Development of a Clinical Decision Rule for the Early Safe Discharge of Patients with Mild Traumatic Brain Injury and Findings on Computed Tomography Brain Scan: A Retrospective Cohort Study.

International guidelines recommend routine hospital admission for all patients with mild traumatic brain injury (TBI) who have injuries on computed tomography (CT) brain scan. Only a small proportion of these patients require neurosurgical or critical care intervention. We aimed to develop an accurate clinical decision rule to identify low-risk patients safe for discharge from the emergency department (ED) and facilitate earlier referral of those requiring intervention. A retrospective cohort study of case notes of patients admitted with initial Glasgow Coma Scale 13-15 and injuries identified by CT was completed. Data on a primary outcome measure of clinically important deterioration (indicating need for hospital admission) and secondary outcome of neurosurgery, intensive care unit admission, or intubation (indicating need for neurosurgical admission) were collected. Multi-variable logistic regression was used to derive models and a risk score predicting deterioration using routinely reported clinical and radiological candidate variables identified in a systematic review. We compared the performance of this new risk score with the Brain Injury Guideline (BIG) criteria, derived in the United States. A total of 1699 patients were included from three English major trauma centers. A total of 27.7% (95% confidence interval [CI], 25.5-29.9) met the primary and 13.1% (95% CI, 11.6-14.8) met the secondary outcomes of deterioration. The derived clinical decision rule suggests that patients with simple skull fractures or intracranial bleeding <5 mm in diameter who are fully conscious could be safely discharged from the ED. The decision rule achieved a sensitivity of 99.5% (95% CI, 98.1-99.9) and specificity of 7.4% (95% CI, 6.0-9.1) to the primary outcome. The BIG criteria achieved the same sensitivity, but lower specificity (5%). Our empirical models showed good predictive performance and outperformed the BIG criteria. This would potentially allow ED discharge of 1 in 20 patients currently admitted for observation. However, prospective external validation and economic evaluation are required.

The Extended Supervised Learning Event (ESLE): Assessing Nontechnical Skills in Emergency Medicine Trainees in the Workplace.

STUDY OBJECTIVE: The contribution of emergency medicine clinicians' nontechnical skills in providing safe, high-quality care in the emergency department (ED) is well known. In 2015, the UK Royal College of Emergency Medicine introduced explicit validated descriptors of nontechnical skills needed to function effectively in the ED. A new nontechnical skills assessment tool that provided a score for 12 domains of nontechnical skills and detailed narrative feedback, the Extended Supervised Learning Event (ESLE), was introduced and was mandated as part of the Royal College of Emergency Medicine assessment schedule. We aim to evaluate the psychometric reliability of the ESLE in its first year of use. METHODS: ESLEs were mandated for all UK emergency medicine trainees in the final 4 years of a 6-year national training program from August 2015. The completed assessments were uploaded to the Royal College of Emergency Medicine e-portfolio. All assessments recorded in the Royal College of Emergency Medicine e-portfolio database between August 2015 and August 2016 were anonymized and analyzed for psychometric reliability, using generalizability theory. Decision analysis was used to model the effect of altering the number of episodes and assessors on reliability. RESULTS: A total of 1,390 ESLEs were analyzed. The majority (62%) of the variation in nontechnical skills scores was attributable to the trainee's ability. The circumstances of the event (eg, case complexity, workload) accounted for 21% and the stringency or leniency of assessors the remaining 16%. Decision analysis suggests that 3 ESLEs by 2 or more assessors, as currently recommended in the Royal College of Emergency Medicine curriculum, provide an assessment with a reliability coefficient of 0.8. CONCLUSION: Board-certified-equivalent emergency medicine supervisors are able to provide reliable assessments of emergency medicine trainees' nontechnical skills in the workplace by using the ESLE.

Palliative care in the emergency department: A systematic literature qualitative review and thematic synthesis.

BACKGROUND: Despite a fast-paced environment, the emergency clinician has a duty to meet the palliative patient's needs. Despite suggested models and interventions, this remains challenging in practice. AIM: To raise awareness of these challenges by exploring the experience of palliative care patients and their families and informal carers attending the emergency department, and of the clinicians caring for them. DESIGN: Qualitative systematic literature review and thematic synthesis. Search terms related to the population (palliative care patients, family carers, clinicians), exposure (the emergency department) and outcome (experience). The search was international but restricted to English and used a qualitative filter. Title, abstracts and, where retrieved, full texts were reviewed independently by two reviewers against predefined inclusion criteria arbitrated by a third reviewer. Studies were appraised for quality but not excluded on that basis. DATA SOURCES: MEDLINE [1946-], Embase[1947-], CINAHL [1981-] and PsycINFO [1987-] with a bibliography search. RESULTS: 19 papers of 16 studies were included from Australia ( n = 5), the United Kingdom ( n = 5), and United States ( n = 9) representing 482 clinical staff involved in the emergency department (doctors, nurses, paramedics, social workers, technicians), 61 patients and 36 carers. Nine descriptive themes formed three analytic themes: 'Environment and Purpose', 'Systems of Care and Interdisciplinary Working' and 'Education and Training'. CONCLUSION: In the included studies, provision of emergency palliative care is a necessary purpose of the emergency department. Failure to recognise this, gain the necessary skills or change to systems better suited to its delivery perpetuates poor implementation of palliative care in this environment.

Best evidence topic reports. BET 2: Are patients who have used chewing gum at an increased risk of aspiration during sedation?

A short-cut review was carried out to establish whether patients who have chewed gum are at increased risk of aspiration during sedation. Twenty-nine papers were found, of which six 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. The clinical bottom line is that patients who have chewed gum in the past 6 h may theoretically be at increased risk of aspiration. This should be considered when making a balanced decision about the use of procedural sedation.

Evaluation of the DAVROS (Development And Validation of Risk-adjusted Outcomes for Systems of emergency care) risk-adjustment model as a quality indicator for healthcare.

BACKGROUND AND OBJECTIVE: Risk-adjusted mortality rates can be used as a quality indicator if it is assumed that the discrepancy between predicted and actual mortality can be attributed to the quality of healthcare (ie, the model has attributional validity). The Development And Validation of Risk-adjusted Outcomes for Systems of emergency care (DAVROS) model predicts 7-day mortality in emergency medical admissions. We aimed to test this assumption by evaluating the attributional validity of the DAVROS risk-adjustment model. METHODS: We selected cases that had the greatest discrepancy between observed mortality and predicted probability of mortality from seven hospitals involved in validation of the DAVROS risk-adjustment model. Reviewers at each hospital assessed hospital records to determine whether the discrepancy between predicted and actual mortality could be explained by the healthcare provided. RESULTS: We received 232/280 (83%) completed review forms relating to 179 unexpected deaths and 53 unexpected survivors. The healthcare system was judged to have potentially contributed to 10/179 (8%) of the unexpected deaths and 26/53 (49%) of the unexpected survivors. Failure of the model to appropriately predict risk was judged to be responsible for 135/179 (75%) of the unexpected deaths and 2/53 (4%) of the unexpected survivors. Some 10/53 (19%) of the unexpected survivors died within a few months of the 7-day period of model prediction. CONCLUSIONS: We found little evidence that deaths occurring in patients with a low predicted mortality from risk-adjustment could be attributed to the quality of healthcare provided.

Deriving the East Riding Elbow Rule (ER2): a maximally sensitive decision tool for elbow injury.

OBJECTIVE: To derive a maximally sensitive decision rule for clinical practice to rule out the need for x-ray examination after elbow injury in adults and children. METHODS: Emergency department patients with acute elbow injury were recruited. Practitioners used their usual judgement to assess whether x-ray examination was required. Radiographs were reported on by radiologists blind to clinical assessment. Patients not x-rayed were followed-up at 7 days by telephone interview, and those with ongoing pain were recalled for assessment. Recursive partitioning was used to derive a maximally sensitive decision tool. Inter-rater variability for significant discriminators was subsequently evaluated by a cohort of 20 emergency department clinicians. RESULTS: 492 patients were recruited (May 2006-November 2008): 50.4% were male; 26.8% were children; 444 (90.2%) had an x-ray; 167 (37.6%) showed abnormality. A follow-up telephone interview was conducted with 28; none were recalled. Thirteen could not be contacted, none of whom returned within 3 months. Sixteen patients with fractures were able to fully extend their elbow. The sensitivity of elbow extension alone was 84% (95% CI 77% to 88%), with specificity of 54% (95% CI 53% to 58%). A 100% sensitive (95% CI 97% to 100%) decision rule for adults (n=348) was derived based on (1) inability to fully extend the elbow, (2) tenderness over radial head, olecranon or medial epicondyle, and (3) presence of bruising (specificity 24% (95% CI 19% to 30%)). A similar rule for children could not be derived. CONCLUSIONS: A simple and highly sensitive clinical decision rule for adult elbow fracture was derived in our cohort. A validation study in a second population is now required. At present, we are unable to recommend a rule-out strategy for elbow injuries in children.

A cohort study of outcomes following head injury among children and young adults in full-time education.

OBJECTIVE: To estimate the prevalence of post-concussive symptoms (PCS) following head injury among adolescents in full-time education and to identify prognostic factors at presentation to the emergency department (ED) that may predict the development of PCS. METHODS: An observational cohort study of all head injured patients aged 13-21 and in full-time education presenting to an inner city ED was performed. Subjects were followed up at 1 and 6 months after injury by structured telephone interview to assess for the presence of symptoms or ongoing disability. Presentation data of those identified as having PCS underwent regression analysis to isolate potential prognostic indicators for such problems. RESULTS: Of the 188 patients recruited, 5.9% (95% CI 3.3% to 10.2%) still had some symptoms after 6 months, with half of these claiming that such symptoms were affecting everyday living. Of these patients, 82% were assaulted as the cause of their injury and nearly 40% had no conventional indicators of head injury severity at presentation. After 1 month, 46/188 (24.5%, 95% CI 18.9% to 31.1%) patients had some degree of symptoms, most of whom were discharged directly from the ED. Potential prognostic indicators identified were a reduced Glasgow Coma Score (GCS) (<15) at presentation and being assaulted as the cause of injury. CONCLUSION: The prevalence of PCS 6 months following head injury for the selected sub-group was 5.9%, and 10.6% if assaulted. Most patients who developed PCS were discharged directly from the ED.

S100B serum level predicts computed tomography findings after minor head injury.

BACKGROUND: Mild head injury (MHI) implies a risk for traumatic brain injury and even a small risk for development of an intracranial hematoma. Head computed tomography (CT) is recommended for early detection of such pathologic findings. The present multicenter study was performed to investigate whether determination of protein S100B in serum could contribute to the selection of patients for CT scanning. METHODS: We included 226 patients with a history of head injury and a Glasgow Coma Scale (GCS) score of 13 to 15 at admission to hospital. Blood samples for S100B analysis and head CT were obtained within 12 hours after the injury. The diagnostic properties of S100B measurements for prediction of intracranial injury revealed by CT were tested with receiver operating characteristic (ROC) analysis and cross-table analysis at different cut-off levels. We also included analysis of S100B levels normalized to correspond to blood sampling 1 hour after the injury. RESULTS: CT showed intracranial injury in 21 (9.3%) patients. S100B levels were significantly (p < 0.001) elevated in patients with intracranial injury (mean, 0.36; 95% CI, 0.21-0.50 microg/L) compared with those in patients without intracranial injury (mean, 0.18; 95% CI, 0.16-0.20 microg/L). ROC curve analysis showed a significant (p = 0.001) area under the curve (0.73; 95% CI, 0.62-0.84). Cross-table analysis showed that 20 of 21 (sensitivity 0.95) patients with intracranial injury were detected at a cut-off level of 0.10 microg/L, but 141 of 205 (specificity 0.31) patients with no such injury also had a S100B level above this limit. Exclusion of cases with blood samples collected more than 3 hours after injury or normalization did not improve the diagnostic properties. CONCLUSION: Determination of serum S100B cannot replace the clinical examination or use of CT for patients with minor head injury, but adding S100B measurement to the clinical evaluation might support selection of patients for CT scanning.

Head injury outcome prediction: a role for protein S-100B?

INTRODUCTION: Prediction of the likely outcome of head injury from the outset would allow early rehabilitation to be targeted at those with most to gain. Clinical evaluation of a head injured patient may be confounded by intoxicants such as alcohol. Imaging modalities are insensitive (CT) or impractical (MR) for screening populations of such patients. A peripheral marker that reflected the extent of brain injury might offer an objective indication of likely adverse sequelae. This review evaluates the evidence for Protein S-100B as such a marker. METHODS: A search of published literature revealed 18 studies designed to evaluate the relation between serum S-100B and measures of outcome after head injury. RESULTS: A cut-off point of 2.5microg/L is related to dependent disability in those presenting with low conscious level, and may be a specific test for this. There appears to be a relation between initial serum S-100B concentration and measures of disability as well as post-concussion symptoms for those with seemingly mild injuries. There does not appear to be a relation between S-100B and measures of neuropsychological performance. CONCLUSION: Patients with high levels of S-100B at initial assessment (>2.5microg/L) may represent a high risk group for disability after head trauma.

Rapid elimination of protein S-100B from serum after minor head trauma.

Protein S-100B is released into the circulation after traumatic brain injury, and its serum concentration relates to measures of injury severity and outcome. These properties have led to interest in its development as a marker for clinical use, particularly in the prediction of adverse outcome for those with apparently trivial injuries. Before it can be used in populations of patients with head injuries, however, more needs to be understood about its release and elimination. This study was designed to estimate the elimination half-life of S-100B from the circulation after minor head trauma. We studied 14 patients with minor head injuries and measured serum S-100B serially after initial assessment in the Emergency Department of an inner city teaching hospital. We used curve-fit analysis to estimate the elimination constant that best fitted our data, and from this estimated the elimination half-life of protein S-100B. We estimated the mean half-life in this setting to be 97 min (95% confidence interval [CI] of 75-136 min). S-100B is cleared rapidly, relative to the time elapsed between injury and initial assessment in the Emergency Department. Variation in the time elapsed between injury and sampling is likely to influence the accuracy of head injury outcome prediction based on S-100B concentrations in serum, and should be considered when designing future studies.

Best evidence topic report. Abdominal radiography in "body packers".

A short cut review was carried out to establish whether an abdominal radiograph has clinical utility in the management of patients who claim to have swallowed drug filled packages. Twelve papers were found using the reported search, of which two 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. A clinical bottom line is stated.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Phenytoin or paraldehyde as the second drug for convulsions in children.

A short cut review was carried out to establish whether phenytoin or paraldehyde should be given as the second drug for resistant fits in children. Altogether 41 papers were found using the reported search, of which none answered the question posed. Further research is needed in this area.