Derivation and validation of a risk adjustment model for predicting seven day mortality in emergency medical admissions: mixed prospective and retrospective cohort study

Objectives To derive and validate a risk adjustment model for predicting seven day mortality in emergency medical admissions, to test the value of including physiology and blood parameters, and to explore the constancy of the risk associated with each model variable across a range of settings

The Recognition of STEMI by Paramedics and the Effect of Computer inTerpretation (RESPECT): a randomised crossover feasibility study

Background : The appropriate management of patients with ST-segment elevation myocardial infarction (STEMI) depends on accurate interpretation of the 12-lead ECG by paramedics. Computer interpretation messages on ECGs are often provided, but the effect they exert on paramedics’ decision-making is not known. The objective of this study was to assess the feasibility of using an online assessment tool, and collect pilot data, for a definitive trial to determine the effect of computer interpretation messages on paramedics’ diagnosis of STEMI. Methods : The Recognition of STEMI by Paramedics and the Effect of Computer inTerpretation (RESPECT) feasibility study was a randomised crossover trial using a bespoke, web-based assessment tool. Participants were randomly allocated 12 of 48 ECGs, with an equal mix of correct and incorrect computer interpretation messages, and STEMI and STEMI-mimics. The nature of the responses required a cross-classified multi-level model. Results : 254 paramedics consented into the study, 205 completing the first phase and 150 completing phase two. The adjusted OR for a correct paramedic interpretation, when the computer interpretation was correct (true positive for STEMI or true negative for STEMI-mimic), was 1.80 (95% CI 0.84 to 4.91) and 0.58 (95% CI 0.41 to 0.81) when the computer interpretation was incorrect (false positive for STEMI or false negative for STEMI-mimic). The intraclass correlation coefficient for correct computer interpretations was 0.33 for participants and 0.17 for ECGs, and for incorrect computer interpretations, 0.06 for participants and 0.01 for ECGs. Conclusions : Determining the effect of computer interpretation messages using a web-based assessment tool is feasible, but the design needs to take clustered data into account. Pilot data suggest that computer messages influence paramedic interpretation, improving accuracy when correct and worsening accuracy when incorrect

Patient expectations of minor injury care: a cross-sectional survey

ABSTRACT Background and objective Little is known about the expectations of patients attending the emergency department (ED) with minor injuries. Failure to address expectations may lead to dissatisfaction and poor compliance. We aimed to describe patient expectations of minor injury care and explore the association between unmet expectations and patient satisfaction. Methods We undertook a cross-sectional questionnaire survey of 300 patients attending the ED with minor injuries on weekdays between 9:00 and 17:00. Participants completed a questionnaire asking which tests and treatments they expected, which they consequently received, whether explanations were given for tests and treatments, and how they rated satisfaction with care. Results The most frequently expected interventions were x-ray, analgesia and bandage/strapping. In each case the proportion expecting intervention was significantly higher than the proportion receiving intervention: x-ray (58% vs 47%, p<0.001); analgesia (40% vs 20%, p<0.001); bandage/strapping (39% vs 22%, p<0.001). There were no significant differences between the proportions expecting and receiving other interventions. At least one unmet expectation was reported by 208/300 patients (69%) but an explanation was received in 151/208 cases (73%). Conversely, 106 (35%) received an unexpected intervention, of whom 79/106 (74%) received an explanation. Patients with unmet expectations tended to rate the satisfaction lower, but the difference was not statistically significant ( p=0.187). Conclusions Patients often expect interventions for minor injuries that they do not receive, but in most cases an explanation was given. We were unable to demonstrate an association between unmet expectations and reduced satisfaction with care

Illuminating disease and enlightening biomedicine:Raman spectroscopy as a diagnostic tool

The discovery of the Raman effect in 1928 not only aided fundamental understanding about the quantum nature of light and matter but also opened up a completely novel area of optics and spectroscopic research that is accelerating at a greater rate during the last decade than at any time since its inception. This introductory overview focuses on some of the most recent developments within this exciting field and how this has enabled and enhanced disease diagnosis and biomedical applications. We highlight a small number of stimulating high-impact studies in imaging, endoscopy, stem cell research, and other recent developments such as spatially offset Raman scattering amongst others. We hope this stimulates further interest in this already exciting field, by 'illuminating' some of the current research being undertaken by the latest in a very long line of dedicated experimentalists interested in the properties and potential beneficial applications of light

The 3Mg trial: A randomised controlled trial of intravenous or nebulised magnesium sulphate versus placebo in adults with acute severe asthma

Background: Magnesium sulphate, administered by the intravenous (i.v.) or inhaled (nebulised) route, has been proposed as a treatment for adults with acute severe asthma. Existing trials show mixed results and uncertain evidence of benefit. Objectives: We aimed to determine whether i.v. or nebulised magnesium sulphate improves symptoms of breathlessness and reduces the need for hospital admission in adults with acute severe asthma. Design: Multicentre, double-blind, placebo-controlled, three-arm, randomised trial. Setting: The emergency departments of 34 acute hospitals in the UK. Participants: We recruited 1109 adults (age > 16 years) with acute severe asthma [peak expiratory flow rate (PEFR) 25 breaths per minute, heart rate > 110 beats per minute or inability to complete sentences in one breath]. Patients with life-threatening features or a contraindication to either nebulised or intravenous magnesium sulphate were excluded. Interventions: Participants were randomly allocated to i.v. magnesium sulphate (2 g over 20 minutes) or nebulised magnesium sulphate (3 × 500 mg over 1 hour) or standard therapy alone. Main outcome measures: The primary outcome was the proportion of patients admitted to hospital (either after emergency department treatment or at any time over the subsequent 7 days) and breathlessness measured on a 100-mm visual analogue scale (VAS) over 2 hours after initiation of treatment. Results: We randomised 406 patients to i.v. magnesium sulphate, 339 to nebulised magnesium sulphate and 364 to placebo. Hospital admission was recorded for 394, 332 and 358 patients, respectively, and VAS breathlessness for 357, 296 and 323 patients respectively. Mean age was 36.1 years and 763 out of 1084 (70%) patients were female. Intravenous magnesium sulphate was associated with an odds ratio (OR) of 0.73 [95% confidence interval (CI) 0.51 to 1.04; p = 0.083] for hospital admission, an improvement in VAS breathlessness that was 2.6mm (95% CI -1.6 to 6.8 mm; p = 0.231) greater than that associated with placebo and an improvement in PEFR that was 2.4 l/minute (95% CI -8.8 to 13.6 l/minute; p = 0.680) greater than that associated with placebo. Nebulised magnesium sulphate was associated with an OR of 0.96 (95% CI 0.65 to 1.40; p = 0.819) for hospital admission, an improvement in VAS breathlessness that was 2.6mm (95% CI -1.8mm to 7.0 mm; p = 0.253) less than that associated with placebo and an improvement in PEFR that was 2.6 l/minute (95% CI -9.2 to 14.5 l/minute; p = 0.644) less than that associated with placebo. There were no significant differences between i.v. or nebulised magnesium sulphate and placebo for any other outcomes. The number (%) of patients reporting any side effect was 61 (15.5%) in the i.v. group, 52 (15.7%) in the nebuliser group and 36 (10.1%) in the placebo group. The ORs for suffering any side effect were 1.68 (95% CI 1.07 to 2.63; p = 0.025) for i.v. compared with placebo and 1.67 (95% CI 1.05 to 2.66; p = 0.031) for nebuliser compared with placebo. Conclusions: We were unable to demonstrate a clinically worthwhile benefit from magnesium sulphate in acute severe asthma. There was some weak evidence of an effect of i.v. magnesium sulphate on hospital admission, but no evidence of an effect on VAS breathlessness or PEFR compared with placebo. We found no evidence that nebulised magnesium sulphate was more effective than placebo. Trial registration: Current Controlled Trials ISRCTN04417063. Source of funding: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 22. See the NIHR Journals Library programme website for further project information. © Queen's Printer and Controller of HMSO 2014

Developing and assessing the acceptability of an epilepsy first aid training intervention for patients who visit UK emergency departments: A multi-method study of patients and professionals

Epilepsy affects around 1% of the UK population; 40% of whom experience two or more seizures annually. However, most Emergency Department (ED) visits by people with epilepsy (PWE) are clinically unnecessary. Evidence highlights that with correct training, seizures can be safely managed by patients and their families within the community. Arguably therefore, PWE who frequently visit the ED might benefit from a self-management intervention that improves their own and their families' confidence and ability in managing seizures. Currently, no such intervention is available for PWE attending the ED. A collaborative approach (patients, carers, health professionals) was adopted to develop a patient-focused, self-management intervention. An existing group-based seizure management course, offered by the Epilepsy Society, was adapted. Collaborative feedback was sought via a base-line document review, one-to-one semi-structured interviews, and focus group discussions. The applied framework provided a systematic approach from development through to implementation. Participant feedback overall was extremely positive. People with epilepsy who visit the ED reported a positive view of epilepsy seizure first aid training and associated educational materials. Their feedback was then used to develop the optimized intervention presented here. Strengths and perceived barriers to successful implementation and participation, as well as the practical and psychosocial benefits, were identified. We describe the developed intervention together with the process followed. This description, while being project-specific, provides a useful template to assist in the development of interventions more generally. Ongoing evaluation will determine the effects of the training intervention on participants' behavior

Interhospital variation in the RATPAC trial (Randomised Assessment of Treatment using Panel Assay of Cardiac markers)

Background: The RATPAC trial showed that using a point-of-care panel of CK-MB(mass), myoglobin and troponin at baseline and 90 min increased the proportion of patients successfully discharged home, leading to reduced median length of initial hospital stay. However, it did not change mean hospital stay and may have increased mean costs per patient. The aim of this study was to explore variation in outcome and costs between participating hospitals. Methods: RATPAC was a pragmatic multicentre randomised controlled trial (N=2243) and economic analysis comparing diagnostic assessment using the panel to standard care for patients with acute chest pain due to suspected myocardial infarction at six hospitals. The difference in the proportion of patients successfully discharged (primary outcome) and mean costs per patient between the participating hospitals was compared. Results: Point-of-care assessment led to a higher proportion of successful discharges in four hospitals, a lower proportion in one and was equivocal in another. The OR (95% CI) for the primary outcome varied from 0.12 (0.01 to 1.03) to 11.07 (6.23 to 19.66) with significant heterogeneity between the centres (

Managing alcohol-related attendances in emergency care: can diversion to bespoke services lessen the burden?

Acute alcohol intoxication (AAI) has a long history of burdening emergency care services. Healthcare systems around the world have explored a variety of different services that divert AAI away from EDs to better manage their condition. Little formal evaluation has been undertaken, particularly in the UK where alcohol misuse is one of the highest in the world. In this article, we outline a brief history of diversionary services, introduce the concept of Alcohol Intoxication Management Services (AIMS) and describe examples of AIMS in the UK. We then describe Evaluating the Diversion of Alcohol-Related Attendances, a natural experiment including six cities with AIMS compared with six cities without, that involves an ethnographic study, records patient experiences in both AIMS and EDs, assesses impact on key performance indicators in healthcare and evaluates the cost-effectiveness of AIMS