Tom Hughes

Advanced Cardiac Resuscitation Evaluation (ACRE): A randomised single-blind controlled trial of peer-led vs. expert-led advanced resuscitation training

BackgroundAdvanced resuscitation skills training is an important and enjoyable part of medical training, but requires small group instruction to ensure active participation of all students. Increases in student numbers have made this increasingly difficult to achieve.MethodsA single-blind randomised controlled trial of peer-led vs. expert-led resuscitation training was performed using a group of sixth-year medical students as peer instructors. The expert instructors were a senior and a middle grade doctor, and a nurse who is an Advanced Life Support (ALS) Instructor.A power calculation showed that the trial would have a greater than 90% chance of rejecting the null hypothesis (that expert-led groups performed 20% better than peer-led groups) if that were the true situation. Secondary outcome measures were the proportion of High Pass grades in each groups and safety incidents.The peer instructors designed and delivered their own course material. To ensure safety, the peer-led groups used modified defibrillators that could deliver only low-energy shocks.Blinded assessment was conducted using an Objective Structured Clinical Examination (OSCE). The checklist items were based on International Liaison Committee on Resuscitation (ILCOR) guidelines using Ebel standard-setting methods that emphasised patient and staff safety and clinical effectiveness.The results were analysed using Exact methods, chi-squared and t-test.ResultsA total of 132 students were randomised: 58 into the expert-led group, 74 into the peer-led group. 57/58 (98%) of students from the expert-led group achieved a Pass compared to 72/74 (97%) from the peer-led group: Exact statistics confirmed that it was very unlikely (p = 0.0001) that the expert-led group was 20% better than the peer-led group.There were no safety incidents, and High Pass grades were achieved by 64 (49%) of students: 33/58 (57%) from the expert-led group, 31/74 (42%) from the peer-led group. Exact statistics showed that the difference of 15% meant that it was possible that the expert-led teaching was 20% better at generating students with High Passes.ConclusionsThe key elements of advanced cardiac resuscitation can be safely and effectively taught to medical students in small groups by peer-instructors who have undergone basic medical education training.

Improving management of neutropenic sepsis in the emergency department

Neutropenic sepsis (NS) is a common and serious complication of bone marrow dysfunction and cytotoxic chemotherapy. As with all cases of sepsis, rapid recognition and administration of effective antimicrobial therapy is essential to prevent avoidable deaths (Rivers et al, 2001; Mackenzie & Lever, 2007). Patients at risk of NS are instructed to seek urgent specialist advice if they feel unwell. Our hospitals’ policy states that these patients should be assessed by a haematologist on the haematology ward within an hour of admission. A shortage of haematology beds, however, results in a significant number of NS cases presenting to the emergency department (ED) for direct admission. Despite these patients being assessed by doctors covering haematology, significant delays in management have been noted. We studied the ED management of NS over 2 months, identifying delays in management and instigating changes to practice (Study 1). We then repeated the study and compared these results to patients managed on a specialist haematology ward (Study 2). Both studies identified 19 cases managed for neutropenic sepsis in the ED and Study 2 also identified 10 cases managed on the haematology ward. Times are expressed as median averages with interquartile ranges (Fig 1). The median time from admission to the administration of antibiotics in Study 1 was 4 h 14 min (3:29–5:26). The maximum time was 12 h and 39 min in a patient treated with vancomycin for presumed line sepsis. The upper quartile included one patient with diffuse large B-cell lymphoma with a neutrophil count of 0Æ69 · 10/l who waited 7 h and 10 min for meropenem. In this case statim gentamicin was administered in the ED; the first administered dose of meropenem was the subsequent regular dose. Median time to nurse triage was 16 min (8–20). Median delay from triage to documented medical assessment by a haematologist was 45 min (00:22–1:15). The most significant delay was 3 h (1:56–4:30) from medical assessment to administration of antibiotics. This delay had a bimodal distribution centred around 4 h. Two causal factors were identified. Firstly, meropenem was not routinely stocked in the ED due to cost and the perception that it would be needed infrequently. Secondly, although many patients received their antibiotics within the ED 4-h maximum wait, a significant proportion was deferred until they had left the ED. In many such cases antibiotics were not administered until the next prescribed regular dose, which was up to 10 h later in the case of meropenem. Results were presented at the ED and haematology clinical governance meetings to increase awareness of the problem. Agreement was reached with the pharmacy to stock meropenem in the ED. Nurses were encouraged to ensure treatment before patients were transferred out of the ED. Haematology

Management of lercanidipine overdose with hyperinsulinaemic euglycaemia therapy: case report

This case report describes the first reported overdose of the dihydropyridine calcium channel blocker (CCB) lercanidipine. A 49 yr old male presented to the Emergency Department 3 hrs after the ingestion of 560 mg of lercanidipine. In the department he had a witnessed seizure within 15 minutes of arrival attributed to the overdose. Following immediate recovery of consciousness after the seizure, he had refractory hypotension and bradycardia which failed to respond to fluid resuscitation, glucagon therapy, and intravenous calcium. He went on to require vasopressor support with noradrenaline and was treated with high dose insulin therapy which was successful in achieving cardiovascular stability. Vasopressor therapy was no longer required within one half life of lercanidipine, and the total stay on intensive care was one day before transfer to a ward.Calcium channel blocker overdose is an uncommon but life-threatening overdose. Treatment for severe toxicity is similar to b-blocker overdose. Hypotension is treated with intravenous fluid therapy, intravenous calcium and possibly glucagon with vasopressor or inotropic support as required. Atropine is used to attempt reversal of bradycardia. High doses of intravenous insulin with intravenous dextrose as required (hyperinsulinaemic euglycaemia or HIET), has also been successfully reported. Experimental animal data suggests that HIET is of benefit and potentially superior to fluid therapy, calcium, glucagon and potentially vasopressor therapy. HIET effectively and sustainably reverses hypotension, bradycardia and improves myocardial contractility and metabolism. Current advice in calcium channel blocker overdose is to begin therapy early in toxicity, starting with a 1.0 IU/kg insulin bolus followed by an infusion of 0.5 IU/kg/hr of insulin and dextrose as required titrated to clinical response.

Emergency department syndromic surveillance providing early warning of seasonal respiratory activity in England

Seasonal respiratory infections place an increased burden on health services annually. We used a sentinel emergency department syndromic surveillance system to understand the factors driving respiratory attendances at emergency departments (EDs) in England. Trends in different respiratory indicators were observed to peak at different points during winter, with further variation observed in the distribution of attendances by age. Multiple linear regression analysis revealed acute respiratory infection and bronchitis/bronchiolitis ED attendances in patients aged 1-4 years were particularly sensitive indicators for increasing respiratory syncytial virus activity. Using near real-time surveillance of respiratory ED attendances may provide early warning of increased winter pressures in EDs, particularly driven by seasonal pathogens. This surveillance may provide additional intelligence about different categories of attendance, highlighting pressures in particular age groups, thereby aiding planning and preparation to respond to acute changes in EDs, and thus the health service in general.

Syndromic Surveillance Revolution? Public Health Benefits of Modernizing the Emergency Care Patient Health Record in England:

Emergency medicine is a recognized specialty in the United Kingdom (UK), with formal training and accreditation conducted and governed by the Royal College of Emergency Medicine. Health care in the UK is publicly funded and provided by the National Health Service (NHS) through a residence-based (rather than insurance-based) system. Emergency care within emergency departments (EDs) is currently provided free at the point of delivery for everyone, including non-UK residents. Although emergency care in the UK is under the control of a single-payer provider (the NHS), there is currently no single, clinically driven, standardized data set for emergency care in the UK. Each ED manages the collection and storage of data related to its patients, as required for their care, through locally developed processes for electronic data collection, format, and storage. These processes may still include the use of paper records during treatment, to be transcribed to an electronic patient record at a later date. Numerous electronic clinical information systems are currently in use, with many differences in data formats by location, even those running the same software. In England, a subset of the data for each ED visit is collected nationally, to monitor activity and for payment purposes, in the Accident and Emergency Commissioning Data Set (hereinafter, CDS), currently type 010. Created in the 1980s and maintained by NHS Digital (as required by NHS and the UK Department of Health), the CDS is not collated centrally in real time. Each hospital submits data more or less monthly after a series of completion and validation processes. In certain circumstances, an anonymized extract of the CDS is made available through the NHS Secondary Uses Service for further reporting and analysis to support the delivery of NHS health care and for public health purposes. Emergency Department Syndromic Surveillance in England

The influence of a major sporting event upon emergency department attendances; A retrospective cross-national European study

Major sporting events may influence attendance levels at hospital emergency departments (ED). Previous research has focussed on the impact of single games, or wins/losses for specific teams/countries, limiting wider generalisations. Here we explore the impact of the Euro 2016 football championships on ED attendances across four participating nations (England, France, Northern Ireland, Wales), using a single methodology. Match days were found to have no significant impact upon daily ED attendances levels. Focussing upon hourly attendances, ED attendances across all countries in the four hour pre-match period were statistically significantly lower than would be expected (OR 0.97, 95% CI 0.94–0.99) and further reduced during matches (OR 0.94, 95% CI 0.91–0.97). In the 4 hour post-match period there was no significant increase in attendances (OR 1.01, 95% CI 0.99–1.04). However, these impacts were highly variable between individual matches: for example in the 4 hour period following the final, involving France, the number of ED attendances in France increased significantly (OR 1.27, 95% CI 1.13–1.42). Overall our results indicate relatively small impacts of major sporting events upon ED attendances. The heterogeneity observed makes it difficult for health providers to predict how major sporting events may affect ED attendances but supports the future development of compatible systems in different countries to support cross-border public health surveillance.

Retrospective observational study of emergency department syndromic surveillance data during air pollution episodes across London and Paris in 2014

Introduction Poor air quality (AQ) is a global public health issue and AQ events can span across countries. Using emergency department (ED) syndromic surveillance from England and France, we describe changes in human health indicators during periods of particularly poor AQ in London and Paris during 2014. Methods Using daily AQ data for 2014, we identified three periods of poor AQ affecting both London and Paris. Anonymised near real-time ED attendance syndromic surveillance data from EDs across England and France were used to monitor the health impact of poor AQ. Using the routine English syndromic surveillance detection methods, increases in selected ED syndromic indicators (asthma, difficulty breathing and myocardial ischaemia), in total and by age, were identified and compared with periods of poor AQ in each city. Retrospective Wilcoxon-Mann-Whitney tests were used to identify significant increases in ED attendance data on days with (and up to 3 days following) poor AQ. Results Almost 1.5 million ED attendances were recorded during the study period (27 February 2014 to 1 October 2014). Significant increases in ED attendances for asthma were identified around periods of poor AQ in both cities, especially in children (aged 0–14 years). Some variation was seen in Paris with a rapid increase during the first AQ period in asthma attendances among children (aged 0–14 years), whereas during the second period the increase was greater in adults. Discussion This work demonstrates the public health value of syndromic surveillance during air pollution incidents. There is potential for further cross-border harmonisation to provide Europe-wide early alerting to health impacts and improve future public health messaging to healthcare services to provide warning of increases in demand.

Clinical Informatics Competencies in the Emergency Medicine Specialist Training Standards of Five International Jurisdictions

The field of clinical informatics (CI), and specifically the electronic health record, has been identified as a key facilitator to achieve a sustainable evidence‐based health care system for the future. International graduate medical education (GME) programs have been challenged to ensure that their trainees are provided with appropriate skills to deliver effective and efficient health care in an evolving environment.

Retrospective Observational Study of Atypical Winter Respiratory Illness Season Using Real-Time Syndromic Surveillance, England, 2014–15

During winter 2014-15, England experienced severe strains on acute health services. We investigated whether syndromic surveillance could contribute to understanding of the unusually high level of healthcare needs. We compared trends for several respiratory syndromic indicators from that winter to historical baselines. Cumulative and mean incidence rates were compared by winter and age group. All-age influenza-like illness was at expected levels; however, severe asthma and pneumonia levels were above those expected. Across several respiratory indicators, cumulative incidence rates during 2014-15 were similar to those of previous years, but higher for older persons; we saw increased rates of acute respiratory disease, including influenza like illness, severe asthma, and pneumonia, in the 65-74- and >75-year age groups. Age group-specific statistical algorithms may provide insights into the burden on health services and improve early warning in future winters.