The UK Out of Hospital Cardiac Arrest Outcome (OHCAO) project

Introduction: Reducing premature death is a key priority for the UK National Health Service (NHS). NHS Ambulance services treat approximately 30 000 casesof suspected cardiac arrest each year but survival rates vary. The British Heart Foundation and Resuscitation Council (UK) have funded a structured research programme—the Out of Hospital Cardiac Arrest Outcomes (OHCAO) programme. The aim of the project is to establish the epidemiology and outcome of OHCA, explore sources of variation in outcome and establish the feasibility of setting up a national OHCA registry. Methods and analysis: This is a prospective observational study set in UK NHS Ambulance Services. The target population will be adults and children sustaining an OHCA who are attended by an NHS ambulance emergency response and where resuscitation is attempted. The data collected will be characterised broadly as system characteristics, emergency medical services (EMS) dispatch characteristics, patient characteristics and EMS process variables. The main outcome variables of interest will be return of spontaneous circulation and medium—long-term survival (30 days to 10-year survival). Ethics and dissemination: Ethics committee permissions were gained and the study also has received approval from the Confidentiality Advisory Group Ethics and Confidentiality committee which provides authorisation to lawfully hold identifiable data on patients without their consent. To identify the key characteristics contributing to better outcomes in some ambulance services, reliable and reproducible systems need to be established for collecting data on OHCA in the UK. Reports generated from the registry will focus on data completeness, timeliness and quality. Subsequent reports will summarise demographic, patient, process and outcome variables with aim of improving patient care through focus quality improvement initiatives

Impact of prehospital care on outcomes in sepsis : a systematic review

Introduction: Sepsis is a common and potentially life-threatening response to an infection. International treatment guidelines for sepsis advocate that treatment be initiated at the earliest possible opportunity. It is not yet clear if very early intervention by ambulance clinicians prior to arrival at hospital leads to improved clinical outcomes among sepsis patients. Methoda: We systematically searched the electronic databases MEDLINE, EMBASE, CINAHL, the Cochrane Library and PubMed up to June 2015. In addition, subject experts were contacted. We adopted the GRADE (grading recommendations assessment, development and evaluation) methodology to conduct the review and follow PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations to report findings. Results: Nine studies met the eligibility criteria – one study was a randomized controlled trial while the remaining studies were observational in nature. There was considerable variation in the methodological approaches adopted and outcome measures reported across the studies. Because of these differences, the studies did not answer a unique research question and meta-analysis was not appropriate. A narrative approach to data synthesis was adopted. Conclusion: There is little robust evidence addressing the impact of prehospital interventions on outcomes in sepsis. That which is available is of low quality and indicates that prehospital interventions have limited impact on outcomes in sepsis beyond improving process outcomes and expediting the patient’s passage through the emergency care pathway. Evidence indicating that prehospital antibiotic therapy and fluid resuscitation improve patient outcomes is currently lacking. [West J Emerg Med. 2017;17(4)427-437.

Performance characteristics of five triage tools for major incidents involving traumatic injuries to children

Context Triage tools are an essential component of the emergency response to a major incident. Although fortunately rare, mass casualty incidents involving children are possible which mandate reliable triage tools to determine the priority of treatment. Objective To determine the performance characteristics of five major incident triage tools amongst paediatric casualties who have sustained traumatic injuries. Design, setting, participants Retrospective observational cohort study using data from 31,292 patients aged less than 16 years who sustained a traumatic injury. Data were obtained from the UK Trauma Audit and Research Network (TARN) database. Interventions Statistical evaluation of five triage tools (JumpSTART, START, CareFlight, Paediatric Triage Tape/Sieve and Triage Sort) to predict death or severe traumatic injury (injury severity score >15). Main outcome measures Performance characteristics of triage tools (sensitivity, specificity and level of agreement between triage tools) to identify patients at high risk of death or severe injury. Results Of the 31,292 cases, 1029 died (3.3%), 6842 (21.9%) had major trauma (defined by an injury severity score >15) and 14,711 (47%) were aged 8 years or younger. There was variation in the performance accuracy of the tools to predict major trauma or death (sensitivities ranging between 36.4 and 96.2%; specificities 66.0–89.8%). Performance characteristics varied with the age of the child. CareFlight had the best overall performance at predicting death, with the following sensitivity and specificity (95% CI) respectively: 95.3% (93.8–96.8) and 80.4% (80.0–80.9). JumpSTART was superior for the triaging of children under 8 years; sensitivity and specificity (95% CI) respectively: 86.3% (83.1–89.5) and 84.8% (84.2–85.5). The triage tools were generally better at identifying patients who would die than those with non-fatal severe injury. Conclusion This statistical evaluation has demonstrated variability in the accuracy of triage tools at predicting outcomes for children who sustain traumatic injuries. No single tool performed consistently well across all evaluated scenarios

Patient-centred outcomes for prehospital trauma trials: A systematic review and patient involvement exercise

Introduction Outcome measures are used in clinical trials to determine efficacy of interventions. We aimed to determine which outcome measures in prehospital major trauma trials have been reported in the literature, and which of these are most patient-centred. Methods A systematic review identified outcomes reported in prehospital clinical trials of major trauma patients. A search was undertaken using Medline, Embase, clinicaltrials.gov, Web of Science and Google Scholar. Data were summarised by dividing outcomes into common themes which were presented to a Patient and Public Involvement group consisting of trauma survivors and their relatives. This group ranked the categories of outcomes in order of most importance, and agreed consensus statements regarding these outcome measures. Results There were 27 eligible studies, including 9,537 patients. Outcome measures were divided into nine categories: quality of life; length of stay; mortality/survival; physiological parameters; fluid/blood product requirements; complications; health economics; safety and feasibility; and intervention success. Of these, mortality/survival was the most commonly reported category, but over multiple timescales. The Patient and Public Involvement group agreed that the most important category was quality of life, and that mortality/survival should only be reported if concurrently reported with longer term quality of life. Length of stay and health economics were not considered important. Conclusions Outcome measures in prehospital clinical trials in major trauma have been heterogeneous, inconsistent, and not necessarily patient-centred. Trauma survivors considered quality of life and mortality most important when combined. Consensus is required for consistent, patient-centred, outcome measures in order to investigate interventions of meaningful impact to patients

Data quality and 30-day survival for out-of-hospital cardiac arrest in the UK out-of-hospital cardiac arrest registry: A data linkage study

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted. Objectives The Out-of-Hospital Cardiac Arrest Outcomes (OHCAO) project aims to understand the epidemiology and outcomes of out-of-hospital cardiac arrest (OHCA) across the UK. This data linkage study is a subproject of OHCAO. The aim was to establish the feasibility of linking OHCAO data to National Health Service (NHS) patient demographic data and Office for National Statistics (ONS) date of death data held on the NHS Personal Demographics Service (PDS) database to improve OHCAO demographic data quality and enable analysis of 30-day survival from OHCA. Design and setting Data were collected from 1 January 2014 to 31 December 2014 as part of a prospective, observational study of OHCA attended by 10 English NHS Ambulance Services. 28 729 OHCA cases had resuscitation attempted by Emergency Medical Services and were included in the study. Data linkage was carried out using a data linkage service provided by NHS Digital, a national provider of health-related data. To assess data linkage feasibility a random sample of 3120 cases was selected. The sample was securely transferred to NHS Digital to be matched using OHCAO patient demographic data to return previously missing demographic data and provide ONS date of death data. Results A total of 2513 (80.5%) OHCAO cases were matched to patients in the NHS PDS database. Using the linkage process, missing demographic data were retrieved for 1636 (72.7%) out of 2249 OHCAO cases that had previously incomplete demographic data. Returned ONS date of death data allowed analysis of 30-day survival status. The results showed a 30-day survival rate of 9.3%, reducing unknown survival status from 46.1% to 8.5%. Conclusions In this sample, data linkage between the OHCAO registry and NHS PDS database was shown to be feasible, improving demographic data quality and allowing analysis of 30-day survival status

Establishing the values for patient engagement (PE) in health-related quality of life (HRQoL) research: an international, multiple-stakeholder perspective

PurposeActive patient engagement is increasingly viewed as essential to ensuring that patient-driven perspectives are considered throughout the research process. However, guidance for patient engagement (PE) in HRQoL research does not exist, the evidence-base for practice is limited, and we know relatively little about underpinning values that can impact on PE practice. This is the first study to explore the values that should underpin PE in contemporary HRQoL research to help inform future good practice guidance. MethodsA modified ‘World Café’ was hosted as a collaborative activity between patient partners, clinicians and researchers: self-nominated conference delegates participated in group discussions to explore values associated with the conduct and consequences of PE. Values were captured via post-it notes and by nominated note-takers. Data were thematically analysed: emergent themes were coded and agreement checked. Association between emergent themes, values and the Public Involvement Impact Assessment Framework were explored. ResultsEighty participants, including 12 patient partners, participated in the 90-min event. Three core values were defined: (1) building relationships; (2) improving research quality and impact; and (3) developing best practice. Participants valued the importance of building genuine, collaborative and deliberative relationships—underpinned by honesty, respect, co-learning and equity—and the impact of effective PE on research quality and relevance. Conclusions An explicit statement of values seeks to align all stakeholders on the purpose, practice and credibility of PE activities. An innovative, flexible and transparent research environment was valued as essential to developing a trustworthy evidence-base with which to underpin future guidance for good PE practice.Peer reviewe

Epidemiology and outcomes from out-of-hospital cardiac arrests in England

Introduction This study reports the epidemiology and outcomes from out-of-hospital cardiac arrest (OHCA) in England during 2014. Methods Prospective observational study from the national OHCA registry. The incidence, demographic and outcomes of patients who were treated for an OHCA between 1st January 2014 and 31st December 2014 in 10 English ambulance service (EMS) regions, serving a population of almost 54 million, are reported in accordance with Utstein recommendations. Results 28,729 OHCA cases of EMS treated cardiac arrests were reported (53 per 100,000 of resident population). The mean age was 68.6 (SD = 19.6) years and 41.3% were female. Most (83%) occurred in a place of residence, 52.7% were witnessed by either the EMS or a bystander. In non-EMS witnessed cases, 55.2% received bystander CPR whilst public access defibrillation was used rarely (2.3%). Cardiac aetiology was the leading cause of cardiac arrest (60.9%). The initial rhythm was asystole in 42.4% of all cases and was shockable (VF or pVT) in 20.6%. Return of spontaneous circulation at hospital transfer was evident in 25.8% (n = 6302) and survival to hospital discharge was 7.9%. Conclusion Cardiac arrest is an important cause of death in England. With less than one in ten patients surviving, there is scope to improve outcomes. Survival rates were highest amongst those who received bystander CPR and public access defibrillation

Post-admission outcomes of participants in the PARAMEDIC trial : a cluster randomised trial of mechanical or manual chest compressions

Background: The PARAMEDIC cluster randomised trial evaluated the LUCAS mechanical chest compression device, and did not find evidence that use of mechanical chest compression led to an improvement in survival at 30 days. This paper reports patient outcomes from admission to hospital to 12 months after randomisation. Methods: Information about hospital length of stay and intensive care management was obtained through linkage with Hospital Episode Statistics and the Intensive Care National Audit and Research Centre. Patients surviving to hospital discharge were approached to complete questionnaires (SF-12v2, EQ-5D, MMSE, HADS and PTSD-CL) at 90 days and 12 months. The study is registered with Current Controlled Trials, number ISRCTN08233942. Results: 377 patients in the LUCAS arm and 658 patients in the manual chest compression were admitted to hospital. Hospital and intensive care length of stay were similar. Long term follow-up assessments were limited by poor response rates (53.7% at 3 months and 55.6% at 12 months). Follow-up rates were lower in those with worse neurological function. Among respondents, long term health related quality of life outcomes and emotional well-being was similar between groups. Cognitive function, measured by MMSE, was marginally lower in the LUCAS arm mean 26.9 (SD 3.7) compared to control mean 28.0 (SD 2.3), adjusted mean difference −1.5 (95% CI −2.6 to −0.4). Conclusion: There were no clinically important differences identified in outcomes at long term follow-up between those allocated to the mechanical chest compression compared to those receiving manual chest compression

When is low-risk chest pain acceptable risk chest pain?

Undifferentiated chest pain is a presenting complaint facing the emergency medicine clinician with ever increasing frequency.1 Increasing public awareness regarding ischaemic heart disease has helped contribute towards understandable increasing concern. The net result is that patients hold a lower threshold to present to the emergency department (ED) for assessment. With these patients holding a lower pretest probability for acute coronary syndrome, the art of emergency medicine is being able to risk-stratify patients into those requiring admission for further assessment for a possible acute coronary syndrome and discharging home those patients whose likelihood of the disease is under the test threshold. Setting your threshold too high for investigation leads to unacceptable low pick up of cases and a missed opportunity to treat a disease with a significant morbidity and mortality; set your threshold too low for investigation and not only do you exposure patients to the elevated risk of false positives and unnecessary and potentially harmful treatment but you also increase the burden of over investigation upon an acute healthcare system already bursting at the seams