Darren Walter

Accelerated discharge of patients in the event of a major incident: observational study of a teaching hospital

BackgroundSince October 2002 in the UK Primary Care Trusts (PCTs) have had statutory responsibility for having and maintaining a Major Incident plan and since 2005 they have been obliged to co-operate with other responders to an incident. We aimed to establish the number of beds in our Trust which could be freed up over set periods of time in the event of a major incident and the nature and quantity of support which might be required from PCTs in order to achieve this.MethodsRepeated survey over 12 days in 3 months of hospital bed occupancy by type of condition and discharge capacity in an 855-bed UK tertiary teaching hospital also providing secondary care services. Outcome measures were bed spaces which could be generated, timescale over which this could happen and level and type of PCT support which would be required to achieve this.ResultsMean beds available were 78 immediately, a further 69 in 1–4 hours and a further 155 in 4–12 hours, generating a total of 302 beds (36% of hospital capacity) within 12 hours of an incident. This would require support from a PCT of 150,000 population of 10 nursing care beds, 20 therapy-supported intermediate care beds, and 25 care packages in patients own homes.ConclusionIn order to fulfill the requirements of the Civil Contingencies Act 2004, PCTs should plan to have surge capacity in the order of 30 residential placements and 25 community support packages per 150,000 population to support Acute Trusts in the event of a major incident.

A call for consensus on methodology and terminology to improve comparability in the study of preventable prehospital trauma deaths: a systematic literature review

OBJECTIVESnThe study of preventable deaths is essential to trauma research for measuring service quality and highlighting avenues for improving care and as a performance indicator. However, variations in the terminology and methodology of studies on preventable prehospital trauma death limit the comparability and wider application of data. The objective of this study was to describe the heterogeneity in terminology and methodology.nnnMETHODSnWe performed a systematic literature review and report this using the PRISMA guidelines. Searches were conducted using PubMed (including Medline), Ovid, and Embase databases. Studies, with a full text available in English published between 1990 and 2015, meeting the following inclusion criteria were included: analysis of 1) deaths from trauma, 2) occurring in the prehospital phase of care, and 3) application of criteria to ascertain whether deaths were preventable. One author screened database results for relevance by title and abstract. The full text of identified papers was reviewed for inclusion. The reference list of included papers was screened for studies not identified by the database search. Data were extracted on predefined core elements relating to preventability reporting and definitions using a standardized form.nnnRESULTSnTwenty-seven studies meeting the inclusion criteria were identified: 12 studies used two categories to assess the preventability of death while 15 used three categories. Fifteen variations in the terminology of these categories and combination with death descriptors were found. Eleven different approaches were used in defining what constituted a preventable death. Twenty-one included survivability of injuries as a criterion. Methods used to determine survivability differed and eight variations in parameters for categorization of deaths were used. Nineteen used panel review in determining preventability with six implementing panel blinding. Panelxa0composition varied greatly by expertise of personnel. Separation of prehospital deaths differed with 10 separating those dead at scene (DAS) and dead on arrival, three excluding those DAS, three excluding deaths prior to EMS arrival, and 11 not separating prehospital deaths.nnnCONCLUSIONSnThe heterogeneity in methodology, terminology, and definitions of preventable between studies render data incomparable. To facilitate common understanding, comparability, and analysis, a commonly agreed ontology by the prehospital research community is required.

Are prehospital deaths from trauma and accidental injury preventable? A direct historical comparison to assess what has changed in two decades

BACKGROUND & OBJECTIVESnIn 1994, Hussain and Redmond revealed that up to 39% of prehospital deaths from accidental injury might have been preventable had basic first aid care been given. Since then there have been significant advances in trauma systems and care. The exclusion of prehospital deaths from the analysis of trauma registries, giv en the high rate of those, is a major limitation in prehospital research on preventable death. We have repeated the 1994 study to identify any changes over the years and potential developments to improve patient outcomes.nnnMETHODSnWe examined the full Coroners inquest files for prehospital deaths from trauma and accidental injury over a three-year period in Cheshire. Injuries were scored using the Abbreviated-Injury-Scale (AIS-1990) and Injury Severity Score (ISS), and probability of survival estimated using Bulls probits to match the original protocol.nnnRESULTSnOne hundred and thirty-four deaths met our inclusion criteria; 79% were male, average age at death was 53.6 years. Sixty-two were found dead (FD), fifty-eight died at scene (DAS) and fourteen were dead on arrival at hospital (DOA). The predominant mechanism of injury was fall (39%). The median ISS was 29 with 58 deaths (43%) having probability of survival of >50%. Post-mortem evidence of head injury was present in 102 (76%) deaths. A bystander was on scene or present immediately after injury in 45% of cases and prior to the Emergency Medical Services (EMS) in 96%. In 93% of cases a bystander made the call for assistance, in those DAS or DOA, bystander intervention of any kind was 43%.nnnCONCLUSIONSnThe number of potentially preventable prehospital deaths remains high and unchanged. First aid intervention of any kind is infrequent. There is a potentially missed window of opportunity for bystander intervention prior to the arrival of the ambulance service, with simple first-aid manoeuvres to open the airway, preventing hypoxic brain injury and cardiac arrest.

Prehospital deaths from trauma: Are injuries survivable and do bystanders help?

BACKGROUND AND OBJECTIVESnDeaths from trauma occurring in the prehospital phase of care are typically excluded from analysis in trauma registries. A direct historical comparison with Hussain and Redmonds study on preventable prehospital trauma deaths has shown that, two decades on, the number of potentially preventable deaths remains high. Using updated methodology, we aimed to determine the current nature, injury severity and survivability of traumatic prehospital deaths and to ascertain the presence of bystanders and their role following the point of injury including the frequency of first-aid delivery.nnnMETHODSnWe examined the Coroners inquest files for deaths from trauma, occurring in the prehospital phase, over a three-year period in the Cheshire and Manchester (City), subsequently referred to as Manchester, Coronial jurisdictions. Injuries were scored using the Abbreviated-Injury-Scale (AIS-2008), Injury Severity Score (ISS) calculated and probability of survival estimated using the Trauma Audit and Research Networks outcome prediction model.nnnRESULTSnOne hundred and seventy-eight deaths were included in the study (one hundred and thirty-four Cheshire, forty-four Manchester). The World Health Organisations recommendations consider those with a probability of survival between 25-50% as potentially preventable and those above 50% as preventable. The median ISS was 29 (Cheshire) and 27.5 (Manchester) with sixty-two (46%) and twenty-six (59%) respectively having a probability of survival in the potentially preventable and preventable ranges. Bystander presence during or immediately after the point of injury was 45% (Cheshire) and 39% (Manchester). Bystander intervention of any kind was 25% and 30% respectively. Excluding those found dead and those with a probability of survival less than 25%, bystanders were present immediately after the point of injury or within minutes in thirty-three of thirty-five (94%) Cheshire and ten of twelve (83%) Manchester. First aid of any form was attempted in fourteen of thirty-five (40%) and nine of twelve (75%) respectively.nnnCONCLUSIONSnA high number of prehospital deaths from trauma occur with injuries that are potentially survivable, yet first aid intervention is infrequent. Following injury there is a potential window of opportunity for the provision of bystander assistance, particularly in the context of head injury, for simple first-aid manoeuvres to save lives.

Emergency response to 999 calls

Editor—Snooks et al point out that the current 999 emergency response system has problems: increasing demand from the public and ever shorter response time targets.1 They find a lack of evidence on alternative systems and responses in the English medical literature. By restricting their search, they overlook live examples only a few miles from these shores. n nFrance, since the mid-1960s, has had a system which incorporates many of the alternatives quoted by the authors: the Service dAide Medical Urgente (SAMU).2 Calls to the control room are logged by trained telephone operators and then passed on to a “medical dispatcher”: a doctor in emergency medicine, trained by the service. Medical dispatchers may simply provide medical advice to the caller, or they may decide to use one of a range of other responses to a call. These are referral to, or the dispatch of, a primary care doctor; arranging non-urgent transport by a private ambulance; urgent transport by pompiers (emergency technicians working through the fire service); or sending out a mobile intensive care unit with a doctor trained in emergency medicine. Medical dispatchers also coordinate the deployment of additional resources and decide on the most appropriate destination for a patient. n nIn 2001 the service covering Paris received 300u2009000 calls (about 820 calls per day). Only 6% of the calls (50 per day) resulted in the dispatch of a mobile intensive care unit. In 16% of cases (130 per day) a primary care doctor was called. Altogether 205 calls per day were managed by the pompiers, by a private ambulance, or by giving medical advice. The remainder were considered not to warrant an emergency medical response. n nIn contrast, during the same period the greater Manchester ambulance service, which covers an equivalent urban population, received 256u2009000 calls (700 calls per day), all of which received a standard emergency paramedic response. n nIn greater Manchester calls are received by non-physician telephone operators using computer based algorithms to determine the time priority of response. Compliance with the pre-set questions is audited as part of a risk management process. In contrast, the doctor in the French service uses clinical training and experience, without computer support, to decide on the urgency and level of the response. We agree that alternatives to the current 999 system need to be explored. Aspects of the French service and other European models of emergency response deserve to be considered in the list of examples.

Emergency response to 999 calls : Alternatives to the emergency 999 response can be seen in Europe

Editor—Snooks et al point out that the current 999 emergency response system has problems: increasing demand from the public and ever shorter response time targets.1 They find a lack of evidence on alternative systems and responses in the English medical literature. By restricting their search, they overlook live examples only a few miles from these shores. n nFrance, since the mid-1960s, has had a system which incorporates many of the alternatives quoted by the authors: the Service dAide Medical Urgente (SAMU).2 Calls to the control room are logged by trained telephone operators and then passed on to a “medical dispatcher”: a doctor in emergency medicine, trained by the service. Medical dispatchers may simply provide medical advice to the caller, or they may decide to use one of a range of other responses to a call. These are referral to, or the dispatch of, a primary care doctor; arranging non-urgent transport by a private ambulance; urgent transport by pompiers (emergency technicians working through the fire service); or sending out a mobile intensive care unit with a doctor trained in emergency medicine. Medical dispatchers also coordinate the deployment of additional resources and decide on the most appropriate destination for a patient. n nIn 2001 the service covering Paris received 300u2009000 calls (about 820 calls per day). Only 6% of the calls (50 per day) resulted in the dispatch of a mobile intensive care unit. In 16% of cases (130 per day) a primary care doctor was called. Altogether 205 calls per day were managed by the pompiers, by a private ambulance, or by giving medical advice. The remainder were considered not to warrant an emergency medical response. n nIn contrast, during the same period the greater Manchester ambulance service, which covers an equivalent urban population, received 256u2009000 calls (700 calls per day), all of which received a standard emergency paramedic response. n nIn greater Manchester calls are received by non-physician telephone operators using computer based algorithms to determine the time priority of response. Compliance with the pre-set questions is audited as part of a risk management process. In contrast, the doctor in the French service uses clinical training and experience, without computer support, to decide on the urgency and level of the response. We agree that alternatives to the current 999 system need to be explored. Aspects of the French service and other European models of emergency response deserve to be considered in the list of examples.