Mike Clancy

Point of care testing: randomised controlled trial of clinical outcome

Abstract Objectives: To describe the proportion of patients attending an accident and emergency department for whom blood analysis at the point of care brought about a change in management; to measure the extent to which point of care testing resulted in differences in clinical outcome for these patients when compared with patients whose samples were tested by the hospital laboratory. Design: Open, single centre, randomised controlled trial. Blood samples were randomly allocated to point of care testing or testing by the hospitals central laboratory. Setting: The accident and emergency department of the Bristol Royal Infirmary, a large teaching hospital which cares for an inner city population. Subjects: Representative sample of patients who attended the department between April 1996 and April 1997 and who required blood tests. Data collection was structured in 8 hour blocks so that all hours of the day and all days of the week were equally represented. Main outcome measures: The proportion of patients for whom point of care testing brought about a change in treatment in which timing was considered to be critical to clinical outcome. Mortality, the length of stay in hospital, admission rate, the amount of time spent waiting for results of blood tests, the amount of time taken to decide on management plans, and the amount of time patients spent in the department were compared between patients whose samples were tested at the point of care and those whose samples were sent to the laboratory. Results: Samples were obtained from 1728 patients. Changes in management in which timing was considered to be critical occurred in 59 out of 859 (6.9%, 95% confidence interval 5.3% to 8.8%) patients in the point of care arm of the trial. Decisions were made 74 minutes earlier (68 min to 80 min, P<0.0001) when point of care testing was used for haematological tests as compared to central laboratory testing, 86 minutes earlier (80 min to 92 min, P<0.0001) for biochemical tests, and 21 minutes earlier (−3 min to 44 min, P=0.09) for analyses of arterial blood gases. There were no differences between the groups in the amount of time spent in the department, length of stay in hospital, admission rates, or mortality. Conclusion: Point of care testing reduced the time taken to make decisions on patient management that were dependent on the results of blood tests. It also brought about faster changes in treatment for which timing was considered to be critical in about 7% of patients. These changes did not affect clinical outcome or the amount of time patients spent in the department. Key messages Point of care testing reduced the amount of time doctors spent waiting for results of blood tests when compared to the time spent waiting for results from the hospital laboratory in an accident and emergency department The time taken to decide on a management plan was also reduced as a result of the shorter time spent waiting for results of point of care tests About 7% of patients who needed urgent blood testing had changes in treatment in which timing was considered to be critical when point of care testing was used Patients did not spend less time in the accident and emergency department even when test results were available more quickly and patient management decisions were made more quickly. This suggests that the availability of test results is not the factor which slows down the arrangement of further care Improvements in process, such as a reduction in the time doctors wait for test results and the ability to make clinical decisions more quickly, do not seem to improve clinical outcome in this sample of patients

Chest pain units

Patients presenting to hospital with chest pain represent a substantial burden to the NHS. About 500 000 patients attend emergency departments in the United Kingdom each year with chest pain, 1 2 and 20–30% of all medical admissions are for acute chest pain.3 Currently most clinicians working in emergency departments rely on the history, clinical examination, and electrocardiogram (ECG) to decide which patients have acute coronary syndromes and need admission and which to send home. Given the unreliability of these tools alone to either rule in or rule out the diagnosis of acute myocardial infarction4 and unstable angina, it is not surprising that 2–4% of patients with acute myocardial infarction have been sent home from American emergency departments with a high case fatality rate and medicolegal costs. 5 6 The position in the United Kingdom is uncertain, but a recent study identified that 6% of patients who were discharged from …

Epidemiology and predictors of cervical spine injury in adult major trauma patients: a multicenter cohort study

BACKGROUND: Patients with cervical spine injuries are a high-risk group, with the highest reported early mortality rate in spinal trauma. METHODS: This cohort study investigated predictors for cervical spine injury in adult (≥ 16 years) major trauma patients using prospectively collected data of the Trauma Audit and Research Network from 1988 to 2009. Univariate and multivariate logistic regression analyses were used to determine predictors for cervical fractures/dislocations or cord injury. RESULTS: A total of 250,584 patients were analyzed. Median age was 47.2 years (interquartile range, 29.8–66.0) and Injury Severity Score 9 (interquartile range, 4–11); 60.2% were male. Six thousand eight hundred two patients (2.3%) sustained cervical fractures/dislocations alone. Two thousand sixty-nine (0.8%) sustained cervical cord injury with/without fractures/dislocations; 39.9% of fracture/dislocation and 25.8% of cord injury patients suffered injuries to other body regions. Age ≥65 years (odds ratio [OR], 1.45–1.92), males (females OR, 0.91; 95% CI, 0.86–0.96), Glasgow Coma Scale (GCS) score <15 (OR, 1.26–1.30), LeFort facial fractures (OR, 1.29; 95% confidence interval [CI], 1.05–1.59), sports injuries (OR, 3.51; 95% CI, 2.87–4.31), road traffic collisions (OR, 3.24; 95% CI, 3.01–3.49), and falls >2 m (OR, 2.74; 95% CI, 2.53–2.97) were predictive for fractures/dislocations. Age <35 years (OR, 1.25–1.72), males (females OR, 0.59; 95% CI, 0.53–0.65), GCS score <15 (OR, 1.35–1.85), systolic blood pressure <110 mm Hg (OR, 1.16; 95% CI, 1.02–1.31), sports injuries (OR, 4.42; 95% CI, 3.28–5.95), road traffic collisions (OR, 2.58; 95% CI, 2.26–2.94), and falls >2 m (OR, 2.24; 95% CI, 1.94–2.58) were predictors for cord injury. CONCLUSIONS: 3.5% of patients suffered cervical spine injury. Patients with a lowered GCS or systolic blood pressure, severe facial fractures, dangerous injury mechanism, male gender, and/or age ≥35 years are at increased risk. Contrary to common belief, head injury was not predictive for cervical spine involvement. LEVEL OF EVIDENCE: II.

Whiplash associated disorder: incidence and natural history over the first month for patients presenting to a UK emergency department.

Objectives: To describe the epidemiology, process of care, and outcomes at 4–6 weeks after injury among patients with whiplash associated disorder attending a UK emergency department. Methods: All patients presenting during the study period with neck pain following a road traffic accident who met the inclusion criteria were assessed. Patients were followed up with a telephone interview at 4–6 weeks after attendance using the Neck Disability Index (NDI). The patient’s general practitioner (GP) was contacted post attendance to ascertain subsequent healthcare use. Results: A total of 200 patients were recruited to the study, of which 30 were lost to follow up. Four variables, midline tenderness (p = 0.008; 95% CI 0.9 to 6.1), x ray request (p = 0.004; 0.9 to 6.1), wearing a seat belt (p = 0.038; 0.2 to 6.2), and having seen their GP post injury (p = 0.001; CI −10.5 to 6.6), were found to be associated with a higher NDI score at follow up. Significant correlation was identified with a high pain score and an increasing age of patient and high NDI scores. No correlation was found between the impact speed, speed of vehicle struck, or time since incident with the NDI. Two thirds of patients had some disability at 4–6 weeks after injury; 91 patients (54.5%) saw their GP in the intervening period between attending the department and telephone follow up, and 87/170 patients had no idea about their prognosis. Conclusions: This study identifies that there is significant disability associated with whiplash associated disorder. Clear prognostic information would be a useful development.

Recording of vital signs in a district general hospital emergency department

Aim: To examine and explore factors that may influence the recording of vital signs in adult patients within the initial 15 min and again within 60 min of arrival in the “resuscitation” and “major” areas of the emergency department (ED). Methods: A retrospective analysis of recording of vital signs was performed on 400 consecutive sets of notes from adult patients presenting to the “major” or “resuscitation” areas of a district general hospital ED. The effect of staffing levels, triage category and attendances on the recording of vital signs was examined using logistic regression. The main outcome measures were the proportion of patients with all vital signs recorded within 15 min of arrival, the proportion of patients with all vital signs repeated within 60 min of arrival and the outcomes of logistic regression analysis. Results: Only 223/387 patients (58%) had all vital signs recorded within 15 min of arrival and only 29/387 (7%) had all vital signs repeated at 60 min. There was a significant relationship between the failure to record vital signs and lower triage categories. There was no evidence that staffing levels or number of attendances predicted the recording of vital signs within 15 min of arrival. Conclusion: Recording of vital signs was poor and unrelated to staffing levels or numbers of patients attending the ED. Failure to record patients’ vital signs undermines strategies to detect and manage ill patients.

The International Federation for Emergency Medicine framework for quality and safety in the emergency department

All emergency departments (EDs) have an obligation to deliver care that is demonstrably safe and of the highest possible quality. Emergency medicine is a unique and rapidly developing specialty, which forms the hub of the emergency care system and strives to provide a consistent and effective service 24 h a day, 7 days a week. The International Federation of Emergency Medicine, representing more than 70 countries, has prepared a document to define a framework for quality and safety in the ED. Following a consensus conference and with subsequent development, a series of quality indicators have been proposed. These are tabulated in the form of measures designed to answer nine quality questions presented according to the domains of structure, process and outcome. There is an urgent need to improve the evidence base to determine which quality indicators have the potential to successfully improve clinical outcomes, staff and patient experience in a cost-efficient manner—with lessons for implementation.

Determination of the size of the different sepsis categories presenting to a UK teaching hospital emergency department

Aim: To establish the size of the population of patients presenting to a UK emergency department (ED) with systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis and septic shock and to determine their mortality and length of stay. Setting: Southampton General Hospital Emergency Department, a teaching hospital treating 90 000 patients per annum. Method: A retrospective audit of all patients attending the ED for a 1-month period was undertaken in order to classify them into the different sepsis groups. Length of stay and mortality data were abstracted from the Patient Administration System, a computerised database. Results: 137 (SIRS), 123 (sepsis) and 50 (severe sepsis or septic shock) patients were classified from 5832 new patients attending. The median length of stay was 5, 3 and 7.5 days, respectively, and the mortality was 6.6%, 4.1% and 26%, respectively. The incidence of severe sepsis or septic shock was 30 per 1000 patients admitted. Conclusion: The high incidence of severe sepsis and septic shock with its attendant high mortality and length of stay is highlighted. If the figures are annualised, this would equate to 650 cases of severe sepsis or septic shock, of which 169 would die. The ED is well placed to improve this outcome by earlier detection and the use of goal directed therapy.

Point of Care Testing in the Accident and Emergency Department: A Cost Analysis and Exploration of Financial Incentives to use the Technology within the Hospital

Objectives: To compare the costs of current arrangements for testing emergency blood samples from patients attending an accident and emergency (A&E) department in a large teaching hospital in England with point of care testing (POCT). Methods: Estimates were made of the fixed and variable costs of two options: a supplemental option, in which POCT was introduced to A&E only; and a replacement option, in which POCT was introduced to A&E and the intensive therapy unit (ITU), thereby entirely replacing an existing process. Results: For the supplemental option, current arrangements cost £68 466 in total per year; average costs per test were £5.53 (venous in the central laboratory) and £3.60 (arterial on the ITU). Introducing POCT would increase total hospital costs by £35 929, and average costs per test would be £5.32 (venous) and £4.28 (arterial). For the replacement option, current arrangements cost £132 630 in total, and average cost per test (for all tests) was £4.06. Introducing POCT would make hospital savings ranging from £8332 to £20 000, and average cost per test would be £3.78. Conclusions: Introducing POCT results in lower average costs per test. The supplemental option will result in significantly increased costs to the hospital. The replacement option can lead to significant savings. The internal cross-charging arrangements between departments that exist in this hospital may mean that supplemental implementation of POCT could be potentially ‘profitable’ for the A&E department, but would result in higher expenditure for the hospital as a whole.

Digital anaesthesia: one injection or two?

Background Digital nerve blocks (DNB) are performed frequently in the Emergency Department (ED). The aim of this study was to establish whether single injection subcutaneous digital nerve block (SDNB) is as effective as the traditional (two injection) digital nerve block (TDNB) for digital anaesthesia. Method Single blinded, prospective, randomised-controlled multicentre trial within Hampshire EDs. Patients ≥16 years attending the ED with fingertip injuries/infections (distal to the distal-interphalangeal joint) requiring a DNB were randomised to SDNB/TDNB groups. Outcome measures were: primary - successful anaesthesia; secondary - patient distress, clinician satisfaction (CS), complications. Results 76 patients were randomised. (37 received SDNB). At 5 min, more patients in the SDNB group (28/37, 76%) were adequately anaesthetised than in the TDNB group, (22/34, 65%). At 10 min, 33/37 (89%) of the SDNB group compared to 28/34 (82%) of the TDNB group were adequately anaesthetised. The mean (SD) of self-reported distress scores for the SDNB group were lower than those reported for the TDNB group, whereas the mean (SD) of CS scores for SDNB were higher than those reported for TDNB. Neither group reported complications from anaesthesia. Conclusions SDNB is as effective as TDNB. Outcome measures favoured SDNB, but only CS scores achieved statistical significance. Trial recruitment is much slower than anticipated. However, clinical practice has demonstrated that SDNB works and practice is already changing within the Hampshire region, with some departments adopting SDNB as standard practice. Therefore, the results are being presented now to allow clinicians to make an informed choice. Our results may also contribute to future metanalyses.

Life, limb and sight-saving procedures—the challenge of competence in the face of rarity

Emergency physicians require competence in procedures which are required to preserve life, limb viability or sight, and whose urgency cannot await referral to another specialist. Some procedures that fit this description, such as tracheal intubation after neuromuscular blockade in a hypoxaemic patient with trismus, or placement of an intercostal catheter in a patient with a tension pneumothorax, are required sufficiently frequently in elective clinical practice, that competence can be acquired simply by training in emergency department, intensive care or operating room environments. Other procedures, such as resuscitative thoracotomy, may be required so infrequently that the first time a clinician encounters a patient requiring such an intervention may be after the completion of specialist training, or in the absence of colleagues with prior experience in the technique. Some techniques that might be considered limb or life saving may be too technically complex to acquire outside specialist surgical training programs. Examples are damage control laparotomy and limb fasciotomy. One could, however, argue that these are rarely too urgent to await arrival of the appropriate specialist. The procedures which might fit the description of a time-critical life, limb or sight-saving procedure in which it is technically feasible to acquire competence within or alongside an emergency medicine residency, and that cannot …