Patrick K. Plunkett

Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months.

MRC CRASH is a randomised controlled trial (ISRCTN74459797) of the effect of corticosteroids on death and disability after head injury. We randomly allocated 10,008 adults with head injury and a Glasgow Coma Scale score of 14 or less, within 8 h of injury, to a 48-h infusion of corticosteroid (methylprednisolone) or placebo. Data at 6 months were obtained for 9673 (96.7%) patients. The risk of death was higher in the corticosteroid group than in the placebo group (1248 [25.7%] vs 1075 [22.3%] deaths; relative risk 1.15, 95% CI 1.07-1.24; p=0.0001), as was the risk of death or severe disability (1828 [38.1%] vs 1728 [36.3%] dead or severely disabled; 1.05, 0.99-1.10; p=0.079). There was no evidence that the effect of corticosteroids differed by injury severity or time since injury. These results lend support to our earlier conclusion that corticosteroids should not be used routinely in the treatment of head injury.

Randomised controlled trial of general practitioner versus usual medical care in an urban accident and emergency department: process, outcome, and comparative cost

Abstract Objective: To see whether care provided by general practitioners to non-emergency patients in an accident and emergency department differs significantly from care by usual accident and emergency staff in terms of process, outcome, and comparative cost. Design: A randomised controlled trial. Setting: A busy inner city hospitals accident and emergency department which employed three local general practitioners on a sessional basis. Patients: All new attenders categorised by the triage system as “semiurgent” or “delay acceptable.” 66% of all attenders were eligible for inclusion. Main outcome measures: Numbers of patients undergoing investigation, referral, or prescription; types of disposal; consultation satisfaction scores; reattendance to accident and emergency department within 30 days of index visit; health status at one month; comparative cost differences. Results: 4684 patients participated. For semiurgent patients, by comparison with usual accident and emergency staff, general practitioners investigated fewer patients (relative difference 20%; 95% confidence interval 16% to 25%), referred to other hospital services less often (39%; 28% to 47%), admitted fewer patients (45%; 32% to 56%), and prescribed more often (41%; 30% to 54%). A similar trend was found for patients categorised as delay acceptable and (in a separate analysis) by presenting complaint category. 393 (17%) patients who had been seen by general practitioner staff reattended the department within 30 days of the index visit; 418 patients (18%) seen by accident and emergency staff similarly reattended. 435 patients (72% of those eligible) completed the consultation satisfaction questionnaire and 258 (59% of those eligible) provided health status information one month after consultation. There were no differences between patients managed by general practitioners and those managed by usual staff regarding consultation satisfaction questionnaire scores or health status. For all patients seen by general practitioners during the study, estimated marginal and total savings were £Ir1427 and £Ir117005 respectively. Conclusion: General practitioners working as an integral part of an accident and emergency department manage non-emergency accident and emergency attenders safely and use fewer resources than do usual accident and emergency staff. Key messages Key messages A study extending this innovation shows that the care provided to non-emergency patients by general practitioners working as an integral part of an accident and emergency department also differs substantially from the care provided by the usual staff in terms of process Compared with the usual accident and emer- gency department staff, general practitioners investigate fewer patients, refer to other hospital services less often, more often refer patients back to their own general practitioners for follow up, admit fewer patients, and prescribe more often General practitioners within an accident and emergency department have no apparent effect on reattendance rates to the department within 30 days, patient satisfaction, or health status one month after the initial attendance As yet there are no explanations for these differ- ences, which warrant further research

Increasing wait times predict increasing mortality for emergency medical admissions.

Background The actual impact of emergency department (ED) ‘wait’ time on hospital mortality in patients admitted as a medical emergency has often been debated. We have evaluated the impact of such waits on 30-day mortality, for all medical patients over a 7-year period. Methods All patients admitted as medical emergencies by the ED between 2002 and 2008 were studied; we looked at the impact of time to medical referral and subsequent time to a ward bed on any inhospital death within 30 days. Significant univariate predictors of outcome, including Charlsons comorbidity and acute illness severity score, were entered into a multivariate regression model, adjusting the univariate estimates of the readmission status on mortality. Results We studied 23 114 consecutive acute medical admissions between 2002 and 2008. The triage category in the ED was highly predictive of subsequent 30-day mortality ranging from 4.8 (category 5) to 46.1% (category 1). After adjustment for all outcome predictors, including comorbidity and illness severity, both door-to-team and team-to-ward times were independent predictors of death within 30 days with respective odds ratios of 1.13 (95% confidence interval 1.07–1.18), and 1.07 (95% confidence interval 1.02–1.13). Conclusion Delay to admission have been shown to be independently adversely related to mortality outcome. We recommend maximal target limits of 4 and 6 h for referrals and admissions, respectively, based on these mortality observations.

Management of syncope in the Emergency Department: a single hospital observational case series based on the application of European Society of Cardiology Guidelines

AIMS The aim of this study was to evaluate the effect of introducing a European Society of Cardiology guideline-based Integrated Care Plan (ICP) for Syncope on hospital admissions and referral patterns to an outpatient Syncope Management Unit, of patients presenting to an Emergency Department (ED) with a syncopal episode and to determine the underlying causes of syncope. METHODS AND RESULTS This study is a single-centre observational case series of consecutive adult patients presenting to the ED over a 5-month period. Two hundred and fourteen of 18 898 patients (1.1%) had a syncopal episode, 110 (51.4%) of whom were admitted. Forty-six (41.8%) admissions were indicated by the ICP. All potential cardiac syncope cases were admitted. There was a 500% increase in the overall number of referrals to the Syncope Management Unit with a small increase in the number of unnecessary referrals. CONCLUSION The introduction of an ICP for syncope was not associated with any cases with potential adverse outcomes being lost to follow-up and resulted in increased referral rates to the syncope unit. However, hospitalization rates for syncope remain high, and a large number of patients requiring early outpatient assessment were not referred. There remains a need to develop further interventions to guide appropriate and safe syncope management in the ED.

Effect of patients seeing a general practitioner in accident and emergency on their subsequent reattendance: cohort study.

General practitioners working in an accident and emergency department manage non-emergency patients safely and use fewer resources than do usual accident and emergency staff.1 2 In our previous study we speculated that this intervention might have the potential to break the cycle of “inappropriate attendance” at accident and emergency, use of hospital resources, and perceived confirmation of need for a visit.2 We now report the results of a review of the reattendance rates of our original study group. The setting and methodology of our original study have been described.2 In short, patients who had attended St Jamess Hospital accident and emergency department between 1 August 1993 and 1 October 1994 were triaged using a validated system into four categories—“life threatening” (1), “urgent” (2), “semi-urgent” (3), and “delay acceptable” (4). Local general practitioners were employed on a sessional basis to manage patients only from categories 3 and …

Evaluation of suspected renal colic with noncontrast CT in the emergency department: a single institution study.

BACKGROUND AND PURPOSE Noncontrast CT (NCCT) has become the standard Imaging study in the emergency department (ED) diagnosis of nephro- and ureterolithiasis. We undertook to audit the results from the first 500 NCCTs performed for patients presenting to the ED with suspected renal colic. PATIENTS AND METHODS In a retrospective study at one institution from October 2003 to February 2006, 500 patients with suspected stone disease were investigated. In the study, NCCT findings, patient clinical records, and urinary microscopy results were evaluated for 166 women and 334 men. RESULTS Renal or ureteral calculi were identified in 279 (56%) of NCCTs performed. Of the 500, 112 (19%) NCCTs performed identified unexpected intra-abdominal pathology. When the findings deemed to be of low clinical significance were excluded, the number of scans with additional pathology amounted to 67 (13%). These included vascular emergencies, new cancer diagnoses, and gastrointestinal conditions. CONCLUSIONS The variety of diagnoses found unexpectedly on the NCCT that alter a patients treatment demonstrates the pivotal role of NCCT in the triage of these patients rapidly toward optimal therapy. The rapid acquisition time of NCCT has enabled definitive ED patient diagnosis and less bed occupancy for clinically insignificant calculi.

Development of key performance indicators for emergency departments in Ireland using an electronic modified-Delphi consensus approach.

Objective The objective of this study was to develop a consensus among emergency medicine (EM) specialists working in Ireland for emergency department (ED) key performance indicators (KPIs). Methods The method employed was a three-round electronic modified-Delphi process. An online questionnaire with 54 potential KPIs was set up for round 1 of the Delphi process. The Delphi panel consisted of all registered EM specialists in Ireland. Each indicator on the questionnaire was rated using a five-point Likert-type rating scale. Agreement was defined as at least 70% of the responders rating an indicator as ‘agree’ or ‘strongly agree’ on the rating scale. Data were analysed using standard descriptive statistics. Data were also analysed as the mean of the Likert rating with 95% confidence intervals (95% CIs). Sensitivity of the ratings was examined for robustness by bootstrapping the original sample. Statistical analyses were carried out using SPSS version 16.0. Results The response rates in rounds 1, 2 and 3 were 86, 88 and 88%, respectively. Ninety-seven potential indicators reached agreement after the three rounds. In the context of the Donabedian structure–process–outcome framework of performance indicators, 41 (42%) of the agreed indicators were structure indicators, 52 (54%) were process indicators and four (4%) were outcome indicators. Overall, the top-three highest rated indicators were: presence of a dedicated ED clinical information system (4.7; 95% CI 4.6–4.9), ED compliance with minimum design standards (4.7; 95% CI 4.5–4.8) and time from ED arrival to first ECG in suspected cardiac chest pain (4.7; 95% CI 4.5–4.9). The top-three highest rated indicators specific to clinical care of children in EDs were: time to administration of antibiotics in children with suspected bacterial meningitis (4.6; 95% CI 4.5–4.8), separate area available within EDs (seeing both adults and children) to assess children (4.4; 95% CI 4.2–4.6) and time to administration of analgesia in children with forearm fractures (4.4; 95% CI 4.2–4.7). Conclusion Employing a Delphi consensus process, it was possible to reach a consensus among EM specialists in Ireland on a suite of 97 KPIs for EDs.

Impact of a GP cooperative on lower acuity emergency department attendances

Background In 1998 ‘Dubdoc’, Irelands first out-of-hours general practice emergency service, opened in an outpatient suite in St Jamess Hospital with a separate entrance 300 m from the emergency department (ED). Dubdoc was established with the aim of providing an easy access out-of-hours service for ambulatory patients of those doctors supplying the service. Aim To determine whether ED attendances for patients in the lower acuity triage categories 4 and 5 have changed since the establishment of ‘Dubdoc’. Methods A retrospective review of all attendances at the ‘Dubdoc’ service was compared with attendances at the ED for triage categories 4 and 5 of the same hospital over a 9-year period (1999–2007 inclusive) for equivalent times of day. Results ED attendances during ‘Dubdoc’ hours have decreased as a proportion of all attendances for triage categories 4 and 5. ED attendances for triage categories 4 and 5 fell substantially during the study period. Conclusions Although the presence of the ‘Dubdoc’ service has resulted in a decrease in ED attendances for triage categories 4 and 5, this is a minor proportion of the overall decrease in attendances in this group of patients.

Epidemiological findings and medical, legal, and public health challenges of an investigation of severe soft tissue infections and deaths among injecting drug users -- Ireland, 2000.

In May 2000, public health authorities in Dublin, Ireland, identified a cluster of unexplained severe illness among injecting drug users (IDUs). Similar clusters were also reported in Scotland and England. Concurrent investigations were undertaken to identify the aetiology and source of the illnesses. In Dublin, 22 IDUs were identified with injection-site inflammation resulting in hospitalization or death; eight (36%) died. Common clinical findings among patients with severe systemic symptoms included leukaemoid reaction and cardiogenic shock. Seventeen (77%) patients reported injecting heroin intramuscularly in the 2 weeks before illness. Of 11 patients with adequate specimens available for testing, two (18%) were positive by 16S rDNA PCR for Clostridium novyi. Clinical and laboratory findings suggested that histotoxic Clostridia caused a subset of infections in these related clusters. Empiric treatment for infections among IDUs was optimized for anaerobic organisms, and outreach led to increased enrolment in methadone treatment in Dublin. Many unique legal, medical, and public health challenges were encountered during the investigation of this outbreak.

Opt-Out Panel Testing for HIV, Hepatitis B and Hepatitis C in an Urban Emergency Department: A Pilot Study.

Objectives Studies suggest 2 per 1000 people in Dublin are living with HIV, the level above which universal screening is advised. We aimed to assess the feasibility and acceptability of a universal opt-out HIV, Hepatitis B and Hepatitis C testing programme for Emergency Department patients and to describe the incidence and prevalence of blood-borne viruses in this population. Methods An opt-out ED blood borne virus screening programme was piloted from March 2014 to January 2015. Patients undergoing blood sampling during routine clinical care were offered HIV 1&2 antibody/antigen assay, HBV surface antigen and HCV antibody tests. Linkage to care where necessary was co-ordinated by the study team. New diagnosis and prevalence rates were defined as the new cases per 1000 tested and number of positive tests per 1000 tested respectively. Results Over 45 weeks of testing, of 10,000 patient visits, 8,839 individual patient samples were available for analysis following removal of duplicates. A sustained target uptake of >50% was obtained after week 3. 97(1.09%), 44(0.49%) and 447(5.05%) HIV, Hepatitis B and Hepatitis C tests were positive respectively. Of these, 7(0.08%), 20(0.22%) and 58(0.66%) were new diagnoses of HIV, Hepatitis B and Hepatitis C respectively. The new diagnosis rate for HIV, Hepatitis B and Hepatitis C was 0.8, 2.26 and 6.5 per 1000 and study prevalence for HIV, Hepatitis B and Hepatitis C was 11.0, 5.0 and 50.5 per 1000 respectively. Conclusions Opt-out blood borne viral screening was feasible and acceptable in an inner-city ED. Blood borne viral infections were prevalent in this population and newly diagnosed cases were diagnosed and linked to care. These results suggest widespread blood borne viral testing in differing clinical locations with differing population demographic risks may be warranted.