviated mental test score (OR 0.7 (95%CI 0.53 to 0.93)), and admission to hospital as a result of the fall (OR 0.26 (95%CI 0.11 to 0.61)). A history of falls (OR 1.2 (95%CI 1.0 to 1.3)), falling indoors (OR 3.2 (95%CI 1.5 to 6.6)) and a reduced abbreviated mental test score (OR 1.3 (95%CI 1.0 to 1.6)) were found to predict loss to follow up. CONCLUSIONS: The study has focused on a readily identifiable high risk group of people presenting at a key interface between the primary and secondary health care sectors. Analysis of derived predictors offers a practical risk based approach to streamlining referrals that is consistent with an attainable level of service commitment.

Computer assisted assessment and advice for "non-serious" 999 ambulance service callers: the potential impact on ambulance despatch.

OBJECTIVE: To investigate the potential impact for ambulance services of telephone assessment and triage for callers who present with non-serious problems (Category C calls) as classified by ambulance service call takers. DESIGN: Pragmatic controlled trial. Calls identified using priority dispatch protocols as non-serious were allocated to intervention and control groups according to time of call. Ambulance dispatch occurred according to existing procedures. During intervention sessions, nurses or paramedics within the control room used a computerised decision support system to provide telephone assessment, triage and, if appropriate, offer advice to permit estimation of the potential impact on ambulance dispatch. SETTING: Ambulance services in London and the West Midlands. SUBJECTS: Patients for whom emergency calls were made to the ambulance services between April 1998 and May 1999 during four hour sessions sampled across all days of the week between 0700 and 2300. MAIN OUTCOME MEASURES: Triage decision, ambulance cancellation, attendance at an emergency department. RESULTS: In total, there were 635 intervention calls and 611 controls. Of those in the intervention group, 330 (52.0%) were triaged as not requiring an emergency ambulance, and 119 (36.6%) of these did not attend an emergency department. This compares with 55 (18.1%) of those triaged by a nurse or paramedic as requiring an ambulance (odds ratio 2.62; 95% CI 1.78 to 3.85). Patients triaged as not requiring an emergency ambulance were less likely to be admitted to an inpatient bed (odds ratio 0.55; 95% CI 0.33 to 0.93), but even so 30 (9.2%) were admitted. Nurses were more likely than paramedics to triage calls into the groups classified as not requiring an ambulance. After controlling for age, case mix, time of day, day of week, season, and ambulance service, the results of a logistic regression analysis revealed that this difference was significant with an odds ratio for nurses:paramedics of 1.28 (95% CI 1.12 to 1.47). CONCLUSIONS: The findings indicate that telephone assessment of Category C calls identifies patients who are less likely to require emergency department care and that this could have a significant impact on emergency ambulance dispatch rates. Nurses were more likely than paramedics to assess calls as requiring an alternative response to emergency ambulance despatch, but the extent to which this relates to aspects of training and professional perspective is unclear. However, consideration should be given to the acceptability, reliability, and cost consequences of this intervention before it can be recommended for full evaluation.

Comparison of laryngeal mask and intubating laryngeal mask insertion by the naïve intubator.

Seventy-five inexperienced participants were timed inserting the laryngeal mask airway (LMA) and the intubating laryngeal mask (ILM) in one of five cadavers. Adequacy of ventilation was assessed on a three-point scale depending on chest expansion and air leak. Participants were also asked to intubate the trachea via the ILM. The ILM was inserted faster than the LMA (P < 0.05) with a greater proportion achieving adequate ventilation after their first attempt (P < 0.05). Tracheal intubation via the ILM was completed successfully by 67% (52 of 75) of participants. In a questionnaire, participants stated that the ILM was easier to use and the preferred device in an emergency. The results suggest that inexperienced practitioners should use the ILM rather than the LMA for emergency ventilation.

Training and supervision needs and experience: a longitudinal, cross-sectional survey of accident and emergency department senior house officers.

The aim of this study was to investigate senior house officers' (SHOs) perceptions about their training needs, satisfaction with teaching and supervision, and the relationship this has with psychological distress levels. All 171 SHOs employed within 27 accident and emergency (A&E) departments in the South Thames region were sent questionnaires at the start of their attachments in A&E, at the end of months four and six. The questionnaires asked SHOs to rate on visual analogue scales their perceived need for further training for 23 clinical and practical activities relevant to A&E practice. At the end of the fourth month SHOs were asked to indicate who had provided them with the most valuable teaching and supervision, indicate their satisfaction levels with training received, and suggest ways to improve teaching and supervision. SHOs' psychological distress levels were measured in all three questionnaires. Overall, satisfaction with supervision and training was mixed. SHOs perceived greatest need for further training in areas encountered less frequently in A&E. Registrars were the most valued providers of supervision and teaching. Increased numbers of middle grade staff and protected study time were suggested as ways to improve supervision and teaching. SHOs with higher scores for training need at the end of their attachment in A&E expressed significantly less satisfaction with training and higher psychological distress levels. The variation between SHOs' perceptions of training needs indicates the importance of tailoring training and supervision to individual requirements.

Prevention of falls in the elderly trial (PROFET): a randomised controlled trial.

BACKGROUND: Falls in elderly people are a common presenting complaint to accident and emergency departments. Current practice commonly focuses on the injury, with little systematic assessment of the underlying cause, functional consequences, and possibilities for future prevention. We undertook a randomised controlled study to assess the benefit of a structured inderdisciplinary assessment of people who have fallen in terms of further falls. METHODS: Eligible patients were aged 65 years and older, lived in the community, and presented to an accident and emergency department with a fall. Patients assigned to the intervention group (n=184) underwent a detailed medical and occupational-therapy assessment with referral to relevant services if indicated; those assigned to the control group (n=213) received usual care only. The analyses were by intention to treat. Follow-up data were collected every 4 months for 1 year. FINDINGS: At 12-month follow-up, 77% of both groups remained in the study. The total reported number of falls during this period was 183 in the intervention group compared with 510 in the control group (p=0.0002). The risk of falling was significantly reduced in the intervention group (odds ratio 0.39 [95% CI 0.23-0.66]) as was the risk of recurrent falls (0.33 [0.16-0.68]). In addition, the odds of admission to hospital were lower in the intervention group (0.61 [0.35-1.05]) whereas the decline in Barthel score with time was greater in the control group (p<0.00001). INTERPRETATION: The study shows that an interdisciplinary approach to this high-risk population can significantly decrease the risk of further falls and limit functional impairment.

Emergency department senior house officers' consultation difficulties: implications for training.

STUDY OBJECTIVE: We investigated the types of patient presentations that cause senior house officers (SHOs) most difficulty during their tenure in emergency departments and report the extent to which such difficulties are related to SHOs' communication problems, stress, or perceived lack of skills or knowledge. METHODS: We conducted a questionnaire survey of 171 newly appointed SHOs employed in 27 EDs in the South Thames region of England. Subjects were asked to describe the presentation that gave them greatest difficulty during three subsequent shifts at the end of the first and fourth months of their ED appointment. RESULTS: A total of 132 (77%) and 110 (64%) respondents returned questionnaires at the end of the first and fourth months, respectively; 61% (105) responded to both questionnaires. The respondents described 537 of a possible total of 726 cases (74%). Communication problems caused difficulty in 406 (76%) cases, SHOs' experience of stress in 352 (66%) cases, and a perceived lack of knowledge or skills in 281 (52%) cases. Communication problems and the experience of stress occurred in 141 (26%) cases. Patients presenting with mental or behavioral disorders and symptoms most frequently gave rise to communication problems, perceived lack of skills, and the experience of stress. The difficulties described at the two time periods were very similar indicating that experience alone had little effect on these problems. CONCLUSION: ED SHOs may benefit from communication skills training, the opportunity to review difficult case presentations, and the alleviation of organizational stress factors.

Primary care consultation skills training: implementing a new training programme for senior house officers in an accident and emergency department.

Senior house officers (SHOs) in Accident and Emergency (A&E) departments see many patients who present with primary care problems. Until now, most SHOs have lacked postgraduate training in primary care skills to enable them to meet these patients' needs effectively. This paper describes an innovative training programme that has been developing at King's College Hospital, London. It identifies a new opportunity for general practitioners to contribute to the postgraduate medical education of hospital junior medical staff. The training programme was designed to give A&E SHOs protected time in which to reflect on strengths and weaknesses in relation to primary care consultations and learn from their experiences. Its aim was to improve the assessment and management of patients, and to encourage a problem solving approach within the A&E setting. The programme, established in 1992, was developed through collaboration between the departments of A&E Medicine and General Practice and Primary Care. Evaluation has been a central theme in its development, and has been used to ensure that the training meets the needs of each individual set of SHOs and of the department. It has been used in establishing agreement about the training's value and benefits. The authors discuss some of the methodological difficulties encountered in evaluating this type of educational initiative.