Frank Coffey

The UK Burden of Injury Study – a protocol. [National Research Register number: M0044160889]

BackgroundGlobally and nationally large numbers of people are injured each year, yet there is little information on the impact of these injuries on peoples lives, on society and on health and social care services. Measurement of the burden of injuries is needed at a global, national and regional level to be able to inform injured people of the likely duration of impairment; to guide policy makers in investing in preventative measures; to facilitate the evaluation and cost effectiveness of interventions and to contribute to international efforts to more accurately assess the global burden of injuries.Methods/DesignA prospective, longitudinal multi-centre study of 1333 injured individuals, atttending Emergency Departments or admitted to hospital in four UK areas: Swansea, Surrey, Bristol and Nottingham. Specified quotas of patients with defined injuries covering the whole spectrum will be recruited. Participants (or a proxy) will complete a baseline questionnaire regarding their injury and pre-injury quality of life. Follow up occurs at 1, 4, and 12 months post injury or until return to normal function within 12 months, with measures of health service utilisation, impairment, disability, and health related quality of life. National estimates of the burden of injuries will be calculated by extrapolation from the sample population to national and regional computerised hospital in-patient, emergency department and mortality data.DiscussionThis study will provide more detailed data on the national burden of injuries than has previously been available in any country and will contribute to international collaborative efforts to more accurately assess the global burden of injuries. The results will be used to advise policy makers on prioritisation of preventive measures, support the evaluation of interventions, and provide guidance on the likely impact and degree of impairment and disability following specific injuries.

STOP!: a randomised, double-blind, placebo-controlled study of the efficacy and safety of methoxyflurane for the treatment of acute pain

Objective To evaluate the short-term efficacy and safety of methoxyflurane for the treatment of acute pain in patients presenting to an emergency department (ED) with minor trauma. Methods STOP! was a randomised, double-blind, multicentre, placebo-controlled study conducted at six sites in the UK. A total of 300 patients, 90 of whom were adolescent patients (age 12–17 years), were randomised 150:150 to receive either methoxyflurane via a Penthrox inhaler or placebo. The primary end point of the study was the change in pain intensity as measured using the visual analogue scale (VAS) from baseline to 5, 10, 15 and 20 min after the start of study drug inhalation. Patients were supplied with one inhaler containing 3 mL methoxyflurane or 5 mL placebo after enrolment and initial assessments. Age group (adolescent/adult) and baseline VAS score were controlled for in the statistical analyses. Results A total of 149 patients received methoxyflurane, and 149 patients received placebo. Demographic and baseline characteristics were comparable between the groups. Methoxyflurane reduced pain severity significantly more than placebo (p<0.0001) at all time points tested, with the greatest estimated treatment effect of −18.5 mm (adjusted change from baseline) seen at 15 min after the start of treatment. Methoxyflurane was well tolerated, with the majority of adverse reactions being mild, transient and in line with anticipated pharmacological action. Conclusion The results of this study suggest that methoxyflurane administered via the Penthrox inhaler is an efficacious, safe, and rapidly acting analgesic. Trial registration number: NCT01420159.

The impact of injuries study. multicentre study assessing physical, psychological, social and occupational functioning post injury - a protocol

BackgroundLarge numbers of people are killed or severely injured following injuries each year and these injuries place a large burden on health care resources. The majority of the severely injured are not fully recovered 12-18 months later. Psychological disorders are common post injury and are associated with poorer functional and occupational outcomes. Much of this evidence comes from countries other than the UK, with differing health care and compensation systems. Early interventions can be effective in treating psychological morbidity, hence the scale and nature of the problem and its impact of functioning in the UK must be known before services can be designed to identify and manage psychological morbidity post injury.Methods/DesignA longitudinal multi-centre study of 680 injured patients admitted to hospital in four areas across the UK: Nottingham, Leicester/Loughborough, Bristol and Surrey. A stratified sample of injuries will ensure a range of common and less common injuries will be included. Participants will complete a baseline questionnaire about their injury and pre-injury quality of life, and follow-up questionnaires 1, 2, 4, and 12 months post injury. Measures will include health and social care utilisation, perceptions of recovery, physical, psychological, social and occupational functioning and health-related quality of life. A nested qualitative study will explore the experiences of a sample of participants, their carers and service providers to inform service design.DiscussionThis study will quantify physical, psychological, social and occupational functioning and health and social care utilisation following a range of different types of injury and will assess the impact of psychological disorders on function and health service use. The findings will be used to guide the development of interventions to maximise recovery post injury.

Validation of the Canadian c-spine rule in the UK emergency department setting

Aim To determine the potential of the Canadian Cervical Spine Rule (CCR) to safely reduce the number of cervical spine (c-spine) radiographs performed in the UK emergency department setting. Methods The study was conducted in two UK emergency departments with a combined annual attendance of >150 000 adult patients. Over the 24 month trial period, 148 doctors were provided training in the use of the CCR and instructed to assess eligible patients presenting with potential c-spine injury. Doctors were instructed to manage patients according to existing practice and not according to the decision obtained from the rule. A subsample of patients was reassessed by a second doctor to test interobserver reliability. Results A total of 1420 patients were enrolled in the study (50.4% male). 987 (69.5%) had c-spine radiography performed, with 8 (0.6%) having a c-spine injury. If the decision for radiography had been made according to the outcome of the CCR, only 815 (57.4%) would have had c-spine radiography and all 8 abnormal cases would have undergone imaging. Doctors were comfortable using the rule in 91% of cases. Interobserver reliability was good (κ=0.75 95% CI 0.44 to 1.06). Conclusion The CCR can be applied successfully in the UK. Had the CCR been in use during the study period, a 17.4% reduction in radiography could have been achieved without compromising patient care.

Implementing lean methods in the Emergency Department: The role of professions and professional status

PURPOSE The purpose of this paper is to examine the implementation of lean methods in an Emergency Department (ED) and the role of the professions in this process. DESIGN/METHODOLOGY/APPROACH Qualitative, semi-structured interviews with ED staff in a UK NHS hospital. FINDINGS Lean was met with more engagement and enthusiasm by the professionals than is usually reported in the literature. The main reasons for this were a combination of a national policy, the unique clinical environment and the status of the professional project for doctors in emergency medicine. RESEARCH LIMITATIONS/IMPLICATIONS Single site, one-off study. PRACTICAL IMPLICATIONS The status and development of professionals involved may play a big part in the acceptability of initiatives like lean methods in health care. The longer-term sustainability of the organisational changes introduced remains open to question. ORIGINALITY/VALUE This paper analyses the success of lean methods in health care with reference to the professional status and stage of development of the professions involved, using the sociology of professions. This approach has not been used elsewhere.

Keeping children safe at home: protocol for three matched case–control studies of modifiable risk factors for falls

Background Childhood falls result in considerable morbidity, mortality and health service use. Despite this, little evidence exists on protective factors or effective falls prevention interventions in young children. Objectives To estimate ORs for three types of medically attended fall injuries in young children in relation to safety equipment, safety behaviours and hazard reduction and explore differential effects by child and family factors and injury severity. Design Three multicentre case–control studies in UK hospitals with validation of parental reported exposures using home observations. Cases are aged 0–4 years with a medically attended fall injury occurring at home, matched on age and sex with community controls. Children attending hospital for other types of injury will serve as unmatched hospital controls. Matched analyses will use conditional logistic regression to adjust for potential confounding variables. Unmatched analyses will use unconditional logistic regression, adjusted for age, sex, deprivation and distance from hospital in addition to other confounders. Each study requires 496 cases and 1984 controls to detect an OR of 0.7, with 80% power, 5% significance level, a correlation between cases and controls of 0.1 and a range of exposure prevalences. Main outcome measures Falls on stairs, on one level and from furniture. Discussion As the largest in the field to date, these case control studies will adjust for potential confounders, validate measures of exposure and investigate modifiable risk factors for specific falls injury mechanisms. Findings should enhance the evidence base for falls prevention for young children.

Recruiting participants for injury studies in emergency departments

Emergency departments have the potential to maximize recruitment efficiency and minimize recruiting costs For many studies, especially those requiring incident injury cases, emergency departments are the most suitable location for recruiting participants.1 Although the total number of injury attendances is greater in outpatient or primary care settings than in emergency departments,2 geographical spread and the mixture of incident and prevalent cases make recruiting participants from these sites less feasible, more time consuming and more costly. Emergency departments, on the other hand, will see the largest number and spectrum of injury cases, usually presenting very shortly after injury in a single healthcare setting. This has the potential to maximize recruitment efficiency and minimize recruiting costs. Recruiting in emergency departments also provides opportunities to study the aetiology and epidemiology of injuries before recall of events diminishes with time and to enroll participants for studying short- and long-term consequences of injury. They are the only setting in which complete ascertainment of incident cases of specific injuries may be possible—for example, virtually all patients with long bone fractures will attend an emergency department, fewer will attend primary care and a proportion will be admitted to hospital, but this will vary between hospitals depending on a range of factors including clinician preference for management options, bed availability, social circumstances.3,4 Recruiting cases from emergency departments therefore, has the potential to minimize the selection bias inherent in recruiting such cases from other sites. Inspite of the potential for recruiting injured patients to studies within emergency departments, there are characteristics of the clinical setting and of injured patients which may make recruitment difficult. Emergency departments are often busy and crowded places, and the demand for emergency care continues to increase.5 Many emergency departments experience shortfalls in medical staffing and difficulties in recruiting and …

Keeping children safe at home: protocol for a case–control study of modifiable risk factors for scalds

Background Scalds are one of the most common forms of thermal injury in young children worldwide. Childhood scald injuries, which mostly occur in the home, result in substantial health service use and considerable morbidity and mortality. There is little research on effective interventions to prevent scald injuries in young children. Objectives To determine the relationship between a range of modifiable risk factors for medically attended scalds in children under the age of 5 years. Design A multicentre case-control study in UK hospitals and minor injury units with parallel home observation to validate parental reported exposures. Cases will be 0–4 years old with a medically attended scald injury which occurred in their home or garden, matched on gender and age with community controls. An additional control group will comprise unmatched hospital controls drawn from children aged 0–4 years attending the same hospitals and minor injury units for other types of injury. Conditional logistic regression will be used for the analysis of cases and matched controls, and unconditional logistic regression for the analysis of cases and unmatched controls to estimate ORs and 95% CI, adjusted and unadjusted for confounding variables. Main exposure measures Use of safety equipment and safety practices for scald prevention and scald hazards. Discussion This large case-control study will investigate modifiable risk factors for scalds injuries, adjust for potential confounders and validate measures of exposure. Its findings will enhance the evidence base for prevention of scalds injuries in young children.

Keeping children safe at home: protocol for a matched case-control study of modifiable risk factors for poisoning

Background Childhood unintentional and suspected poisonings are a serious public health problem. Evidence from systematic reviews demonstrates that home safety education in combination with safety equipment provision increases the safe storage of medicines and other products. There is lack of evidence that poisoning prevention practices reduce poisoning rates. Objectives To estimate ORs for medically attended poisonings in children aged 0–4 years for items of safety equipment, home hazards and parental safety practices aimed at preventing poisoning, and to explore differential effects by child and family factors. Design Multicentre case-control study in UK hospitals with validation of parent-reported exposures using home observations. Cases are aged 0–4 years with a medically attended poisoning occurring at home, matched on age and sex with community controls. Children attending hospital for other types of injury will serve as unmatched hospital controls. Matched analyses will use conditional logistic regression; unmatched analyses will use unconditional logistic regression to adjust for confounding variables. The study requires 266 poisoning cases and 1064 matched controls to detect an OR of 0.64 for safe storage of medicinal products and of 0.65 for non-medicinal products, with 80% power, a 5% significance level and a correlation between exposures in cases and controls of 0.1. Main outcome measures Unintentional childhood poisoning. Discussion This will be the largest study to date exploring modifiable risk factors for poisoning in young children. Findings will inform: policy makers developing poison prevention strategies, practitioners delivering poison prevention interventions, parents to reduce the risk of poisoning in their homes.

Providing effective trauma care: the potential for service provider views to enhance the quality of care (qualitative study nested within a multicentre longitudinal quantitative study)

Objective To explore views of service providers caring for injured people on: the extent to which services meet patients’ needs and their perspectives on factors contributing to any identified gaps in service provision. Design Qualitative study nested within a quantitative multicentre longitudinal study assessing longer term impact of unintentional injuries in working age adults. Sampling frame for service providers was based on patient-reported service use in the quantitative study, patient interviews and advice of previously injured lay research advisers. Service providers’ views were elicited through semistructured interviews. Data were analysed using thematic analysis. Setting Participants were recruited from a range of settings and services in acute hospital trusts in four study centres (Bristol, Leicester, Nottingham and Surrey) and surrounding areas. Participants 40 service providers from a range of disciplines. Results Service providers described two distinct models of trauma care: an ‘ideal’ model, informed by professional knowledge of the impact of injury and awareness of best models of care, and a ‘real’ model based on the realities of National Health Service (NHS) practice. Participants’ ‘ideal’ model was consistent with standards of high-quality effective trauma care and while there were examples of services meeting the ideal model, ‘real’ care could also be fragmented and inequitable with major gaps in provision. Service provider accounts provide evidence of comprehensive understanding of patients’ needs, awareness of best practice, compassion and research but reveal significant organisational and resource barriers limiting implementation of knowledge in practice. Conclusions Service providers envisage an ‘ideal’ model of trauma care which is timely, equitable, effective and holistic, but this can differ from the care currently provided. Their experiences provide many suggestions for service improvements to bridge the gap between ‘real’ and ‘ideal’ care. Using service provider views to inform service design and delivery could enhance the quality, patient experience and outcomes of care.