Ian Higginson

Early goal-directed therapy: a UK perspective

The surviving sepsis campaign developed guidelines in 2003 that were designed to increase physician awareness of sepsis and to develop a series of recommendations for the management of the patient with sepsis. The guidelines had the support of 11 international professional organisations across a variety of specialties, and advocate aggressive, early goal-oriented resuscitation in appropriate patients.

Demand and capacity planning in the emergency department: how to do it

Background Unless emergency departments have adequate capacity to meet demand, they will fail to meet clinical and performance standards and will be operating in the ‘coping zone’. This carries risks both for staff and patients. Methods As part of a quality improvement programme, the authors undertook an in-depth analysis of demand and capacity for an emergency department in the UK. The paper describes this rigorous approach to capacity planning, which draws on techniques from other industries. Discussion and conclusions Proper capacity planning is vital, but is often poorly done. Planning using aggregated data will lead to inadequate capacity. Understanding demand, and particularly the variation in that demand, is critical to success. Analysis of emergency department demand and capacity is the first step towards effective workforce planning and process redesign.

Tranexamic acid in major trauma: implementation and evaluation across South West England.

Objective To carry out a prospective evaluation of tranexamic acid (TXA) use in trauma patients. Patients and methods TXA was introduced to all emergency ambulances and emergency departments in the South West, UK, on 1 December 2011. We carried out a prospective evaluation of TXA use in trauma patients in the South West Peninsula between December 2011 and December 2012. We collected prehospital and hospital data on TXA administration using the Trauma Audit Research Network database. Data on prehospital administration of TXA were cross-checked with the South Western Ambulance Service Trust. Data were analysed using SPSS (version 20). Results Altogether, 82 patients were administered TXA during the study period. The median age of the patients was 49 years (IQR 30, 66), and 72% were men. One-third of the patients arrived at hospital by air ambulance. During the first 3 months, administration of TXA was limited to one patient each month receiving the drug. However, an upward trend was observed after June until October 2012, with the increment being more than 10 fold in July, September and October 2012. Conclusion This is the first study to evaluate the use of TXA in civilian practice in the UK. Our study shows that ambulance service personnel and emergency departments can effectively administer TXA.

‘Do you know where your cyanide kit is?’: a study of perceived and actual antidote availability to emergency departments in the South West of England

Objective The authors set out to investigate perceived and actual availability of antidotes recommended for stocking in emergency departments (EDs) by the College of Emergency Medicine in EDs in the South West of England. Methods Data collectors were asked to physically locate each relevant antidote in the ED, and check whether the recommended quantity was available. If the antidote was not available in the department, the data collector located where in the hospital stocks were available. Senior medical and nursing staff were asked to specify where they believed the antidotes were stored or who they would ask if they did not know. It was then ascertained whether their source of advice would have known the location. Results 5 out of 6 departments returned data with an overall response rate from senior medical and nursing staff of 80%. Knowledge of common antidote locations was variable, and stocking of antidotes did not universally meet the College of Emergency Medicine recommendations. Conclusion Stocking of important antidotes should be rationalised and simplified using central locations, preferably close to the ED. Clinically important antidotes may not be available for patients when they need them. Clear guidance should be available for staff detailing the location of antidotes. There is a need for clarification around the treatment of cyanide poisoning to facilitate rational antidote stocking for this potentially lethal condition.

The 4-hour standard is a meaningful quality indicator: correlation of performance with emergency department crowding.

Background The 4-h standard performance is a controversial quality indicator. Crowding in emergency departments (EDs) causes increased patient morbidity and mortality. The aim of this study was to investigate the relationship between 4-h standard performance and ED crowding as measured by occupancy. Methods A retrospective observational study was carried out using the computerized Emergency Department Information System. Daily occupancy was considered in three ways: as minutes per day spent at occupancy thresholds of 70, 80, 90 and 100%; as the peak occupancy of resuscitation and majors beds at any point in the day; and as a percentage of the total potential ED bed minutes used during the day. Results An inverse relationship was observed between occupancy and 4-h standard performance using each method. Performance could be sustained at 70% occupancy, but deteriorated in a linear manner at a progressively increasing rate at 80, 90 and 100% occupancy (all P<0.01). A stepwise decrease in the mean performance was observed with increasing peak occupancy (P<0.001). A similar decrease in performance was observed with increasing 24-h overall occupancy (P<0.001). Conclusion This study has identified a clear and consistent correlation between ED crowding and performance against the 4-h standard. Because crowding is associated with harm, the 4-h standard is a meaningful quality metric for UK hospitals. Systematic measurement of ED crowding using occupancy may play a role in improving the quality of care delivered within the urgent care system.

Why do parents use the emergency department for minor injury and illness? A cross-sectional questionnaire

Objective To understand decision-making when bringing a child to an emergency department. Design A cross-sectional survey of parents attending with children allocated a minor triage category. Setting Emergency department in South West England, serving 450,000 people per annum. Participants All English-speaking parents/caregivers whose children attended the emergency department and were triaged as minor injury/illness. Main outcome measures Parental and child characteristics, injury/illness characteristics, advice seeking behaviour, views regarding emergency department service improvement, GP access and determinants of emergency department use. Results In sum, 373 responses were analysed. The majority of attendances were for minor injury, although illness was more common in <4 year olds. Most presentations were within 4 h of injury/illness and parents typically sought advice before attending. Younger parents reported feeling more stressed. Parents of younger children perceived the injury/illness to be more serious, reporting greater levels of worry, stress, helplessness and upset and less confidence. Parents educated to a higher level were more likely to administer first-aid/medication. Around 40% did not seek advice prior to attending and typically these were parents aged <24 and parents of <1 year olds. The main determinants of use were: advised by someone other than a GP; perceived urgency; perceived appropriateness. The need for reassurance also featured. Conclusions The findings suggest that it is difficult for parents to determine whether their child’s symptoms reflect minor conditions. Efforts should focus on building parental confidence and self-help and be directed at parents of younger children and younger parents. This is in addition to appropriate minor injury/illness assessment and treatment services.

Factors affecting blood sample haemolysis: a cross-sectional study.

Objective To determine the effect of blood sampling through an intravenous catheter compared with a needle in Emergency Department blood sampling. Methods We undertook a prospective, cross-sectional study in a UK university teaching hospital Emergency Department. A convenience sample of 985 patients who required blood sampling via venepuncture was collected. A total of 844 complete sets of data were analysed. The median age was 63 years, and 57% of patients were male. The primary outcome measure was the incidence of haemolysis in blood samples obtained via a needle compared with samples obtained via an intravenous catheter. Secondary outcome measures defined the effect on sample haemolysis of the side of the patient the sample was obtained from, the anatomical location of sampling, the perceived difficulty in obtaining the sample, the order of sample tubes collected, estimated tourniquet time and bench time. Data were analysed with logistic regression, and expressed as odds ratios (95% confidence intervals; P-values). Results Blood samples obtained through an intravenous catheter were more likely to be haemolysed than those obtained via a needle, odds ratio 5.63 (95% confidence interval 2.49–12.73; P<0.001). Conclusion Blood sampling via an intravenous catheter was significantly associated with an increase in the likelihood of sample haemolysis compared with sampling with a needle. Wherever practicable, blood samples should be obtained via a needle in preference to an intravenous catheter. Future research should include both an economic evaluation, and staff and patient satisfaction of separating blood sampling and intravenous catheter placement.

Unconscious incompetence and the foundation years

One popular educational model suggests that trainees progress through the following sequence of competencies, and awareness of those competencies: 1. Unconscious incompetence 2. Conscious incompetence 3. Conscious competence 4. Unconscious competence In our experience this model does not fit with training in emergency medicine. An additional first step can be added to represent the new senior house …

VALIDATION OF THE SHORT FORM OF THE INTERNATIONAL CROWDING MEASURE IN EMERGENCY DEPARTMENTS (ICMED): INTERNATIONAL STUDY

Objectives & Background There is little consensus on the best way to measure emergency department crowding. We have previously developed a consensus based measure, the International Crowding Measure in Emergency Departments (ICMED). This measure has both flow and non-flow items, and also contains items which measure Input, Throughput and Output. We aimed to externally validate a short form of the ICMED against emergency physicians perceptions of crowding and danger across a wide variety of Emergency Departments. Face validity is important to support implementation of any measure Methods We performed an observational validation study in seven emergency departments in five different countries. We recorded sICMED observations and the most senior available emergency physicians perceptions of crowding and danger at the same time. We performed a times series regression model to account for clustering and correlation. Results 397 data points were analysed. The sICMED showed moderate positive correlations with emergency physicians perceptions of crowding r=0.4110, p<0.05) and danger (r=0.4566, p<0.05.) There was considerable variation in the performance of the sICMED between different emergency departments. The sICMED was only slightly better than measuring occupancy or emergency department boarding time. Conclusion The short form of the ICMED has moderate face validity in measuring crowding. This is an important first step in validating this measure. The measure performs less well in Emergency Departments that are constantly crowded. Figure 1

WHAT SHOULD BE DONE TO REDUCE EMERGENCY DEPARTMENT CROWDING? – A DELPHI STUDY

Objectives & Background Emergency department crowding is a serious public health problem throughout the developed world. In 2015 the UK Royal College of Emergency Medicine was charged by its executive with producing a toolkit to reduce crowding. This study was commissioned to inform said toolkit. The goal of the study was to develop a list of interventions to deal with crowding and exit block, based on consensus of a group of senior emergency physicians. Methods The Delphi technique was used to undertake a formal blinded consensus study. 33 experts were invited. These were committee members of the Royal College of Emergency Medicine who worked as emergency physicians in a diverse range of UK hospitals. Responses were collected using the web based survey tool SurveyMonkey over eight weeks in spring 2015. In round 1, experts suggested interventions to reduce crowding. In round 2, experts reviewed all proposals. Any proposal that was endorsed by at least 80% of experts (level chosen a priori) was included in the final recommendations. The authors then decided which professional role would be most able to deliver each intervention. Results Of 33 experts invited, 23 agreed to participate in round 1 and 18 in round 2. In round 1, respondents submitted 310 proposals which was reduced to 188 proposals when duplicates and irrelevant comments were removed. In round 1, 117 proposals reached the threshold of 80% agreement. These included 112 interventions recommended to reduce crowding (20 input, 40 throughput, 37 output and 15 multi-dimensional measures) as well as 5 interventions that should be avoided. Conclusion We have developed a list of 117 expert-endorsed recommendations to deal with emergency department crowding. We not only identified which interventions to implement but also which to avoid. For each intervention we decided who should deliver it. Our findings provide useful advice to clinicians, commissioners, managers and policy makers.