Delivering manual cardiopulmonary resuscitation (CPR) in a diving bell: an analysis of head-to-chest and knee-to-chest compression techniques.

Introduction: Chest compression often cannot be administered using conventional techniques in a diving bell. Multiple alternative techniques are taught, including head-to-chest and both prone and seated knee-to-chest compressions, but there are no supporting efficacy data. This study evaluated the efficacy, safety and sustainability of these techniques. Methods: Chest compressions were delivered by a team of expert cardiopulmonary resuscitation (CPR) providers. The primary outcome was proportion of chest compressions delivered to target depth compared to conventional CPR. Techniques found to be safe and potentially effective by the study team were further trialled by 20 emergency department staff members. Results: Expert providers delivered a median of 98% (interquartile range [IQR] 1.5%) of chest compressions to the target depth using conventional CPR. Only 32% (IQR 60.8%) of head-to-chest compressions were delivered to depth; evaluation of the technique was abandoned due to adverse effects. No study team member could register sustained compression outputs using prone knee-to-chest compressions. Seated knee-to-chest were delivered to depth 12% (IQR 49%) of the time; some compression providers delivered > 90% of compressions to depth. Conclusions: Head-to-chest compressions have limited efficacy and cause harm to providers; they should not be taught or used. Prone knee-to-chest compressions are ineffective. Seated knee-to-chest compressions have poor overall efficacy but some providers deliver them well. Further research is required to establish whether this technique is feasible, effective and sustainable in a diving bell setting, and whether it can be taught and improved with practise.

An evaluation of the NUI Compact Chest Compression Device (NCCD), a mechanical CPR device suitable for use in the saturation diving environment.

Introduction: Provision of manual chest compressions in a diving bell using a conventional technique is often impossible, and alternative techniques are poorly evidenced in terms of efficacy and sustainability. The first mechanical cardiopulmonary resuscitation (CPR) device suitable for use in this environment, the NUI Compact Chest Compression Device (NCCD), has recently been designed and manufactured. This study assessed both the efficacy of the device in delivering chest compressions to both prone and seated manikins, and the ability of novice users to apply and operate it. Methods: Compression efficacy was assessed using a Resusi Anne QCPR intelligent manikin, and the primary outcome was the proportion of compressions delivered to target depth (50-60 mm). The gold standard was that achieved by expert CPR providers delivering manual CPR; the LUCAS 3 mCPR device was a further comparator. Results: The NCCD delivered 100% of compressions to target depth compared to 98% for the gold standard (interquartile range 1.5%) and 98% for the LUCAS 3 when applied to both supine and seated manikins. The NCCD sometimes became dislodged and had to be reapplied when used with a seated manikin. Conclusions: The NCCD can deliver chest compressions at target rate and depth to both supine and seated manikins with efficacy equivalent to manual CPR and the LUCAS 3. It can become dislodged when applied to a seated manikin; its design has now been altered to prevent this. New users can be trained in use of the NCCD quickly, but practise is required to ensure effective use.

The clinical effectiveness of the STUMBL score for the management of ED patients with blunt chest trauma compared to clinical evaluation alone.

The STUMBL (STUdy of the Management of BLunt chest wall trauma) score is a new prognostic score to assist ED (Emergency Department) decision making in the management of blunt chest trauma. This is a retrospective cohort chart review study conducted in a UK University Hospital ED seeing 120,000 patients a year, comparing its performance characteristics to ED clinician judgement. All blunt chest trauma patients that presented to our ED over a 6-month period were included. Patients were excluded if age < 18, if they had immediate life-threatening injury, required critical care admission for other injuries or in case of missing identification data. Primary endpoint was complication defined as any of lower respiratory tract infection, pulmonary consolidation, empyema, pneumothorax, haemothorax, splenic or hepatic injury and 30-day mortality. Clinician judgement (clinician decision to admit) and STUMBL score were compared using the receiver-operating curve (ROC) and sensitivity analysis. Three hundred and sixty-nine patients were included. ED clinicians admitted 95 of 369 patients. ED clinician decision to admit had a sensitivity of 83.9% and specificity of 86.0% for predicting complications. STUMBL score ≥ 11 had a sensitivity of 79.0% and specificity of 77.9% for the same and would have led to 117 of 369 patients being admitted. Area under the curve (AUC) of STUMBL score and ED clinician decision to admit was 0.84 (95% CI 0.78-0.90) and 0.85 (95% CI 0.79-0.91), respectively. Our findings show that a STUMBL score ≥ 11 performs no better than ED clinician judgement and leads to more patients being admitted to hospital.

Salbutamol for analgesia in renal colic: study protocol for a prospective, randomised, placebo-controlled phase II trial (SARC).

BACKGROUND: Renal colic is the pain experienced by a patient when a renal calculus (kidney stone) causes partial or complete obstruction of part of the renal outflow tract. The standard analgesic regimes for renal colic are often ineffective; in some studies, less than half of patients achieve complete pain relief, and a large proportion of patients require rescue analgesia within 4 h. Current analgesic regimes are also associated with significant side effects including nausea, vomiting, drowsiness and respiratory depression. It has been hypothesised that beta adrenoreceptor agonists, such as salbutamol, may reduce the pain of renal colic. They have been shown to impact a number of factors that target the physiological causes of pain in renal colic (ureteric spasm and increased peristalsis, increased pressure at the renal pelvis and prostaglandin release with inflammation). There is biological plausibility and a body of evidence sufficient to suggest that this novel treatment for the pain of renal colic should be taken to a phase II clinical trial. The aim of this trial is to test whether salbutamol is an efficacious analgesic adjunct when added to the standard analgesic regime for patients presenting to the ED with subsequently confirmed renal colic. METHODS: A phase II, randomised, placebo-controlled trial will be performed in an acute NHS Trust in the East Midlands. Patients presenting to the emergency department with pain requiring IV analgesia and working diagnosis of renal colic will be randomised to receive standard analgesia ± a single intravenous injection of Salbutamol. Secondary study objectives will explore the feasibility of conducting a larger, phase III trial. DISCUSSION: The trial will provide important information about the efficacy of salbutamol as an analgesic adjunct in renal colic. It will also guide the development of a definitive phase III trial to test the cost and clinical effectiveness of salbutamol as an analgesic adjunct in renal colic. Salbutamol benefits from widespread use across the health service for multiple indications, extensive staff familiarity and a good side effect profile; therefore, its potential use for pain relief may have significant benefits for patient care. TRIAL REGISTRATION: ISRCTN Registry ISRCTN14552440 . Registered on 22 July 2019.

Trends in emergency department litigation within the NHS: a retrospective database analysis.

The objectives of this study are to examine trends in litigation related to emergency department care within the NHS. The study is based on retrospective database analysis. NHS Resolution databases of litigation activity pertaining to Type I emergency departments within the NHS are used. The main outcome measures were number of claims, number of successful claims, costs associated with litigation and costs per claim, all in comparison to patterns of ED attendance numbers and inflation. The results showed that the annual cost of litigation relating to emergency department care within the NHS has increased from £25.5 million in 2005/6 to £161.9 million in 2017/18. Mean cost per claim has increased from £58,252 in 2005/6 to £168,966 in 2017/18. The number of claims received has increased significantly; the proportion of these which were successful has remained constant. Therefore, it was concluded that the costs of litigation are increasing disproportionately to inflation and attendance numbers. Multiple potential causes are discussed, with significant implications for clinical practice.

Can an ECG performed during emergency department triage and interpreted as normal by computer analysis safely wait for clinician review until the time of patient assessment? A pilot study.

INTRODUCTION: Electrocardiograms (ECGs) are frequently performed during patient triage in Emergency Departments (EDs). Emergency Physicians (EPs) are interrupted during other tasks to review ECGs. Critics believe this practice could lead to distraction with consequent medical error and decision fatigue. ECGs can be interpreted by computer software at the time of capture; some evidence exists to suggest that an ECG performed during ED triage with an immediate computer interpretation (ICI) of 'normal' will seldom contain information necessitating a change to triage management. MATERIAL AND METHODS: All ED triage ECGs performed in the Royal Derby Hospital between 13th July 2017 and 12th July 2018 in patients without chest pain and with an ICI of 'normal' were identified through a database search. Forty were randomly selected and reviewed by two EPs (blinded to patient details, ICI and outcome) who were asked to identify those that required a change to triage management. RESULTS: The study processes were feasible. At least one of the two EP reviewers felt that a change to triage management was required in 48% of cases (e.g. "review patient", "obtain blood gas", "review old ECGs"); they agreed on the need for change of management in 13% of cases. An ICI of normal had a NPV of 53% (95% CI 37-67%) for the need for a change to triage management based upon ECG findings. Inter-observer agreement was poor (kappa = 0.17). CONCLUSIONS: Based on these results, ED triage ECGs should still be presented to EPs for immediate review regardless of the ICI. Inter-observer agreement between EPs was poor. Further research is required to link triage ECG interpretation, need for intervention and patient outcome.

Prospective observational study to examine health-related quality of life and develop models to predict long-term patient-reported outcomes 6 months after hospital discharge with blunt thoracic injuries.

OBJECTIVE: This study aimed to examine the long-term outcomes and health-related quality of life in patients with blunt thoracic injuries over 6 months from hospital discharge and develop models to predict long-term patient-reported outcomes. DESIGN: A prospective observational study using longitudinal survey design. SETTING: The study recruitment was undertaken at 12 UK hospitals which represented diverse geographical locations and covered urban, suburban and rural areas across England and Wales. PARTICIPANTS: 337 patients admitted to hospital with blunt thoracic injuries were recruited between June 2018-October 2020. METHODS: Participants completed a bank of two quality of life surveys (Short Form-12 (SF-12) and EuroQol 5-Dimensions 5-Levels) and two pain questionnaires (Brief Pain Inventory and painDETECT Questionnaire) at four time points over the first 6 months after discharge from hospital. A total of 211 (63%) participants completed the outcomes data at 6 months after hospital discharge. OUTCOMES MEASURES: Three outcomes were measured using pre-existing and validated patient-reported outcome measures. Outcomes included: Poor physical function (SF-12 Physical Component Score); chronic pain (Brief Pain Inventory Pain Severity Score); and neuropathic pain (painDETECT Questionnaire). RESULTS: Despite a trend towards improving physical functional and pain at 6 months, outcomes did not return to participants perceived baseline level of function. At 6 months after hospital discharge, 37% (n=77) of participants reported poor physical function; 36.5% (n=77) reported a chronic pain state; and 22% (n=47) reported pain with a neuropathic component. Predictive models were developed for each outcome highlighting important data collection requirements for predicting long-term outcomes in this population. Model diagnostics including calibration and discrimination statistics suggested good model fit in this development cohort. CONCLUSIONS: This study identified the recovery trajectories for patients with blunt thoracic injuries over the first 6 months after hospital discharge and present prognostic models for three important outcomes which after external validation could be used as clinical risk stratification scores.

Handheld electronic device use in patient care: the emergency department patient perspective-a cross-sectional survey.

BACKGROUND: Staff use of smartphones and tablets in the healthcare setting is increasingly prevalent, but little is known about whether this use is acceptable to patients. Staff are concerned that the use of handheld electronic devices (HEDs) may be negatively misconstrued by patients. The HED can be a valuable tool, offering the emergency clinician access to a wealth of resources; it is therefore vital that patient views are addressed during their widespread adoption into clinical practice. METHODS: Patients, or those accompanying them, within the ED of the Royal Derby Hospital between April and June 2017 were asked to complete a survey consisting of 22 questions. Data collection took place to include all times of day and every day of the week. Every eligible individual within the department during a data collection period was approached. RESULTS: A total of 438 respondents successfully completed the survey with a response rate of 92%. Only 2% of those who observed staff using HEDs during their ED visit thought that they were being used for non-clinical purposes. 339 (78%) agreed that staff should be allowed to use HEDs in the workplace. Concerns expressed by respondents included devices being used for non-clinical purposes and data security. The main suggestion by respondents was that the purpose of the HEDs should be explained to patients to avoid misinterpretation. CONCLUSION: Our survey shows that the majority of survey respondents felt that clinical staff should be allowed to use HEDs in the workplace and that many of the concerns raised could be addressed with adequate patient information and clear governance.

Mitigating the Psychological Impact of COVID-19 on Healthcare Workers: A Digital Learning Package.

The coronavirus pandemic (COVID-19) will undoubtedly have psychological impacts for healthcare workers, which could be sustained; frontline workers will be particularly at risk. Actions are needed to mitigate the impacts of COVID-19 on mental health by protecting and promoting the psychological wellbeing of healthcare workers during and after the outbreak. We developed and evaluated a digital learning package using Agile methodology within the first three weeks of UK outbreak. This e-package includes evidence-based guidance, support and signposting relating to psychological wellbeing for all UK healthcare employees. A three-step rapid development process included public involvement activities (PPIs) (STEP 1), content and technical development with iterative peer review (STEP 2), and delivery and evaluation (STEP 3). The package outlines the actions that team leaders can take to provide psychologically safe spaces for staff, together with guidance on communication and reducing social stigma, peer and family support, signposting others through psychological first aid (PFA), self-care strategies (e.g., rest, work breaks, sleep, shift work, fatigue, healthy lifestyle behaviours), and managing emotions (e.g., moral injury, coping, guilt, grief, fear, anxiety, depression, preventing burnout and psychological trauma). The e-package includes advice from experts in mental wellbeing as well as those with direct pandemic experiences from the frontline, as well as signposting to public mental health guidance. Rapid delivery in STEP 3 was achieved via direct emails through professional networks and social media. Evaluation included assessment of fidelity and implementation qualities. Essential content was identified through PPIs (n = 97) and peer review (n = 10) in STEPS 1 and 2. The most important messages to convey were deemed to be normalisation of psychological responses during a crisis, and encouragement of self-care and help-seeking behaviour. Within 7 days of completion, the package had been accessed 17,633 times, and healthcare providers had confirmed immediate adoption within their health and wellbeing provisions. Evaluation (STEP 3, n = 55) indicated high user satisfaction with content, usability and utility. Assessment of implementation qualities indicated that the package was perceived to be usable, practical, low cost and low burden. Our digital support package on 'psychological wellbeing for healthcare workers' is free to use, has been positively evaluated and was highly accessed within one week of release. It is available here: Supplementary Materials. This package was deemed to be appropriate, meaningful and useful for the needs of UK healthcare workers. We recommend provision of this e-package to healthcare workers alongside wider strategies to support their psychological wellbeing during and after the COVID-19 pandemic.

Increased Risk of Acute Pancreatitis with Codeine Use in Patients with a History of Cholecystectomy.

BACKGROUND: Codeine has a spasmodic effect on sphincter of Oddi and is suspected to cause acute pancreatitis in patients with a history of cholecystectomy. AIMS: To assess the association between codeine use and acute pancreatitis in patients with a previous cholecystectomy. METHODS: We conducted a retrospective nested case-control study using the 2005-2015 MarketScan® Commercial Claims and Encounters Database. The cohort included patients aged 18-64; cohort entry began 365 days after cholecystectomy. Odds ratios (ORs) and 95% CIs for acute pancreatitis hospitalization were estimated comparing use of codeine with non-use of codeine. In a secondary analysis, use of codeine was compared with an active comparator: use of non-steroidal anti-inflammatory drugs (NSAIDs). RESULTS: Of the 664,083 patients included in the cohort, 1707 patients were hospitalized for acute pancreatitis (incidence 1.1 per 1000 person-years) and were matched to 17,063 controls. Compared with non-use of codeine, use of codeine was associated with an increased risk of acute pancreatitis (OR 2.67; 95% CI 1.63, 4.36), particularly elevated in the first 15 days of codeine use (OR 5.37; 95% CI 2.70, 10.68). Compared with use of NSAIDs, use of codeine was also associated with an increased risk of acute pancreatitis (OR 2.64; 95% CI 1.54, 4.52). CONCLUSION: Codeine is associated with an increased risk of acute pancreatitis in patients who have previously undergone cholecystectomy; greater clinician awareness of this association is needed.

ß-Adrenoreceptor agonists in the management of pain associated with renal colic: a systematic review.

OBJECTIVES: To determine whether ß-adrenoreceptor agonists are effective analgesics for patients with renal colic through a systematic review of the literature. SETTING: Adult emergency departments or acute assessment units. PARTICIPANTS: Human participants with proven or suspected renal colic. INTERVENTIONS: ß-adrenoreceptor agonists. OUTCOME MEASURES: Primary: level of pain at 30 min following administration of the ß-agonist. Secondary: level of pain at various time points following ß-agonist administration; length of hospital stay; analgesic requirement; stone presence, size and position; degree of hydronephrosis. RESULTS: 256 records were screened and 4 identified for full-text review. No articles met the inclusion criteria. CONCLUSIONS AND IMPLICATIONS: There is no evidence to support or refute the proposed use of ß-agonists for analgesia in patients with renal colic. Given the biological plausibility and existing literature base, clinical trials investigating the use of ß-adrenoreceptor agonists in the acute setting for treatment of the pain associated with renal colic are recommended. TRIAL REGISTRATION NUMBER: CRD42015016266.

Codeine: An Under-Recognized and Easily Treated Cause of Acute Abdominal Pain.

We present 2 cases of acute abdominal pain secondary to oral codeine that resolved after the administration of intravenous naloxone.

Summertime and the patient is itchy.

A 21-year-old man presented to the emergency department with a 36 h history of a painful, itchy maculopapular rash and associated vesicles to his arms and neck. He had no history of exposure to new chemicals or hygiene products and no significant medical history. His physiological observations were normal and systemic examination was unremarkable. On close inspection the rash was noted to be present only on areas of skin exposed while wearing a polo shirt. On further questioning it transpired that he had been gardening 12 h prior to the development of the rash. A diagnosis of phytophotodermatitis was made. The patient was discharged with chlorphenamine, simple analgesia and the advice to wear a long-sleeved t-shirt and sunscreen when gardening in future. Phytophotodermatitis is a cutaneous reaction caused by contact with light-sensitising compounds found in plants and exposure to ultraviolet A radiation. It is self-limiting and can be managed symptomatically.