A quantitative evaluation of aerosol generation during cardiopulmonary resuscitation.

It is unclear if cardiopulmonary resuscitation is an aerosol-generating procedure and whether this poses a risk of airborne disease transmission to healthcare workers and bystanders. Use of airborne transmission precautions during cardiopulmonary resuscitation may confer rescuer protection but risks patient harm due to delays in commencing treatment. To quantify the risk of respiratory aerosol generation during cardiopulmonary resuscitation in humans, we conducted an aerosol monitoring study during out-of-hospital cardiac arrests. Exhaled aerosol was recorded using an optical particle sizer spectrometer connected to the breathing system. Aerosol produced during resuscitation was compared with that produced by control participants under general anaesthesia ventilated with an equivalent respiratory pattern to cardiopulmonary resuscitation. A porcine cardiac arrest model was used to determine the independent contributions of ventilatory breaths, chest compressions and external cardiac defibrillation to aerosol generation. Time-series analysis of participants with cardiac arrest (n = 18) demonstrated a repeating waveform of respiratory aerosol that mapped to specific components of resuscitation. Very high peak aerosol concentrations were generated during ventilation of participants with cardiac arrest with median (IQR [range]) 17,926 (5546-59,209 [1523-242,648]) particles.l-1 , which were 24-fold greater than in control participants under general anaesthesia (744 (309-2106 [23-9099]) particles.l-1 , p < 0.001, n = 16). A substantial rise in aerosol also occurred with cardiac defibrillation and chest compressions. In a complimentary porcine model of cardiac arrest, aerosol recordings showed a strikingly similar profile to the human data. Time-averaged aerosol concentrations during ventilation were approximately 270-fold higher than before cardiac arrest (19,410 (2307-41,017 [104-136,025]) vs. 72 (41-136 [23-268]) particles.l-1 , p = 0.008). The porcine model also confirmed that both defibrillation and chest compressions generate high concentrations of aerosol independent of, but synergistic with, ventilation. In conclusion, multiple components of cardiopulmonary resuscitation generate high concentrations of respiratory aerosol. We recommend that airborne transmission precautions are warranted in the setting of high-risk pathogens, until the airway is secured with an airway device and breathing system with a filter.

Trends and associated factors for Covid-19 hospitalisation and fatality risk in 2.3 million adults in England.

The Covid-19 mortality rate varies between countries and over time but the extent to which this is explained by the underlying risk in those infected is unclear. Using data on all adults in England with a positive Covid-19 test between 1st October 2020 and 30th April 2021 linked to clinical records, we examined trends and risk factors for hospital admission and mortality. Of 2,311,282 people included in the study, 164,046 (7.1%) were admitted and 53,156 (2.3%) died within 28 days of a positive Covid-19 test. We found significant variation in the case hospitalisation and mortality risk over time, which remained after accounting for the underlying risk of those infected. Older age groups, males, those resident in areas of greater socioeconomic deprivation, and those with obesity had higher odds of admission and death. People with severe mental illness and learning disability had the highest odds of admission and death. Our findings highlight both the role of external factors in Covid-19 admission and mortality risk and the need for more proactive care in the most vulnerable groups.

Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children.

OBJECTIVE: To determine whether full elbow extension as assessed by the elbow extension test can be used in routine clinical practice to rule out bony injury in patients presenting with elbow injury. DESIGN: Adults: multicentre prospective interventional validation study in secondary care. Children: multicentre prospective observational study in secondary care. SETTING: Five emergency departments in southwest England. PARTICIPANTS: 2127 adults and children presenting to the emergency department with acute elbow injury. INTERVENTION: Elbow extension test during routine care by clinical staff to determine the need for radiography in adults and to guide follow-up in children. MAIN OUTCOME MEASURES: Presence of elbow fracture on radiograph, or recovery with no indication for further review at 7-10 days. RESULTS: Of 1740 eligible participants, 602 patients were able to fully extend their elbow; 17 of these patients had a fracture. Two adult patients with olecranon fractures needed a change in treatment. In the 1138 patients without full elbow extension, 521 fractures were identified. Overall, the test had sensitivity and specificity (95% confidence interval) for detecting elbow fracture of 96.8% (95.0 to 98.2) and 48.5% (45.6 to 51.4). Full elbow extension had a negative predictive value for fracture of 98.4% (96.3 to 99.5) in adults and 95.8% (92.6 to 97.8) in children. Negative likelihood ratios were 0.03 (0.01 to 0.08) in adults and 0.11 (0.06 to 0.19) in children. CONCLUSION: The elbow extension test can be used in routine practice to inform clinical decision making. Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.

Can patients apply the Ottawa ankle rules to themselves?

OBJECTIVE: To determine whether patients with an ankle injury obtained the same results as clinicians when applying the Ottawa ankle rules (a validated clinical decision rule) to themselves. METHODS: Patients aged >15 years presenting to an inner city emergency department within 48 h of an ankle injury were asked to assess their own injury using the Ottawa ankle rules. The results of their self-assessment were compared with those of a treating clinician. RESULTS: Poor interobserver agreement was found between patients and clinicians. CONCLUSIONS: Making the Ottawa ankle rule more widely available to the general public is unlikely to reduce healthcare demand. Indeed, given the apparently low specificity of the rule, demand could actually increase as a result.

Factors influencing parent satisfaction in a children's emergency department: prospective questionnaire-based study.

OBJECTIVE: To identify the factors considered by parents to be most important in determining overall satisfaction with care in a children's emergency department, and to assess whether these factors are influenced by the child's age and triage category. DESIGN: A prospective questionnaire-based study of parents attending a paediatric emergency department with their child. SETTING: Bristol Royal Hospital for Children, Bristol, UK. PARTICIPANTS: The parent or next of kin adult accompanying a child to the emergency department during the study period. OUTCOME MEASURES: The primary outcome measure was the response to the questionnaire. The secondary outcome analysed responses according to the child's age and triage category. RESULTS: During the sampling period questionnaires were distributed to the parent or accompanying adult of 247 children, of which 225 (91%) were completed. The most important factors were: a clear explanation of the child's diagnosis and treatment plan; the ability of a parent to stay with their child at all times; rapid and adequate pain relief; and staff attitude. These factors significantly outranked waiting times and other process issues. The age and triage category of the child did not influence these preferences. CONCLUSION: Despite recent emphasis on waiting times and emergency department throughput in the UK, parents still value the clinical interaction above process issues when their child visits an emergency department. Current efforts to reduce the time spent by children in an emergency department must not undermine the core service values that are most appreciated by parents, and which will lead to the greatest satisfaction.

Why are we here? A study of patient actions prior to emergency hospital admission.

INTRODUCTION: Emergency department (ED) attendances and subsequent hospital admissions are rising in the United Kingdom. The reasons for this are unclear but may relate to recent changes in primary care and public perception. The actions taken by patients or their relatives before emergency hospital admission, the reasons for these actions and their outcome were determined. METHODS: Adult patients admitted to an inner city teaching hospital with a medical or surgical illness were interviewed using a semistructured questionnaire. Data were collected and analyzed regarding the actions taken before arrival at hospital, the reasons for taking these actions, their outcome and future intentions. 200 patients were interviewed. RESULTS: Direct attendance at the ED was more common when help was sought by bystanders or persons known only slightly to the patient (p = 0.03). 57 patients (28.5%) attended the ED directly, 45 of whom dialled 999 for an emergency ambulance. Most patients who attended the ED directly did so as a result of the perceived severity or urgency of their condition and there was incomplete awareness of the out-of-hours GP service. CONCLUSION: The majority of adult patients who are admitted to hospital with an acute illness seek professional help from primary care in the first instance. Those who attend the ED generally perceive their problem as more urgent or severe, or have an ambulance called on their behalf. The shift towards ED care appears partly driven by changes in general practice and unfamiliarity with the new arrangements for out-of-hours primary care provision.

Self-inflating bag or Mapleson C breathing system for emergency pre-oxygenation?

BACKGROUND: A crossover study was performed in healthy volunteers to compare the efficacy of a self-inflating bag with the Mapleson C breathing system for pre-oxygenation. METHOD: 20 subjects breathed 100% oxygen for 3 min using each device, with a 30 min washout period. The end tidal oxygen concentration and subjective ease of breathing were compared. RESULTS: There was a statistically significant difference in performance between the two devices, with the Mapleson C providing higher end expiratory oxygen concentrations at 3 min. The mean (SD) end expiratory oxygen concentration was 74.2 (3.8)% for the self-inflating bag (95% CI 72.4% to 75.9%) and 86.2 (3.7)% for the Mapleson C system (95% CI 84.5 to 88.0); p<0.0001. The 95% CI of the difference between the mean values for end expiratory oxygen concentration at 3 min was 10.0% to 14.2%. There was also a statistically significant difference in the subjective ease of breathing, favouring the Mapleson C system. CONCLUSION: The Mapleson C breathing system is more effective and subjectively easier to breathe through than a self-inflating bag when used for pre-oxygenation. However, these benefits must be weighed against the increased level of skill required and possible complications when using a Mapleson C breathing system.

Effects of storage at -20 degrees C on ischaemia-modified albumin results.

BACKGROUND: Ischaemia-modified albumin (IMA) is being studied as a new marker for reversible ischaemia in patients presenting with possible cardiac chest pain. The conditions under which samples are stored prior to analysis may be critical in influencing the analytical result and hence the cut-off used in any particular study. METHODS: Sixty-eight samples taken during a study assessing the performance of IMA for risk stratification in patients presenting with possible cardiac chest pain were analysed both within 2.5 h of collection and after periods of storage at -20 degrees C. RESULTS: Samples stored at -20 degrees C yielded IMA values on average 3 units higher than those analysed within 2.5 h (mean 90.5 vs. 87.5; P < 0.00001). A Bland-Altman plot showed that the difference was not concentration dependent. CONCLUSIONS: These results indicate that decision cut-offs will be influenced by conditions of sample storage prior to IMA analysis, and that these should be stated in detail for each study.

The PRIMA study: presentation ischaemia-modified albumin in the emergency department.

OBJECTIVES: To investigate the diagnostic accuracy of presentation ischaemia-modified albumin (IMA), in addition to cardiac troponin I (TnI), as a strategy to rapidly ascribe low risk to patients with chest pain attending an emergency department, and to determine whether IMA has the potential to reduce transit time in emergency departments. METHODS: A prospective observational study was carried out in two emergency departments (belonging to the John Radcliffe Hospital, Oxford, UK; and the Frenchay Hospital, Bristol, UK) of similar size. Consecutive adult patients presenting with features of possible ischaemic cardiac chest pain and a normal electrocardiogram were eligible. The index test (measurement of IMA and TnI at presentation) and reference standard (delayed TnI measurement, taken at least 8 h after pain onset) were applied to all recruited patients. All clinicians were blinded to the results of the index test. Assays were carried out in a single laboratory using standard techniques. RESULTS: 399 patients were recruited; 277 patients had a result for both the index test and reference standard. The sensitivity was 97.6% (95% confidence interval (CI) 87.4 to 99.9), negative predictive value 97% (95% CI 84.2 to 99.9) and specificity 13.6% (95% CI 9.5 to 18.7). Sensitivity analysis showed similar findings in three alternative scenarios. Receiver operating characteristic analysis indicated that a different "cut-off" value for IMA would not improve the properties of the test. The median potential time saved (n = 268) was 6 h and 10 min. CONCLUSION: The diagnostic accuracy of presentation IMA in this study does not support its use as an effective risk stratification tool for patients with chest pain in the emergency department. The sensitivity is insufficiently high, with a small number of false negatives undermining the safety of the test. Frequent false positives produce a low specificity that limits the practical value of the test.

Effect of an extended scope physiotherapy service on patient satisfaction and the outcome of soft tissue injuries in an adult emergency department.

OBJECTIVES: To evaluate the effect of introducing an extended scope physiotherapy (ESP) service on patient satisfaction, and to measure the functional outcome of patients with soft tissue injuries attending an adult emergency department (ED), comparing management by ESPs, emergency nurse practitioners (ENPs), and all grades of ED doctor. METHODS: The ESP service operated on four days out of every seven in a week in an urban adult ED. A satisfaction questionnaire was sent to all patients with a peripheral soft tissue injury and fractures (not related to the ankle) within one week of attending the ED. Patients with a unilateral soft tissue ankle injury were sent the acute Short Form 36 (SF-36) functional outcome questionnaire, with additional visual analogue scales for pain, at 4 and 16 weeks after their ED attendance. Waiting times and time spent with individual practitioners was also measured. RESULTS: The ESP service achieved patient satisfaction that was superior to either ENPs or doctors. Overall 55% of patients seen by the ESP service strongly agreed that they were satisfied with the treatment they received, compared with 39% for ENPs and 36% for doctors (p = 0.048). Assessment of long-term outcome from ankle injury was undermined by poor questionnaire return rates. There was a trend towards improved outcomes at four weeks in those patients treated by an ESP, but this did not achieve statistical significance. CONCLUSION: Adding an ESP service to the interdisciplinary team achieves higher levels of patient satisfaction than for either doctors or ENPs. Further outcomes research, conducted in a wider range of emergency departments and integrated with an economic analysis, is recommended.

Randomised controlled trial of combined paracetamol and ibuprofen for fever.

A randomised open label study of the combined use of paracetamol and ibuprofen to rapidly reduce fever is reported. The advantage of using both medications is less than half a degree centigrade in the first hour, and insufficient to warrant routine use.

Patient satisfaction in emergency medicine.

A systematic review was undertaken to identify published evidence relating to patient satisfaction in emergency medicine. Reviewed papers were divided into those that identified the factors influencing overall satisfaction in emergency department patients, and those in which a specific intervention was evaluated. Patient age and race influenced satisfaction in some, but not all, studies. Triage category was strongly correlated with satisfaction, but this also relates to waiting time. The three most frequently identified service factors were: interpersonal skills/staff attitudes; provision of information/explanation; perceived waiting times. Seven controlled intervention studies were found. These suggested that increased information on ED arrival, and training courses designed to improve staff attitudes and communication, are capable of improving patient satisfaction. None of the intervention studies looked specifically at the effect of reducing the perceived waiting time. Key interventions to improve patient satisfaction will be those that develop the interpersonal and attitudinal skills of staff, increase the information provided, and reduce the perceived waiting time. Future research should use a mixture of quantitative and qualitative methods to evaluate specific interventions.

The safety and effectiveness of minor injuries telemedicine.

OBJECTIVES: To determine the safety of minor injuries telemedicine compared with on-site specialist care, current practice, and a robust gold standard, and to assess the clinical effectiveness of this new technique. METHODS: Patients presenting to a peripheral hospital within 10 days of injury were separately assessed by each of: an emergency medicine specialist based at a district general hospital using telemedicine, a second on-site emergency medicine specialist, and an on-site general practitioner (representing current practice). The primary outcome measure was discrepancies between these three medical assessments and a gold standard. All patients were subsequently randomised to follow one of the independent treatment plans generated by the above assessments. Secondary outcomes were recovery and further use of healthcare services measured seven days after recruitment, and consultation duration. RESULTS: 600 patients were recruited over a 12 month period. Overall, 73 discrepancies were identified, with 12 important over-treatments and 11 important under-treatments. No consultation modality was clearly superior to any other, and there were no statistically significant differences in the secondary outcomes of clinical effectiveness measured at seven days. The mean duration of a telemedicine consultation (6.0 min) was almost twice as long as an on-site specialist (3.1 min) or on-site general practitioner consultation (3.4 min) (p<0.0001 in both cases). CONCLUSIONS: Minor injuries telemedicine is safe and clinically effective, providing care that is equivalent to specialist on-site assessment and the current practice of treatment by a general practitioner. There is no evidence that telemedicine provides superior care, and there are a number of process issues that may impede successful implementation of this new technique.

What is the effect of reporting all emergency department radiographs?

OBJECTIVES: To evaluate the effect of formal radiological reporting of all emergency department (ED) radiographs on clinical practice and patient outcome, and to consider whether a selective reporting policy might prove safe and effective. METHODS: All radiographs taken in a single ED over a six month period were prospectively studied simultaneously in both the emergency and radiology departments to detect cases where a radiograph that was considered normal by ED staff was then reported as abnormal by the reporting radiologist. Whenever such a discrepancy occurred the patient's records were scrutinised to ascertain the source of the discrepancy, with a gold standard interpretation derived from senior clinical review and additional investigations where indicated. The clinical impact of the radiologist's formal report was then assessed. Accuracy of interpretation was considered in relation to the grade of ED staff and the radiographic examination obtained. RESULTS: During the study period, 19468 new patient attendances to the ED generated 11749 radiographic examinations. Discrepancies were detected in 175 patients (1.5% of all radiographic examinations). Of these, 136 (1.2%) were subsequently shown to have been incorrectly interpreted in the ED (ED false negatives), with 40 patients (0.3%) undergoing a change in management as a result. In the remaining 39 the ED interpretation was judged to be correct (radiology false positives), with 16 patients undergoing further investigations or visits to the ED to confirm this. CONCLUSIONS: The formal reporting of ED radiographs by the radiology department detects a number of clinically important abnormalities that have been overlooked. However, this formal reporting also generates a number of incorrect interpretations that may lead to further unnecessary investigations. Some groups of ED radiographs (such as those interpreted by an ED consultant and films of the fingers and toes) may not require formal radiological reporting. The adoption of a selective reporting policy may reduce the reporting workload of the radiology department without compromising patient care.

Prehospital thrombolysis: lessons from Sweden and their application to the United Kingdom.

OBJECTIVE: To study the successful implementation of paramedic administered prehospital thrombolysis in Sweden, and to consider the implications of this for the UK. METHODS: A series of research visits were undertaken, including visits to Uppsala Hospital and dispatch centre, ambulance stations in several counties of Sweden and Dalarna County, which has one of the longest experiences of telemedicine supported prehospital thrombolysis in Europe. Data relating to prehospital thrombolysis, stages in successful implementation, and potential barriers to change were identified. RESULTS: Two thirds of the hospitals in Sweden now have some form of prehospital thrombolysis. A nationally agreed and standardised training programme and the fact that many ambulance paramedics are also qualified nurses has facilitated successful introduction, but Sweden's low population density is also an important factor. Data from Dalarna County indicate that the median "pain to needle" time has been reduced by 45 minutes with a concurrent reduction in complications from 50% to 25% (p=0.018). Inhospital mortality has also reduced from 12% to 6%, but with the small numbers involved this improvement does not achieve statistical significance (p=0.36). CONCLUSION: If the outcome of acute myocardial infarction in the United Kingdom is to be improved, and National Service Framework targets met, then prehospital thrombolysis is an important development. Several technical solutions already exist, and a single bolus thrombolytic agent is now available, but the main barriers to full implementation are related to the establishment of an effective training programme and the organisational changes that will facilitate this new practice. High quality research is urgently needed to guide the implementation of prehospital thrombolysis in a clinically and cost effective way.

The case for urban prehospital thrombolysis.

This is the first part in a debate on the benefits and disadvantages of urban prehospital thrombolysis. I put the case for prehospital thrombolysis in the urban environment and argue that it is a rational development that will save lives and reduce long term morbidity.

Can nurses working in remote units accurately request and interpret radiographs?

OBJECTIVE: Recent changes in the NHS have seen nurses take on roles that are traditionally filled by doctors, leading to the development of emergency nurse practitioners (ENPs). In addition to this, increasing interest has focused on telemedicine (literally, medicine at a distance) as a way of supporting remote emergency departments and minor injuries units from larger centres. The vast majority of these consultations are related to peripheral limb trauma and require a radiograph to be viewed as an integral part of the telemedical consultation. The aim of this study was therefore to determine whether nurses working alone in a peripheral unit are able to appropriately request, and accurately interpret, peripheral limb radiographs. METHODS: In this prospective study the four qualified nurses working in a peripheral unit were permitted to request a defined set of radiographs after limb trauma. A written protocol for nurse requested radiographs was supported by individual teaching sessions. At the time that the radiograph was requested basic demographic details were recorded and the patient was also assessed by two senior doctors in emergency medicine, one in person and one via a telemedicine link, both of whom independently considered whether the radiograph requested by the nurse was appropriate in that patient. Nursing staff were also asked to provide a provisional interpretation of each film, and this was compared with a gold standard derived from the interpretations of the two emergency physicians who had seen the patient and the final radiologist's report. RESULTS: The first 300 patients who had a radiograph requested by a member of the nursing staff were studied over a period of 12 months. Altogether 93 radiographs (31%) were positive for recent bony trauma or radio-opaque foreign body. Eleven radiographs (3.7%) were judged by both emergency physicians to be inappropriate. Three radiographs (1%) were requested outside the limits of the protocol, but all three were judged to be appropriate and occurred within the first two months of the study. A total of 32 (10.7%) of the radiographs were incorrectly interpreted by nursing staff with 26 false positives, four false negatives and two cases where the nurse observed an abnormality but failed to identify it correctly. The sensitivity of nurse interpretation was therefore 96%, with a specificity of 87%. CONCLUSION: Experienced nurses, working without continuous medical supervision in a remote unit, are able to request appropriate radiographs of the peripheral limbs. Nurses requesting radiographs in this way can also interpret these films to a high standard, though with a tendency to err on the side of caution, generating many more false positive results than false negatives.

Burns and scalds in pre-school children attending accident and emergency: accident or abuse?

OBJECTIVES: To assess how frequently and adequately information relating to the possibility of non-accidental injury (NAI) is documented and considered by doctors assessing pre-school children with burns and scalds in the accident and emergency (A&E) department, and to determine the effect of introducing a routine reminder mechanism into the A&E notes, coupled with an improved programme of NAI education and awareness. METHODS: The records of 100 pre-school children attending an A&E department with a burn or scald were reviewed against nine pre-determined standards. Changes in policy were instituted, through a programme of education and the use of a reminder checklist, and the next 100 cases re-audited against the same checklist. RESULTS: Groups one and two were similar in their demographic characteristics. The reminder checklist was included in 60% of group two notes, and when included was completed in 97%. The child protection register was rarely consulted. There was a statistically significant increase in recording the following: time that the injury had occurred, the consistency of the history, the compatibility of the injury with the history given, the consideration of the possibility of NAI, the general state and behaviour of the child and the presence or absence of any other injuries. The rate of referral for a further opinion regarding the possibility of NAI increased from 0 to 3%, but failed to reach statistical significance. CONCLUSIONS: Prevailing awareness and documentation regarding the possibility of NAI was found to be poor, but a programme of intervention combining education and the use of a reminder checklist improved both awareness and documentation of NAI, as well as referral rates for further assessment. This strategy may prove applicable to children of all ages and injury types, reducing the number of cases of child abuse that are overlooked in the A&E department.