Sex and gender reporting in UK emergency medicine trials from 2010 to 2023: a systematic review.

BACKGROUND: Female participants are underrepresented in randomised control trials conducted in urgent care settings. Although sex and gender are frequently reported within demographic data, it is less common for primary outcomes to be disaggregated by sex or gender. The aim of this review is to report sex and gender of participants in the primary papers published on research listed on the National Institute of Health and Care Research (NIHR) Trauma and Emergency Care (TEC) portfolio and how these data are presented. METHODS: This is a systematic review of the published outputs of interventional trials conducted in UK EDs. Interventional trials were eligible to be included in the review if they were registered on the NIHR TEC research portfolio from January 2010, if the primary paper was published before 31 December 2023 and if the research was delivered primarily in the ED. Trials were identified through the NIHR open data platform and the primary papers were identified through specific searches using MedLine, EMBASE and PubMed. The primary objective of the review is to quantify the proportion of sex-disaggregated or gender-disaggregated primary outcomes in clinical trials within UK emergency medicine. RESULTS: The initial search revealed 169 registered research projects on the NIHR TEC portfolio during the study period, of which 24 met the inclusion criteria. Overall, 76 719 participants were included, of which 31 374 (40%) were female. Only one trial (CRYOSTAT-2) reported a sex-disaggregated analysis of the effect of the intervention on either primary or secondary outcomes, and no sex-based difference in treatment effect was detected. CONCLUSIONS: Fewer females than males were included in TEC trials from 2010 to 2023. One trial reported the primary outcome stratified by sex. There is significant scope to increase the scientific value of TEC trials to females by funders.

Cessation of Smoking Trial in the Emergency Department (COSTED): a multicentre randomised controlled trial.

BACKGROUND: Supporting people to quit smoking is one of the most powerful interventions to improve health. The Emergency Department (ED) represents a potentially valuable opportunity to deliver a smoking cessation intervention if it is sufficiently resourced. The objective of this trial was to determine whether an opportunistic ED-based smoking cessation intervention can help people to quit smoking. METHODS: In this multicentre, parallel-group, randomised controlled superiority trial conducted between January and August 2022, adults who smoked daily and attended one of six UK EDs were randomised to intervention (brief advice, e-cigarette starter kit and referral to stop smoking services) or control (written information on stop smoking services). The primary outcome was biochemically validated abstinence at 6 months. RESULTS: An intention-to-treat analysis included 972 of 1443 people screened for inclusion (484 in the intervention group, 488 in the control group). Of 975 participants randomised, 3 were subsequently excluded, 17 withdrew and 287 were lost to follow-up. The 6-month biochemically-verified abstinence rate was 7.2% in the intervention group and 4.1% in the control group (relative risk 1.76; 95% CI 1.03 to 3.01; p=0.038). Self-reported 7-day abstinence at 6 months was 23.3% in the intervention group and 12.9% in the control group (relative risk 1.80; 95% CI 1.36 to 2.38; p<0.001). No serious adverse events related to taking part in the trial were reported. CONCLUSIONS: An opportunistic smoking cessation intervention comprising brief advice, an e-cigarette starter kit and referral to stop smoking services is effective for sustained smoking abstinence with few reported adverse events. TRIAL REGISTRATION NUMBER: NCT04854616.

Fluid biomarkers and neuroimaging in mild traumatic brain injury: current uses and potential future directions for clinical use in emergency medicine.

Mild traumatic brain injury is a common presentation to the emergency department, with current management often focusing on determining whether a patient requires a CT head scan and/or neurosurgical intervention. There is a growing appreciation that approximately 20%-40% of patients, including those with a negative (normal) CT, will develop ongoing symptoms for months to years, often termed post-concussion syndrome. Owing to the requirement for improved diagnostic and prognostic mechanisms, there has been increasing evidence concerning the utility of both imaging and blood biomarkers.Blood biomarkers offer the potential to better risk stratify patients for requirement of neuroimaging than current clinical decisions rules. However, improved assessment of the clinical utility is required prior to wide adoption. MRI, using clinical sequences and advanced quantitative methods, can detect lesions not visible on CT in up to 30% of patients that may explain, at least in part, some of the ongoing problems. The ability of an acute biomarker (be it imaging, blood or other) to highlight those patients at greater risk of ongoing deficits would allow for greater personalisation of follow-up care and resource allocation.We discuss here both the current evidence and the future potential clinical usage of blood biomarkers and advanced MRI to improve diagnostic pathways and outcome prediction following mild traumatic brain injury.

Usability of electronic health record systems in UK EDs.

BACKGROUND: The large volume of patients, rapid staff turnover and high work pressure mean that the usability of all systems within the ED is important. The transition to electronic health records (EHRs) has brought many benefits to emergency care but imposes a significant burden on staff to enter data. Poor usability has a direct consequence and opportunity cost in staff time and resources that could otherwise be employed in patient care. This research measures the usability of EHR systems in UK EDs using a validated assessment tool. METHODS: This was a survey completed by members and fellows of the Royal College of Emergency Medicine conducted during summer 2019. The primary outcome was the System Usability Scale Score, which ranges from 0 (worst) to 100 (best). Scores were compared with an internationally recognised measure of acceptable usability of 68. Results were analysed by EHR system, country, healthcare organisation and physician grade. Only EHR systems with at least 20 responses were analysed. RESULTS: There were 1663 responses from a total population of 8794 (19%) representing 192 healthcare organisations (mainly UK NHS), and 25 EHR systems. Fifteen EHR systems had at least 20 responses and were included in the analysis. No EHR system achieved a median usability score that met the industry standard of acceptable usability.The median usability score was 53 (IQR 35-68). Individual EHR systems' scores ranged from 35 (IQR 26-53) to 65 (IQR 44-80). CONCLUSION: In this survey, no UK ED EHR system met the internationally validated standard of acceptable usability for information technology.

Short-stay admissions at an inner city hospital: a cross-sectional analysis.

OBJECTIVE: To investigate factors predictive of short hospital admissions and appropriate placement to inpatient versus clinical decision units (CDUs). METHOD: This is a retrospective analysis of attendance and discharge data from an inner-city ED in England for December 2013. The primary outcome was admission for less than 48 hours either to an inpatient unit or CDU. Variables included: age, gender, ethnicity, deprivation score, arrival date and time, arrival method, admission outcome and discharge diagnosis. Analysis was performed by cross-tabulation followed by binary logistic regression in three models using the outcome measures above and seeking to identify factors associated with short-stay admission. RESULTS: There were 2119 (24%) admissions during the study period and 458 were admitted for less than 24 hours. Those who were admitted in the middle of the week or with ambulatory care sensitive conditions (ACSCs) were significantly more likely to experience short-stays. Older patients and those who arrived by ambulance were significantly more likely to have a longer hospital stay. There was no association of length of inpatient stay with being admitted in the last 10 min of a 4 hours ED stay. CONCLUSION: Only a few factors were independently predictive of short stays. Patients with ACSCs were more likely to have short stays, regardless of whether they were admitted to CDU or an inpatient ward. This may be a group of patients that could be targeted for dedicated outpatient management pathways or CDU if they need admission.

Short-term neurocognitive and symptomatic outcomes following mild traumatic brain injury: A prospective multi-centre observational cohort study.

OBJECTIVE: To determine the short-term cognitive and symptomatic outcome following mild traumatic brain injury. METHODS: Setting: Emergency Departments of two UK tertiary referral hospitals. PARTICIPANTS: Adult patients presenting to the Emergency Departments of the Royal London Hospital and Salford Royal Hospital with suspected traumatic brain injury within 24 hours and Glasgow Coma Score > 8. A non-TBI comparison group included adult patients with no head or neck injury. DESIGN: Prospective multi-centre cohort study. MAIN MEASURES: The Standardized Assessment of Concussion (SAC), the Concussion Symptom Inventory (CSI) and total number of symptoms, measured at baseline and 72 hours. RESULTS: This study enrolled 189 patients with and 51 patients without TBI. Patients with TBI had marked cognitive impairment which persisted at 72 hours (SAC score at baseline = 25 [23-27] vs 72 hours = 25 [22-27]; p = 0.1). Patients with TBI had persistent high symptom severity, although this had decreased at 72 hours (CSI score at baseline = 9 [4-22] vs 72 hours = 5 [1-19], p = 0.002). A similar pattern was observed with the total number of symptoms (baseline = 4 [2-8] vs 72 hours = 0 [0-4]; p < 0.001). Patients with TBI had worse neurocognitive function, higher overall symptom severity and higher total number of symptoms compared with patients without TBI. Patients without TBI' neurocognitive function and symptom severity remained constant, but the number of symptoms reduced between baseline and 72 hours. CONCLUSION: There is a cognitive deficit and symptom burden in patients with mild TBI presenting to the Emergency Department which persists at 72 hours.

The benefits of respectful interactions: fluid alliancing and inter-occupational information sharing in primary care.

Though inter-occupational interactions in health care have been the focus of increasing attention, we still know little about how such interactions shape information sharing in clinical settings. This is particularly true in primary care where research on teams and collaboration has been based on individual perceptions of work (using surveys and interviews) rather than observing the interactions that directly mediate the inter-occupational flow of information. To explore how interactions shape information sharing, we conducted a secondary analysis of ethnographic data from 27 primary care practices. Ease of information sharing among nurses and doctors is linked to the degree to which practices feature respectful interactions, with practices in the sample falling into one of three categories (those with low, uneven, and high degrees of respectful interactions). Those practices with the highest degree of respectful interactions demonstrate what we describe as fluid-alliancing: flexible interactions between individuals from different occupational groups in which bidirectional information sharing occurs for the benefit of patients and the efficacy of the practice community. We conclude by arguing that this process unlocks the strengths of all practice members, and that leadership should encourage respectful interactions to augment organisational efficacy and the ability of individual practice members to provide quality patient care.

Unexpected death within 72 hours of emergency department visit: were those deaths preventable?

INTRODUCTION: We aimed to determine the rate of preventable death in patients who died early and unexpectedly following hospital admission from the emergency department (ED). METHODS: We conducted a retrospective multicenter study in four centers from the Paris metropolitan area. Inclusion criteria were medical patients who died in hospital within 72 hours of ED attendance and were not admitted to the intensive care unit (unexpected death). Exclusion criteria were limitations of care determined by treating physicians. The existence of a limitation of care decision was adjudicated by two independent chart abstractors. Preventable death was defined as death occurring as a result of medical error. For each selected patient with unexpected death, charts were examined for medical errors and rated on a 1 to 5 preventability scale (from very unlikely to very likely) for the preventability of the death. The primary endpoint was the likely preventable death, rated as 4 or 5 on the preventability scale. RESULTS: We retrieved 555 charts; 47 unexpected deaths were analysed; 24 (51%) were considered as preventable. There was a median number of medical errors of two. The most common process breakdowns were incorrect choice of treatment (47% of patients) and failure to order appropriate diagnostic tests (38% of patients). The most common medical error was a severe delay or absence of recommended treatment for severe sepsis, which occurred in 10 (42%) patients. CONCLUSIONS: In our sample, more than half of unexpected deaths are related to a medical error, and could have been prevented.

Cross-checking to reduce adverse events resulting from medical errors in the emergency department: study protocol of the CHARMED cluster randomized study.

BACKGROUND: Medical errors and preventable adverse events are a major cause of concern, especially in the emergency department (ED) where its prevalence has been reported to be roughly of 5-10% of visits. Due to a short length of stay, emergency patients are often managed by a sole physician - in contrast with other specialties where they can benefit from multiples handover, ward rounds and staff meetings. As some studies report that the rate and severity of errors may decrease when there is more than one physician involved in the management in different settings, we sought to assess the impact of regular systematic cross-checkings between physicians in the ED. DESIGN: The CHARMED (Cross-checking to reduce adverse events resulting from medical errors in the emergency department) study is a multicenter cluster randomized study that aim to evaluate the reduction of the rate of severe medical errors with implementation of systematic cross checkings between emergency physician, compared to a control period with usual care. This study will evaluate the effect of this intervention on the rate of severe medical errors (i.e. preventable adverse events or near miss) using a previously described two-level chart abstraction. We made the hypothesis that implementing frequent and systematic cross checking will reduce the rate of severe medical errors from 10 to 6% - 1584 patients will be included, 140 for each period in each center. DISCUSSION: The CHARMED study will be the largest study that analyse unselected ED charts for medical errors. This could provide evidence that frequent systematic cross-checking will reduce the incidence of severe medical errors. TRIAL REGISTRATION: Clinical Trials, NCT02356926.

Prospective observational study of peripheral intravenous cannula utilisation and frequency of intravenous fluid delivery in the emergency department-Convenience or necessity?

BACKGROUND: Peripheral Intravenous Cannulas (PIVCs) are frequently utilised in the Emergency Department (ED) for delivery of medication and phlebotomy. They are associated with complications and have an associated cost to departmental resources. A growing body of international research suggests many of the PIVCs inserted in the ED are unnecessary. METHODS: The objective of this study was to determine the rates of PIVC insertion and use. This was a prospective observational study conducted in one UK ED and one Italian ED. Adult ED patients with non-immediate triage categories were included over a period of three weeks in the UK ED in August 2016 and two weeks in the Italian ED in March and August 2017. Episodes of PIVC insertion and data on PIVC utilisation in adults were recorded. PIVC use was classified as necessary, unnecessary or unused. The proportion of unnecessary and unused PIVCs was calculated. PIVCs were defined as unnecessary if they were either used for phlebotomy only, or solely for IV fluids in patients that could have potentially been hydrated orally (determined against a priori defined criteria). PIVC classified as unused were not used for any purpose. RESULTS: A total of 1,618 patients were included amongst which 977 PIVCs were inserted. Of the 977 PIVCs, 413 (42%) were necessary, 536 (55%) were unnecessary, and 28 (3%) were unused. Of the unnecessary PIVCs, 473 (48%) were used solely for phlebotomy and 63 (6%) were used for IV fluids in patients that could drink. CONCLUSIONS: More than half of PIVCs placed in the ED were unnecessary in this study. This suggests that clinical decision making about the benefits and risks of PIVC insertion is not being performed on an individual basis.

Association between age older than 75 years and exceeded target waiting times in the emergency department: a multicenter cross-sectional survey in the Paris metropolitan area, France.

STUDY OBJECTIVE: We seek to evaluate whether age greater than 75 years is an independent predictor of prolonged waiting time in the emergency department (ED). METHODS: We retrospectively analyzed all adult attendances to 9 EDs within the Paris area during 2011. The primary endpoint was target waiting time exceeded, defined as a waiting time for medical assessment longer than the maximal recommended waiting time according to triage level. To assess our primary objective, we performed logistic regression using patient- and ED-related variables to determine whether age greater than 75 years was independently associated with higher rate of target waiting time exceeded. RESULTS: A total of 317,793 patients were included, of whom 173,629 (55%) had an exceeded target waiting time. Mean age was 45.8 years and 12.7% were older than 75 years. Target waiting time was exceeded for 55% of patients: 53% for patients younger than 75 years (95% confidence interval [CI] 53% to 54%) versus 64% for older patients (95% CI 63% to 65%), relative risk 1.20. In the multivariate analysis, age greater than 75 years was independently associated with an exceeded target waiting time (odds ratio [OR] 1.30; 95% CI 1.27 to 1.33). Other variables associated with exceeded target waiting time were triage level (OR 5.45 [95% CI 5.32 to 5.60] for triage level 2 versus triage level 4), high daily occupancy (OR 3.78 [95% CI 3.53 to 4.03]), day of the week (OR 1.12 [95% CI 1.09 to 1.14] for Monday), and time of the visit (OR 1.79 [95% CI 1.76 to 1.82] from 6 pm to 8 am). CONCLUSION: Patients older than 75 years are less likely to be seen within the target waiting time.

AWAreness during REsuscitation - II: A multi-center study of consciousness and awareness in cardiac arrest.

INTRODUCTION: Cognitive activity and awareness during cardiac arrest (CA) are reported but ill understood. This first of a kind study examined consciousness and its underlying electrocortical biomarkers during cardiopulmonary resuscitation (CPR). METHODS: In a prospective 25-site in-hospital study, we incorporated a) independent audiovisual testing of awareness, including explicit and implicit learning using a computer and headphones, with b) continuous real-time electroencephalography(EEG) and cerebral oxygenation(rSO2) monitoring into CPR during in-hospital CA (IHCA). Survivors underwent interviews to examine for recall of awareness and cognitive experiences. A complementary cross-sectional community CA study provided added insights regarding survivors' experiences. RESULTS: Of 567 IHCA, 53(9.3%) survived, 28 of these (52.8%) completed interviews, and 11(39.3%) reported CA memories/perceptions suggestive of consciousness. Four categories of experiences emerged: 1) emergence from coma during CPR (CPR-induced consciousness [CPRIC]) 2/28(7.1%), or 2) in the post-resuscitation period 2/28(7.1%), 3) dream-like experiences 3/28(10.7%), 4) transcendent recalled experience of death (RED) 6/28(21.4%). In the cross-sectional arm, 126 community CA survivors' experiences reinforced these categories and identified another: delusions (misattribution of medical events). Low survival limited the ability to examine for implicit learning. Nobody identified the visual image, 1/28(3.5%) identified the auditory stimulus. Despite marked cerebral ischemia (Mean rSO2 = 43%) normal EEG activity (delta, theta and alpha) consistent with consciousness emerged as long as 35-60 minutes into CPR. CONCLUSIONS: Consciousness. awareness and cognitive processes may occur during CA. The emergence of normal EEG may reflect a resumption of a network-level of cognitive activity, and a biomarker of consciousness, lucidity and RED (authentic "near-death" experiences).

Assembly and coherent control of a register of nuclear spin qubits.

The generation of a register of highly coherent, but independent, qubits is a prerequisite to performing universal quantum computation. Here we introduce a qubit encoded in two nuclear spin states of a single 87Sr atom and demonstrate coherence approaching the minute-scale within an assembled register of individually-controlled qubits. While other systems have shown impressive coherence times through some combination of shielding, careful trapping, global operations, and dynamical decoupling, we achieve comparable coherence times while individually driving multiple qubits in parallel. We highlight that even with simultaneous manipulation of multiple qubits within the register, we observe coherence in excess of 105 times the current length of the operations, with [Formula: see text] seconds. We anticipate that nuclear spin qubits will combine readily with the technical advances that have led to larger arrays of individually trapped neutral atoms and high-fidelity entangling operations, thus accelerating the realization of intermediate-scale quantum information processors.

Spatio-Temporal Flexibility of Attention Inferred from Drivers' Steering Movements.

Participants attempted to center a cursor on a video display of a winding roadway with a rate control system. Fourier analysis of their steering movements in response to sinusoidal perturbations of the roadway revealed how much attention they allocated to different roadway preview locations. We compared a full 1.0 s of preview with preview restricted to a narrow slit around 0.3 s or 0.6 s. Participants were able to flexibly shift their attention to either slit. However, they performed better in terms of root-mean-squared error, velocity error, and acceleration error with the fuller view. They concentrated their attention over a range from 0.1 s to 0.3 s of preview in a manner qualitatively consistent with Miller's optimal control model.

Point-of-care Ultrasound Diagnosis of Acute Abdominal Aortic Occlusion.

Acute aortic occlusion is an emergent vascular condition not encountered routinely. Given its varied presentations, including neurovascular deficits and mimicking an acute abdomen, the diagnosis is often delayed causing increased morbidity and mortality. We present a case of acute abdominal aortic occlusion masquerading as sudden onset lower extremity pain and weakness in an 86-year-old female requiring emergent thrombectomy. This is only the second case report to discuss the use of point-of-care ultrasound to expedite diagnosis and management.1.

Males Receive Low-Tidal Volume Component of Lung Protective Ventilation More Frequently than Females in the Emergency Department.

INTRODUCTION: Mechanical ventilation is a commonly performed procedure in the emergency department (ED). Approximately 240,000 patients per year receive mechanical ventilation in the ED representing 0.23% of ED visits. An ED-based trial published in 2017 showed that a bundle of interventions in mechanically ventilated patients, including low tidal volume ventilation, reduced the development of acute respiratory distress syndrome by nearly 50%. Prior literature has shown that as many as 40% of ED patients do not receive lung protective ventilation. Our goal was to determine whether differences exist between the percent of males vs females who are ventilated at ≥ 8 milliliters per kilogram (mL/kg) of predicted body weight. METHODS: We conducted this study at Temple University Hospital, a tertiary care center located in Philadelphia, Pennsylvania. This was a planned subgroup analysis of study looking at interventions to improve adherence to recommended tidal volume settings. We used a convenience sample of mechanically ventilated patients in our ED between September 1, 2017, and September 30, 2018. All adult patient > 18 years old were eligible for inclusion in the study. Our primary outcome measure was the number of patients who had initial tidal volumes set at > 8 mL/kg of predicted body weight. Our secondary outcome was the number of patients who had tidal volumes set at ≥ 8 mL/kg at 60 minutes after initiation of mechanical ventilation. RESULTS: A total of 130 patients were included in the final analysis. We found that significantly more females were initially ventilated with tidal volumes ≥ 8 mL/kg compared to men: 56% of females vs 9% of males (p=<0.001). Data was available for 107 patients (82%) who were in the ED at 60 minutes after initiation of mechanical ventilation. Again, a significantly larger percentage of females were ventilated with tidal volumes ≥ 8 mL/kg at 60 minutes: 56% of females vs 10% of males (p<0.001). CONCLUSION: The vast majority of tidal volumes ≥ 8 mL/kg during mechanical ventilation occurs in females. We suggest that objective measurements, such as a tape measure and tidal volume card, be used when setting tidal volumes for all patients, especially females.