Cervical spine immobilisation following blunt trauma in pre-hospital and emergency care: A systematic review

OBJECTIVES

To assess whether different cervical spine immobilisation strategies (full immobilisation, movement minimisation or no immobilisation), impact neurological and/or other outcomes for patients with suspected cervical spinal injury in the pre-hospital and emergency department setting.

DESIGN

Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Cochrane Library and two research registers were searched until September 2023.

ELIGIBILITY CRITERIA

All comparative studies (prospective or retrospective) that examined the potential benefits and/or harms of immobilisation practices during pre-hospital and emergency care of patients with a potential cervical spine injury (pre-imaging) following blunt trauma.

DATA EXTRACTION AND SYNTHESIS

Two authors independently selected and extracted data. Risk of bias was appraised using the Cochrane ROBINS-I tool for non-randomised studies. Data were synthesised without meta-analysis.

RESULTS

Six observational studies met the inclusion criteria. The methodological quality was variable, with most studies having serious or critical risk of bias. The effect of cervical spine immobilisation practices such as full immobilisation or movement minimisation during pre-hospital and emergency care did not show clear evidence of benefit for the prevention of neurological deterioration, spinal injuries and death compared with no immobilisation. However, increased pain, discomfort and anatomical complications were associated with collar application during immobilisation.

CONCLUSIONS

Despite the limited evidence, weak designs and limited generalisability, the available data suggest that pre-hospital cervical spine immobilisation (full immobilisation or movement minimisation) was of uncertain value due to the lack of demonstrable benefit and may lead to potential complications and adverse outcomes. High-quality randomised comparative studies are required to address this important question.

TRIAL REGISTRATION

PROSPERO REGISTRATION Fiona Lecky, Abdullah Pandor, Munira Essat, Anthea Sutton, Carl Marincowitz, Gordon Fuller, Stuart Reid, Jason Smith. A systematic review of cervical spine immobilisation following blunt trauma in pre-hospital and emergency care. PROSPERO 2022 CRD42022349600 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022349600.

Prehospital early warning scores for adults with suspected sepsis: the PHEWS observational cohort and decision-analytic modelling study

Background

Guidelines for sepsis recommend treating those at highest risk within 1 hour. The emergency care system can only achieve this if sepsis is recognised and prioritised. Ambulance services can use prehospital early warning scores alongside paramedic diagnostic impression to prioritise patients for treatment or early assessment in the emergency department.

Objectives

To determine the accuracy, impact and cost-effectiveness of using early warning scores alongside paramedic diagnostic impression to identify sepsis requiring urgent treatment.

Design

Retrospective diagnostic cohort study and decision-analytic modelling of operational consequences and cost-effectiveness.

Setting

Two ambulance services and four acute hospitals in England.

Participants

Adults transported to hospital by emergency ambulance, excluding episodes with injury, mental health problems, cardiac arrest, direct transfer to specialist services, or no vital signs recorded.

Interventions

Twenty-one early warning scores used alongside paramedic diagnostic impression, categorised as sepsis, infection, non-specific presentation, or other specific presentation.

Main outcome measures

Proportion of cases prioritised at the four hospitals; diagnostic accuracy for the sepsis-3 definition of sepsis and receiving urgent treatment (primary reference standard); daily number of cases with and without sepsis prioritised at a large and a small hospital; the minimum treatment effect associated with prioritisation at which each strategy would be cost-effective, compared to no prioritisation, assuming willingness to pay £20,000 per quality-adjusted life-year gained.

Results

Data from 95,022 episodes involving 71,204 patients across four hospitals showed that most early warning scores operating at their pre-specified thresholds would prioritise more than 10% of cases when applied to non-specific attendances or all attendances. Data from 12,870 episodes at one hospital identified 348 (2.7%) with the primary reference standard. The National Early Warning Score, version 2 (NEWS2), had the highest area under the receiver operating characteristic curve when applied only to patients with a paramedic diagnostic impression of sepsis or infection (0.756, 95% confidence interval 0.729 to 0.783) or sepsis alone (0.655, 95% confidence interval 0.63 to 0.68). None of the strategies provided high sensitivity (> 0.8) with acceptable positive predictive value (> 0.15). NEWS2 provided combinations of sensitivity and specificity that were similar or superior to all other early warning scores. Applying NEWS2 to paramedic diagnostic impression of sepsis or infection with thresholds of > 4, > 6 and > 8 respectively provided sensitivities and positive predictive values (95% confidence interval) of 0.522 (0.469 to 0.574) and 0.216 (0.189 to 0.245), 0.447 (0.395 to 0.499) and 0.274 (0.239 to 0.313), and 0.314 (0.268 to 0.365) and 0.333 (confidence interval 0.284 to 0.386). The mortality relative risk reduction from prioritisation at which each strategy would be cost-effective exceeded 0.975 for all strategies analysed.

Limitations

We estimated accuracy using a sample of older patients at one hospital. Reliable evidence was not available to estimate the effectiveness of prioritisation in the decision-analytic modelling.

Conclusions

No strategy is ideal but using NEWS2, in patients with a paramedic diagnostic impression of infection or sepsis could identify one-third to half of sepsis cases without prioritising unmanageable numbers. No other score provided clearly superior accuracy to NEWS2. Research is needed to develop better definition, diagnosis and treatments for sepsis.

Study registration

This study is registered as Research Registry (reference: researchregistry5268).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/136/10) and is published in full in Health Technology Assessment; Vol. 28, No. 16. See the NIHR Funding and Awards website for further award information.

Prognostic accuracy of eight triage scores in suspected COVID-19 in an Emergency Department low-income setting: An observational cohort study

Introduction

Previous studies deriving and validating triage scores for patients with suspected COVID-19 in Emergency Department settings have been conducted in high- or middle-income settings. We assessed eight triage scores' accuracy for death or organ support in patients with suspected COVID-19 in Sudan.

Methods

We conducted an observational cohort study using Covid-19 registry data from eight emergency unit isolation centres in Khartoum State, Sudan. We assessed performance of eight triage scores including: PRIEST, LMIC-PRIEST, NEWS2, TEWS, the WHO algorithm, CRB-65, Quick COVID-19 Severity Index and PMEWS in suspected COVID-19. A composite primary outcome included death, ventilation or ICU admission.

Results

In total 874 (33.84 %, 95 % CI:32.04 % to 35.69 %) of 2,583 patients died, required intubation/non-invasive ventilation or HDU/ICU admission . All risk-stratification scores assessed had worse estimated discrimination in this setting, compared to studies conducted in higher-income settings: C-statistic range for primary outcome: 0.56-0.64. At previously recommended thresholds NEWS2, PRIEST and LMIC-PRIEST had high estimated sensitivities (≥0.95) for the primary outcome. However, the high baseline risk meant that low-risk patients identified at these thresholds still had a between 8 % and 17 % risk of death, ventilation or ICU admission.

Conclusion

None of the triage scores assessed demonstrated sufficient accuracy to be used clinically. This is likely due to differences in the health care system and population (23 % of patients died) compared to higher-income settings in which the scores were developed. Risk-stratification scores developed in this setting are needed to provide the necessary accuracy to aid triage of patients with suspected COVID-19.

Randomised controlled trial of analgesia for the management of acute severe pain from traumatic injury: study protocol for the paramedic analgesia comparing ketamine and morphine in trauma (PACKMaN)

BACKGROUND

Prehospital analgesia is often required after traumatic injury, currently morphine is the strongest parenteral analgesia routinely available for use by paramedics in the United Kingdom (UK) when treating patients with severe pain. This protocol describes a multi-centre, randomised, double blinded trial comparing the clinical and cost-effectiveness of ketamine and morphine for severe pain following acute traumatic injury.

METHODS

A two arm pragmatic, phase III trial working with two large NHS ambulance services, with an internal pilot. Participants will be randomised in equal numbers to either (1) morphine or (2) ketamine by IV/IO injection. We aim to recruit 446 participants over the age of 16 years old, with a self-reported pain score of 7 or above out of 10. Randomised participants will receive a maximum of 20 mg of morphine, or a maximum of 30 mg of ketamine, to manage their pain. The primary outcome will be the sum of pain intensity difference. Secondary outcomes measure the effectiveness of pain relief and overall patient experience from randomisation to arrival at hospital as well as monitoring the adverse events, resource use and cost-effectiveness outcomes.

DISCUSSION

The PACKMAN study is the first UK clinical trial addressing the clinical and cost-effectiveness of ketamine and morphine in treating acute severe pain from traumatic injury treated by NHS paramedics. The findings will inform future clinical practice and provide insights into the effectiveness of ketamine as a prehospital analgesia.

TRIAL REGISTRATION

ISRCTN, ISRCTN14124474. Registered 22 October 2020, https://www.isrctn.com/ISRCTN14124474.

Prehospital early warning scores for adults with suspected sepsis: retrospective diagnostic cohort study

BACKGROUND

Ambulance services need to identify and prioritise patients with sepsis for early hospital assessment. We aimed to determine the accuracy of early warning scores alongside paramedic diagnostic impression to identify sepsis that required urgent treatment.

METHODS

We undertook a retrospective diagnostic cohort study involving adult emergency medical cases transported to Sheffield Teaching Hospitals ED by Yorkshire Ambulance Service in 2019. We used routine ambulance service data to calculate 21 early warning scores and categorise paramedic diagnostic impressions as sepsis, infection, non-specific presentation or other presentation. We linked cases to hospital records and identified those meeting the sepsis-3 definition who received urgent hospital treatment for sepsis (reference standard). Analysis determined the accuracy of strategies that combined early warning scores at varying thresholds for positivity with paramedic diagnostic impression.

RESULTS

We linked 12 870/24 955 (51.6%) cases and identified 348/12 870 (2.7%) with a positive reference standard. None of the strategies provided sensitivity greater than 0.80 with positive predictive value greater than 0.15. The area under the receiver operating characteristic curve for the National Early Warning Score, version 2 (NEWS2) applied to patients with a diagnostic impression of sepsis or infection was 0.756 (95% CI 0.729, 0.783). No other early warning score provided clearly superior accuracy to NEWS2. Paramedic impression of sepsis or infection had sensitivity of 0.572 (0.519, 0.623) and positive predictive value of 0.156 (0.137, 0.176). NEWS2 thresholds of >4, >6 and >8 applied to patients with a diagnostic impression of sepsis or infection, respectively, provided sensitivities and positive predictive values of 0.522 (0.469, 0.574) and 0.216 (0.189, 0.245), 0.447 (0.395, 0.499) and 0.274 (0.239, 0.313), and 0.314 (0.268, 0.365) and 0.333 (0.284, 0.386).

CONCLUSION

No strategy is ideal but using NEWS2 alongside paramedic diagnostic impression of infection or sepsis could identify one-third to half of sepsis cases without prioritising unmanageable numbers. No other score provided clearly superior accuracy to NEWS2.

TRIAL REGISTRATION NUMBER

researchregistry5268, https://www.researchregistry.com/browse-the-registry%23home/registrationdetails/5de7bbd97ca5b50015041c33/.

Heading Frequency and Risk of Cognitive Impairment in Retired Male Professional Soccer Players

Importance

Although professional soccer players appear to be at higher risk of neurodegenerative disease, the reason remains unknown.

Objective

To examine whether heading frequency is associated with risk of cognitive impairment in retired professional soccer players.

Design, Setting, and Participants

A UK nationwide cross-sectional study was conducted between August 15, 2020, and December 31, 2021, in 459 retired male professional soccer players older than 45 years and registered with the Professional Footballers' Association or a League Club Players' Association.

Exposure

Data on heading frequency in 3 bands-0 to 5, 6 to 15, and more than 15 times per match or training session and other soccer-specific risk factors, such as player position and concussion-were collected through a self-reported questionnaire.

Main Outcomes and Measures

Cognitive impairment was defined using the Telephone Interview for Cognitive Status-modified as scores of less than or equal to 21. Hopkins Verbal Learning Test, verbal fluency, and independent activities of daily living were also assessed. Test Your Memory and physician-diagnosed dementia/Alzheimer disease were self-reported via the questionnaire. Adjusted odds ratios (AORs) with 95% CIs were calculated.

Results

Of 468 retired male professional soccer players who completed questionnaires (mean [SD] age, 63.68 [10.48]; body mass index, 27.22 [2.89]), 459 reported heading frequency: 114 headed 0 to 5 times, 185 headed 6 to 15 times, 160 headed more than 15 times per match, and 125 headed 0 to 5 times, 174 headed 6 to 15 times, and 160 headed more than 15 times per training session during their careers. The prevalence of cognitive impairment was 9.78% (0-5 times), 14.78% (6-15 times), and 15.20% (>15 times) per match (P = .51). Compared with players reporting 0 to 5 headers per match, the AORs were 2.71 (95% CI, 0.89-8.25) for players reporting 6 to 15 headers per match and 3.53 (95% CI, 1.13-11.04) for players reporting more than 15 headers per match (P = .03 for trend). Corresponding AORs for heading frequency per training session were 2.38 (95% CI, 0.82-6.95) for those reporting 6 to 15, and 3.40 (95% CI, 1.13-10.23) for those reporting more than 15 in comparison with those who reported 0 to 5 (P = .03 for trend). Concussion involving memory loss was also associated with a greater risk of cognitive impairment (AOR, 3.16; 95% CI, 1.08-9.22). Similar results were observed with other cognitive tests and self-reported physician-diagnosed dementia/Alzheimer disease.

Conclusions and Relevance

The findings of this study suggest that repetitive heading during a professional soccer career is associated with an increased risk of cognitive impairment in later life. Further study is needed to establish the upper threshold for heading frequency to mitigate this risk.

External validation of triage tools for adults with suspected COVID-19 in a middle-income setting: an observational cohort study

BACKGROUND

Tools proposed to triage ED acuity in suspected COVID-19 were derived and validated in higher income settings during early waves of the pandemic. We estimated the accuracy of seven risk-stratification tools recommended to predict severe illness in the Western Cape, South Africa.

METHODS

An observational cohort study using routinely collected data from EDs across the Western Cape, from 27 August 2020 to 11 March 2022, was conducted to assess the performance of the PRIEST (Pandemic Respiratory Infection Emergency System Triage) tool, NEWS2 (National Early Warning Score, version 2), TEWS (Triage Early Warning Score), the WHO algorithm, CRB-65, Quick COVID-19 Severity Index and PMEWS (Pandemic Medical Early Warning Score) in suspected COVID-19. The primary outcome was intubation or non-invasive ventilation, death or intensive care unit admission at 30 days.

RESULTS

Of the 446 084 patients, 15 397 (3.45%, 95% CI 34% to 35.1%) experienced the primary outcome. Clinical decision-making for inpatient admission achieved a sensitivity of 0.77 (95% CI 0.76 to 0.78), specificity of 0.88 (95% CI 0.87 to 0.88) and the negative predictive value (NPV) of 0.99 (95% CI 0.99 to 0.99). NEWS2, PMEWS and PRIEST scores achieved good estimated discrimination (C-statistic 0.79 to 0.82) and identified patients at risk of adverse outcomes at recommended cut-offs with moderate sensitivity (>0.8) and specificity ranging from 0.41 to 0.64. Use of the tools at recommended thresholds would have more than doubled admissions, with only a 0.01% reduction in false negative triage.

CONCLUSION

No risk score outperformed existing clinical decision-making in determining the need for inpatient admission based on prediction of the primary outcome in this setting. Use of the PRIEST score at a threshold of one point higher than the previously recommended best approximated existing clinical accuracy.

LMIC-PRIEST: Derivation and validation of a clinical severity score for acutely ill adults with suspected COVID-19 in a middle-income setting

BACKGROUND

Uneven vaccination and less resilient health care systems mean hospitals in LMICs are at risk of being overwhelmed during periods of increased COVID-19 infection. Risk-scores proposed for rapid triage of need for admission from the emergency department (ED) have been developed in higher-income settings during initial waves of the pandemic.

METHODS

Routinely collected data for public hospitals in the Western Cape, South Africa from the 27th August 2020 to 11th March 2022 were used to derive a cohort of 446,084 ED patients with suspected COVID-19. The primary outcome was death or ICU admission at 30 days. The cohort was divided into derivation and Omicron variant validation sets. We developed the LMIC-PRIEST score based on the coefficients from multivariable analysis in the derivation cohort and existing triage practices. We externally validated accuracy in the Omicron period and a UK cohort.

RESULTS

We analysed 305,564 derivation, 140,520 Omicron and 12,610 UK validation cases. Over 100 events per predictor parameter were modelled. Multivariable analyses identified eight predictor variables retained across models. We used these findings and clinical judgement to develop a score based on South African Triage Early Warning Scores and also included age, sex, oxygen saturation, inspired oxygen, diabetes and heart disease. The LMIC-PRIEST score achieved C-statistics: 0.82 (95% CI: 0.82 to 0.83) development cohort; 0.79 (95% CI: 0.78 to 0.80) Omicron cohort; and 0.79 (95% CI: 0.79 to 0.80) UK cohort. Differences in prevalence of outcomes led to imperfect calibration in external validation. However, use of the score at thresholds of three or less would allow identification of very low-risk patients (NPV ≥0.99) who could be rapidly discharged using information collected at initial assessment.

CONCLUSION

The LMIC-PRIEST score shows good discrimination and high sensitivity at lower thresholds and can be used to rapidly identify low-risk patients in LMIC ED settings.

Cognitive Impairment and Self-Reported Dementia in UK Retired Professional Soccer Players: A Cross Sectional Comparative Study

BACKGROUND

Previous studies based on death certificates have found professional soccer players were more likely to die with neurodegenerative diseases, including dementia. Therefore, this study aimed to investigate whether retired professional male soccer players would perform worse on cognitive tests and be more likely to self-report dementia diagnosis than general population control men.

METHODS

A cross-sectional comparative study was conducted between August 2020 and October 2021 in the United Kingdom (UK). Professional soccer players were recruited through different soccer clubs in England, and general population control men were recruited from the East Midlands in the UK. We obtained self-reported postal questionnaire data on dementia and other neurodegenerative diseases, comorbidities and risk factors from 468 soccer players and 619 general population controls. Of these, 326 soccer players and 395 general population controls underwent telephone assessment for cognitive function.

RESULTS

Retired soccer players were approximately twice as likely to score below established dementia screening cut-off scores on the Hopkins Verbal Learning Test (OR 2.06, 95%CI 1.11-3.83) and Verbal Fluency (OR 1.78, 95% CI 1.18-2.68), but not the Test Your Memory, modified Telephone Interview for Cognitive Status, and Instrumental Activities of Daily Living. Analyses were adjusted for age, education, hearing loss, body mass index, stroke, circulatory problems in the legs and concussion. While retired soccer players were younger, had fewer cardiovascular diseases and other morbidities and reported healthier lifestyles, 2.8% of retired soccer players reported medically diagnosed dementia and other neurodegenerative disease compared to 0.9% of controls (OR = 3.46, 95% CI 1.25-9.63) after adjustment for age and possible confounders.

CONCLUSIONS

UK male retired soccer players had a higher risk of performing below established cut-off scores of dementia screening tests and were more likely to self-report medically diagnosed dementia and neurodegenerative diseases, despite having better overall physical health and fewer dementia risk factors. Further study is needed to determine specific soccer-related risk factors.

1482 Prognostic accuracy of triage tools for adults with suspected COVID-19 in a middle-income setting

Aims, Objectives and Background

Uneven vaccination in low- and middle-income settings and less resilient health care provision mean that emergency health care systems may still be at risk of being overwhelmed during periods of increased COVID-19 infection. Risk stratification tools proposed to allow rapid triage of need for admission in ED settings have almost exclusively been developed and validated in high-income settings during early waves of the pandemic.

Our study aimed to estimate the accuracy of risk-stratification tools recommended to predict severe illness in adults with suspected COVID-19 infection in the Western Cape of South Africa.

Method and Design

An observational cohort study using routinely electronically collected clinical information in all state-run hospitals in the Western Cape between 27th August 2020 and 11th March 2022 was conducted to assess performance of the PRIEST tool, NEWS2, the WHO algorithm, CRB-65, TEWS, Quick Covid Severity Index and PMEWS in patients with suspected COVID-19. The primary outcome was death, respiratory support or ICU admission.

Abstract 1482 Figure 1

Performance of tools predicting composite primary outcome for total study period

Abstract 1482 Figure 2

Performance of tools predicting composite primary outcome for the Omicron period

Abstract 1482 Table 1

Triage tool diagnostic accuracy statistics (95% CI) for predicting any adverse outcome (entire study period)

ToolN*C-statisticThresholdN (%) above thresholdSensitivitySpecificityPPVNPVCRB-65432,5840.70(0.70, 0.71)>0102,964 (23.8%)0.61(0.61, 0.61)0.78(0.77, 0.78)0.09(0.09, 0.09)0.98(0.98, 0.98)NEWS2433,1010.80(0.79, 0.80)>1178835 (41.3%)0.83(0.83, 0.83)0.6(0.6,0.6)0.07(0.07–0.07)0.99(0.99, 0.99)PMEWS438,8100.79(0.79, 0.79)>2199,386 (45.4%)0.85(0.85, 0.85)0.56(0.56, 0.56)0.06(0.06, 0.07)0.99 (0.99,0.99)PRIEST438,8800.82(0.82, 0.82)>4158,893 (36.2%)0.83(0.83, 0.83)0.65 (0.65,0.66)0.08(0.08, 0.08)0.99(0.99, 0.99)WHO437,8500.71(0.71, 0.72)>0235,775 (53.8%)0.82(0.81, 0.82)0.47(0.47, 0.47)0.05(0.05, 0.05)0.99(0.99, 0.99)TEWS432,6120.72(0.71, 0.72)>2134,097 (31%)0.62(0.62, 0.62)0.70(0.70, 0.70)0.07(0.07, 0.07)0.98(0.98, 0.98)Quick COVID446,0880.70(0.69, 0.70)>335,145 (7.9%)0.33(0.33, 0.33)0.93(0.93, 0.93)0.14(0.14, 0.14)0.98(0.98, 0.98)

*Patients with <3 parameters were excluded from analysis when estimating performance

Abstract 1482 Table 2

Triage tool diagnostic accuracy statistics (95% CI) for predicting any adverse outcome (Omicron period)

ToolN*C-statisticThresholdN (%) above thresholdSensitivitySpecificityPPVNPVCRB-65136,9610.69(0.68, 0.70)>031,373 (22.9%)0.59(0.59, 0.59)0.78(0.78, 0.78)0.05(0.05, 0.05)0.99(0.99, 0.99)NEWS2137,1250.77(0.76, 0.78)>176,183 (55.6%)0.87(0.87, 0.87)0.45(0.45, 0.45)0.03(0.03, 0.03)0.99(0.99, 0.99)PMEWS138,9540.76(0.75, 0.76)>259,876 (43.1%)0.80(0.80, 0.80)0.58(0.58, 0.58)0.04(0.04, 0.04)0.99(0.99, 0.99)PRIEST158,8930.78(0.77, 0.79)>446,529 (33.5%)0.75(0.75, 0.75)0.67(0.67, 0.67)0.04(0.04, 0.04)0.99(0.99, 0.99)WHO138,6660.62(0.61, 0.63)>072,599 (52.4%)0.70(0.70, 0.70)0.48(0.48, 0.48)0.03(0.03, 0.03)0.99(0.99, 0.99)TEWS136,9670.73(0.72, 0.74)>239,509 (28.8%)0.64(0.64, 0.64)0.72(0.72, 0.72)0.04(0.04, 0.04)0.99(0.99, 0.99)Quick COVID1405200.61(0.60, 0.63)>38,210(6.4%)0.17(0.17, 0.17)0.94(0.94, 0.94)0.06(0.06, 0.06)0.98(0.98, 0.98)

*Patients with <3 parameters were excluded from analysis when estimating performance

Results and Conclusion

Of the 446,084 patients, 15,397 patients (3.45%, 95% CI:34% to 35.1%) experienced the primary outcome. Figure 1 presents the ROC curves for the triage tools for the total study period and figure 2 for the period of the Omicron wave. NEWS2, PMEWS, PRIEST tool and WHO algorithm identified patients at risk of adverse outcomes at recommended cut-offs with moderate sensitivity (>0.8) and specificity ranging from 0.47 (NEWS2) to 0.65 (PRIEST tool). The low prevalence of the primary outcome, especially in the Omicron period, meant use of these tools would have more than doubled admissions with only a small reduction in risk of false negative triage.

Triage tools developed specifically in low- and middle-income settings may be needed to provide accurate risk prediction. Existing triage tools may need to be used at varying thresholds to reflect different baseline-line risks of adverse outcomes in different settings.

LMIC-PRIEST: Derivation and validation of a clinical severity score for acutely ill adults with suspected COVID-19 in a middle-income setting

Background

Uneven vaccination and less resilient health care systems mean hospitals in LMICs are at risk of being overwhelmed during periods of increased COVID-19 infection. Risk-scores proposed for rapid triage of need for admission from the emergency department (ED) have been developed in higher-income settings during initial waves of the pandemic.

Methods

Routinely collected data for public hospitals in the Western Cape, South Africa from the 27 th August 2020 to 11 th March 2022 were used to derive a cohort of 446,084 ED patients with suspected COVID-19. The primary outcome was death or ICU admission at 30 days. The cohort was divided into derivation and Omicron variant validation sets. We developed the LMIC-PRIEST score based on the coefficients from multivariable analysis in the derivation cohort and existing triage practices. We externally validated accuracy in the Omicron period and a UK cohort.

Results

We analysed 305,564, derivation 140,520 Omicron and 12,610 UK validation cases. Over 100 events per predictor parameter were modelled. Multivariable analyses identified eight predictor variables retained across models. We used these findings and clinical judgement to develop a score based on South African Triage Early Warning Scores and also included age, sex, oxygen saturation, inspired oxygen, diabetes and heart disease. The LMIC-PRIEST score achieved C-statistics: 0.82 (95% CI: 0.82 to 0.83) development cohort; 0.79 (95% CI: 0.78 to 0.80) Omicron cohort; and 0.79 (95% CI: 0.79 to 0.80) UK cohort. Differences in prevalence of outcomes led to imperfect calibration in external validation. However, use of the score at thresholds of three or less would allow identification of very low-risk patients (NPV ≥0.99) who could be rapidly discharged using information collected at initial assessment.

Conclusion

The LMIC-PRIEST score shows good discrimination and high sensitivity at lower thresholds and can be used to rapidly identify low-risk patients in LMIC ED settings.

What is already known on this subject

Uneven vaccination in low- and middle-income countries (LMICs) coupled with less resilient health care provision mean that emergency health care systems in LMICs may still be at risk of being overwhelmed during periods of increased COVID-19 infection.Risk-stratification scores may help rapidly triage need for hospitalisation. However, those proposed for use in the ED for patients with suspected COVID-19 have been developed and validated in high-income settings.

What this study adds

The LMIC-PRIEST score has been robustly developed using a large routine dataset from the Western Cape, South Africa and is directly applicable to existing triage practices in LMICs.External validation across both income settings and COVID-19 variants showed good discrimination and high sensitivity (at lower thresholds) to a composite outcome indicating need for inpatient admission from the ED.

How this study might affect research practice or policy

Use of the LMIC-PRIEST score at thresholds of three or less would allow identification of very low-risk patients (negative predictive value ≥0.99) across all settings assessedDuring periods of increased demand, this could allow the rapid identification and discharge of patients from the ED using information collected at initial assessment.

Foot and ankle Osteoarthritis and Cognitive impairment in retired UK Soccer players (FOCUS): protocol for a cross-sectional comparative study with general population controls

INTRODUCTION

Professional footballers commonly experience sports-related injury and repetitive microtrauma to the foot and ankle, placing them at risk of subsequent chronic pain and osteoarthritis (OA) of the foot and ankle. Similarly, repeated heading of the ball, head/neck injuries and concussion have been implicated in later development of neurodegenerative diseases such as dementia. A recent retrospective study found that death from neurodegenerative diseases was higher among former professional soccer players compared with age matched controls. However, well-designed lifetime studies are still needed to provide evidence regarding the prevalence of these conditions and their associated risk factors in retired professional football players compared with the general male population.

OBJECTIVES

To determine whether former professional male footballers have a higher prevalence than the general male population of: (1) foot/ankle pain and radiographic OA; and (2) cognitive and motor impairments associated with dementia and Parkinson's disease. Secondary objectives are to identify specific football-related risk factors such as head impact/concussion for neurodegenerative conditions and foot/ankle injuries for chronic foot/ankle pain and OA.

METHODS AND ANALYSIS

This is a cross-sectional, comparative study involving a questionnaire survey with subsamples of responders being assessed for cognitive function by telephone assessment, and foot/ankle OA by radiographic examination. A sample of 900 adult, male, ex professional footballers will be recruited and compared with a control group of 1100 age-matched general population men between 40 and 100 years old. Prevalence will be estimated per group. Poisson regression will be performed to determine prevalence ratio between the populations and logistic regression will be used to examine risk factors associated with each condition in footballers.

ETHICS AND DISSEMINATION

This study was approved by the East Midlands-Leicester Central Research Ethics Committee on 23 January 2020 (REC ref: 19/EM/0354). The study results will be disseminated at national and international meetings and submitted for peer-review publication.

Individual risk factors predictive of major trauma in pre-hospital injured older patients: a systematic review

Background

Older adults with major trauma are frequently under-triaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to identify which individual risk factors and predictors are likely to increase the risk of major trauma in elderly patients presenting to emergency medical services (EMS) following injury, to inform future elderly triage tool development.

Methods

Several electronic databases (including Medline, EMBASE, CINAHL and the Cochrane Library) were searched from inception to February 2021. Prospective or retrospective diagnostic studies were eligible if they examined a prognostic factor (often termed predictor or risk factor) for, or diagnostic test to identify, major trauma. Selection of studies, data extraction and risk of bias assessments using the Quality in Prognostic Studies (QUIPS) tool were undertaken independently by at least two reviewers. Narrative synthesis was used to summarise the findings.

Results

Nine studies, all performed in US trauma networks, met review inclusion criteria. Vital signs (Glasgow Coma Scale (GCS) score, systolic blood pressure, respiratory rate and shock index with specific elderly cut-off points), EMS provider judgement, comorbidities and certain crash scene variables (other occupants injured, occupant not independently mobile and head-on collision) were identified as significant pre-hospital variables associated with major trauma in the elderly in multi-variable analyses. Heart rate and anticoagulant were not significant predictors. Included studies were at moderate or high risk of bias, with applicability concerns secondary to selected study populations.

Conclusions

Existing pre-hospital major trauma triage tools could be optimised for elderly patients by including elderly-specific physiology thresholds. Future work should focus on more relevant reference standards and further evaluation of novel elderly relevant triage tool variables and thresholds.

An economic evaluation of triage tools for patients with suspected severe injuries in England

BACKGROUND

Many health care systems triage injured patients to major trauma centres (MTCs) or local hospitals by using triage tools and paramedic judgement. Triage tools are typically assessed by whether patients with an Injury Severity Score (ISS) ≥ 16 go to an MTC and whether patients with an ISS < 16 are sent to their local hospital. There is a trade-off between sensitivity and specificity of triage tools, with the optimal balance being unknown. We conducted an economic evaluation of major trauma triage tools to identify which tool would be considered cost-effective by UK decision makers.

METHODS

A patient-level, probabilistic, mathematical model of a UK major trauma system was developed. Patients with an ISS ≥ 16 who were only treated at local hospitals had worse outcomes compared to being treated in an MTC. Nine empirically derived triage tools, from a previous study, were examined so we assessed triage tools with realistic trade-offs between triage tool sensitivity and specificity. Lifetime costs, lifetime quality adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for each tool and compared to maximum acceptable ICERs (MAICERs) in England.

RESULTS

Four tools had ICERs within the normal range of MAICERs used by English decision makers (£20,000 to £30,000 per QALY gained). A low sensitivity (28.4%) and high specificity (88.6%) would be cost-effective at the lower end of this range while higher sensitivity (87.5%) and lower specificity (62.8%) was cost-effective towards the upper end of this range. These results were sensitive to the cost of MTC admissions and whether MTCs had a benefit for patients with an ISS between 9 and 15.

CONCLUSIONS

The cost-effective triage tool depends on the English decision maker's MAICER for this health problem. In the usual range of MAICERs, cost-effective prehospital trauma triage involves clinically suboptimal sensitivity, with a proportion of seriously injured patients (at least 10%) being initially transported to local hospitals. High sensitivity trauma triage requires development of more accurate decision rules; research to establish if patients with an ISS between 9 and 15 benefit from MTCs; or, inefficient use of health care resources to manage patients with less serious injuries at MTCs.

Injured patients who would benefit from expedited major trauma centre care: a consensus-based definition for the United Kingdom

INTRODUCTION

Despite the importance of treating the 'right patient in the right place at the right time', there is no gold standard for defining which patients should receive expedited major trauma centre (MTC) care. This study aimed to define a reference standard applicable to the United Kingdom (UK) National Health Service major trauma networks.

METHODS

A one-day facilitated roundtable expert consensus meeting was conducted at the University of Sheffield, UK, in September 2019. An expert panel of 17 clinicians was purposively sampled, representing all specialities relevant to major trauma management. A consultation process was subsequently held using focus groups with Public and Patient Involvement (PPI) representatives to review and confirm the proposed reference standard.

RESULTS

Four reference standard domains were identified, comprising: need for critical interventions; presence of significant individual anatomical injuries; burden of multiple minor injuries; and important patient attributes. Specific criteria were defined for each domain. PPI consultation confirmed all aspects of the reference standard. A coding algorithm to allow operationalisation in Trauma Audit and Research Network data was also formulated, allowing classification of any case submitted to their database for future research.

CONCLUSIONS

This reference standard defines which patients would benefit from expedited MTC care. It could be used as the target for future pre-hospital injury triage tools, for setting best practice tariffs for trauma care reimbursement and to evaluate trauma network performance. Future research is recommended to compare patient characteristics, management and outcomes of the proposed definition with previously established reference standards.

Baseline SCAT Performance in Men and Women: Comparison of Baseline Concussion Screens Between 6288 Elite Men's and 764 Women's Rugby Players

OBJECTIVE

This study compared Sports Concussion Assessment Tool (SCAT) performance in elite male (6288 players) and female (764 players) rugby players, to determine whether reference limits used for the management and diagnosis of concussion should differ between sexes.

DESIGN

Cross-sectional census sample.

SETTING

Data from World Rugby's Head Injury Assessment management system were analyzed. This data set covers global professional rugby.

PARTICIPANTS

All professional players who underwent baseline SCAT testing as part of World Rugby's concussion management requirement formed the study cohort. Ten thousand seven hundred fifty-four SCAT assessments from 6288 elite male rugby players and 1071 assessments from 764 elite female players were analyzed.

INTERVENTION

Elite men and women rugby players are independent variables.

MAIN OUTCOME MEASURES

Sports Concussion Assessment Tool performance, including symptoms endorsed, cognitive submode performance, and balance performance.

RESULTS

Women endorsed significantly more symptoms, with greater symptom severity, than men (relative ratio 1.34, 95% confidence interval, 1.25-1.45 women vs men). Women outperformed men in cognitive submodes with the exception of immediate memory and delayed recall and made fewer balance errors than men during the modified Balance Error Scoring System. Clinical reference limits, defined as submode score achieved by the worst-performing 50% of the cohort, did not differ between men and women.

CONCLUSIONS

Women and men perform differently during SCAT baseline testing, although differences are small and do not affect either the baseline or clinical reference limits that identify abnormal test results for most submodes. The greater endorsement of symptoms by women suggests increased risk of adverse concussion outcomes and highlights the importance of accurate evaluation of any symptom endorsement at baseline.

PP25 The take home naloxone intervention multicentre emergency setting feasibility (TIME) trial: an early perspective from one UK ambulance service

Background

Drug poisoning deaths in England and Wales have increased by 52% since 2011 with over half involving opioids. Deaths are preventable if naloxone is administered in time. Take Home Naloxone (THN) kits have been distributed through drug services; however, uptake is low and effectiveness unproven. The TIME trial tests the feasibility of conducting a full randomised controlled trial of providing THN administration and basic life support training to high-risk opioid-users in emergency care settings.

Methods

A multi-site feasibility trial commenced in June 2019 with two hospitals and their surrounding ambulance services (Bristol Royal Infirmary (BRI) with South Western Ambulance NHS Foundation Trust (SWASFT) and Hull Royal Infirmary with Yorkshire Ambulance Service) randomly allocated to intervention arms; and sites in Wrexham and Sheffield allocated as ‘usual care’ controls. SWASFT began recruiting in October 2019 with the aim of recruiting and training 50% (n=111) of paramedics working within the BRI’s catchment area, to supply THN to at least 100 eligible patients during a 12-month period.

Results

The trial was suspended between 17.03.2020-06.08.2020 and extended to 01.03.2021 (COVID-19). Despite this, 121 SWASFT paramedics undertook TIME training. TIME trained paramedics attended 30% (n=57) of the n=190 opioid-related emergency calls requiring naloxone administration during the study period. A total of n=29 potentially eligible patients were identified before and n=28 after the COVID-19 suspension. Two patients were supplied with THN during each period. During the COVID-19 suspension, twenty-two potentially eligible patients were missed. The majority of eligible patients presented with a reduced consciousness level, preventing recruitment (73%; n=42/48). These patients were transported to hospital for further treatment (n=39) or died on scene following advanced life support (n=3).

Conclusions

The lowered consciousness levels of prehospital emergency ambulance patients who present with opioid poisoning, often prevent the delivery of training required to enable the supply of THN.

PP39 What is the risk of major trauma following a fall down stairs? – A systematic review

Background

Specific mechanisms of injury are stated in pre-hospital triage tools to identify suspected cases of major trauma. Falls down stairs are common presentations in UK emergency departments, yet are frequently overlooked as a causative mechanism of major trauma. No prior systematic review has examined this association.

Methods

Seven internationally recognised literature databases and seven grey literature databases were screened utilising a common search strategy from inception until 31 December 2019. Abstracts were screened for relevance by a single reviewer. Full texts were screened and subsequently extracted by 3 separate reviewers against strict inclusion/exclusion criteria. A risk of bias assessment based on GRADE recommendations was performed. In the absence of study heterogeneity, a narrative synthesis was planned. The reporting of this systematic review followed PRISMA 2009 statement guidelines.

Results

5240 articles were identified from database searching, 89 articles had their full texts assessed for eligibility and 6 articles were included for qualitative synthesis. All studies were retrospective in nature and originated from more economically developed countries. 7431 patients who fell down stairs were analysed, of which, 707 (9.5%) met major trauma definitions. Falls down stairs resulted in a significantly increased risk of serious injury compared to other fall mechanisms (OR: 1.621, 95% CI: 1.381 – 1.902, p<0.0005). Analysis of confounding factors demonstrated age (OR: 2.59, 95% CI: 1.57 – 4.28, p<0.001) and alcohol intoxication (OR: 2.6, 95% CI: 1.4 – 4.7, p=0.001) to be significantly associated with major trauma. Risk of bias was moderate to high across all 6 studies.

Conclusion

This systematic review highlighted the paucity of literature surrounding the incidence of major trauma following falls down stairs.

A retrospective cohort study is currently being undertaken to analyse the risk of major trauma following falls down stairs. On completion, the results will be incorporated with the results of this systematic review.

3D Biomechanics of Rugby Tackle Techniques to Inform Future Rugby Research Practice: a Systematic Review

BACKGROUND

The tackle is the most common in-play event in rugby union and rugby league (the rugby codes). It is also associated with the greatest propensity for injury and thus accounts for the most injuries in the sport. It is therefore of critical importance to accurately quantify how tackle technique alters injury risk using gold-standard methodology of three-dimensional motion (3D) capture.

OBJECTIVE

To examine the 3D motion capture methodology of rugby-style tackle techniques to provide recommendations to inform practice for future rugby code research and advance the knowledge of this field.

STUDY DESIGN

Systematic review.

METHODS

Articles published in English language, up to May 2020, were retrieved via nine online databases. All cross-sectional, correlational, observational, and cohort study designs using 3D motion capture of tackle techniques in rugby code players met inclusion criteria for this review. A qualitative synthesis using thematic analysis was pre-specified to identify five key themes.

RESULTS

Seven articles met eligibility criteria. Participant demographic information (theme one) involved a total of 92 rugby union players, ranging in skill level and playing experience. Experimental task design information (theme two) included one-on-one, front-on (n=5) or side-on (n=1) contact between a tackler and a ball carrier, or a tackler impacting a tackle bag or bump pad (n=3). 3D data collection (theme three) reported differing sampling frequencies and marker sets. 3D data reduction and analysis (theme four) procedures could be mostly replicated, but the definitions of temporal events, joint modelling and filtering varied between studies. Findings of the studies (theme five) showed that the one-on-one tackle technique can be altered (n=5) when tackle height, leg drive and/or tackle speed is modified. A study reported tackle coaching intervention.

CONCLUSIONS

This is the first review to evaluate 3D motion capture of rugby-style tackle technique research. A research framework was identified: (i) participant demographic information, (ii) experimental task design information, (iii) 3D motion capture data specifications, and (iv) 3D data reduction and analysis. Adherence of future 3D tackling research to these framework principles will provide critical scientific evidence to better inform injury reduction and performance practices in the rugby codes.

TRIAL REGISTRATION

The review was registered with PROSPERO (registration number CRD42018092312 ).

Diagnostic accuracy of prehospital triage tools for identifying major trauma in elderly injured patients: A systematic review

BACKGROUND

Older adults with major trauma are frequently undertriaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to evaluate the diagnostic performance of prehospital triage tools to identify suspected elderly trauma patients in need of specialized trauma care.

METHODS

Several electronic databases (including MEDLINE, EMBASE, and the Cochrane Library) were searched from inception to February 2019. Prospective or retrospective diagnostic studies were eligible if they examined prehospital triage tools as index tests (either scored theoretically using observed patient variables or evaluated according to actual paramedic transport decisions) compared with a reference standard for major trauma in elderly adults who require transport by paramedics following injury. Selection of studies, data extraction, and risk of bias assessments using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool were undertaken independently by at least two reviewers. Narrative synthesis was used to summarize the findings.

RESULTS

Fifteen studies met the inclusion criteria, with 11 studies examining theoretical accuracy, three evaluating real-life transport decisions, and one assessing both (of 21 individual index tests). Estimates for sensitivity and specificity were highly variable with sensitivity estimates ranging from 19.8% to 95.5% and 57.7% to 83.3% for theoretical accuracy and real life triage performance, respectively. Specificity results were similarly diverse ranging from 17.0% to 93.1% for theoretical accuracy and 46.3% to 78.9% for actual paramedic decisions. Most studies had unclear or high risk of bias and applicability concerns. There were no obvious differences between different triage tools, and findings did not appear to vary systematically with major trauma prevalence, age, alternative reference standards, study designs, or setting.

CONCLUSION

Existing prehospital triage tools may not accurately identify elderly patients with serious injury. Future work should focus on more relevant reference standards, establishing the best trade-off between undertriage and overtriage, optimizing the role prehospital clinician judgment, and further developing geriatric specific triage variables and thresholds.

LEVEL OF EVIDENCE

Systematic review, level III.

Bypassing the nearest emergency department for a more distant neurosurgical centre in traumatic brain injury patients

BACKGROUND AND OBJECTIVE

Major trauma triage within regional trauma networks (RTN) select patients with suspected TBI for bypass to specialist neuroscience centres (SNC), expediting neurosurgical care but may delay resuscitation. This comparative effectiveness study assessed the impact of this strategy on the risk adjusted hospital survival rates of patients confirmed to have intracranial injury on brain computed tomography (CT) scan.

METHOD

A retrospective cohort study was conducted using Trauma Audit and Research Network trauma registry data. Adult patients with a TBI on CT scan were included if they presented between June 2015 to February 2016 to SNCs or non-specialist acute hospitals (NSAH) in the North of England (South Cumbria, Lancashire and the North East Region). Patients were identified as having bypassed a nearer NSAH emergency department (ED) to a SNC using google maps. Their standardised excess survival rate was compared to TBI patients who received primary treatment at a NSAH. A multivariate logistic regression model predicting 30-day survival after TBI (Ps14ⁿ)¹ was used to adjust for variation in casemix between cohorts.

STUDY DESIGN AND RESULTS

355 patients met the study inclusion criteria, with 89/355 (25%) of TBI patients bypassing a nearer NSAH to a SNC, and 266/355 (75%) receiving primary treatment at an NSAH. The median severity of intracranial injury was equivalent (median Head Abbreviated Injury Scale 4 (IQR 4-5) in each group. There was no statistically significant difference in the standardised excess survival rate between the two cohorts; +6.15% for bypass (95% CI -1.24% to +13.55%) versus -1.12% for non-bypass (95% CI -4.51% to +2.25%).

CONCLUSION AND FUTURE RESEARCH

No statistically significant survival benefit was identified for TBI patients who bypassed the nearest ED to attend a SNC compared to those receiving treatment at the nearest NSAH, however a clinically significant 7% excess survival rate merits a larger study.

11 External validation of the Dutch prediction model for prehospital triage of trauma patients in South West region of England, United Kingdom

Aims/Objectives/Background

This is the first external validation of a European empirically derived prediction model for identifying major trauma in an unselected group of injured patients transported by ambulance in the United Kingdom.

Methods/Design

This study was an external validation of a Dutch prediction model for identifying major trauma using a retrospective cohort of injured patients who ambulance crews transported to hospitals in the South West region of England. Major trauma was defined as Injury Severity Score (ISS)>15.

Participants were patients ≥16 years with a suspected injury and transported by ambulance from February 1, 2017 to February 1, 2018. This study had a census sample of cases available to us over a one year period.

We tested the accuracy of the prediction model in terms of discrimination, calibration, clinical usefulness, sensitivity and specificity and under- and over triage rates compared to existing trauma triage practices in the South West region.

Results/Conclusions

A total of 68 698 adult patients were included in the final external validation cohort. The median age of patients was 72 (i.q.r. 46–84); 55.5% were female; and 524 (0.8%) had an ISS>15. In comparison the Dutch cohort was younger (45 years), more were male (58.3%) and more patients had an ISS>15. (8.8%) The model achieved good discrimination with a C-Statistic 0.75 (95% CI, 0.73 – 0.78). At a maximal specificity of 50% the model resulted in a sensitivity of 86%. The model improved undertriage rates at the expense of increased overtriage rates compared with routine trauma triage methods in the South West of England.

The Dutch prediction model for identifying major trauma can lower the undertriage rate to 17%, however it would increase the overtriage rate to 50% in this UK cohort. Further research is needed to determine whether the model can be practically implemented by paramedics and is cost-effective.

PP32 Major trauma triage tools study (MATTS) expert consensus meetings

Introduction

Major trauma triage tools are used to identify patients for bypass to Major Trauma Centres (MTCs). Bypass has been associated with improved patient outcomes following major trauma. The aim of the Major Trauma Triage Tools Study (MATTS) is to produce an evidence-based triage tool to be implemented across UK ambulance services.

Methods

Two independently chaired 1-day expert consensus meetings comprised of senior clinical professionals from specialties relevant to major trauma and prehospital triage were conducted as part of Phase 1 of the MATTS project, each with a distinct focus:

To define a reference standard of major trauma

Produce a new triage tool

Facilitated round table discussions were conducted with consensus developed through arbitration. In the first meeting a multi-domain reference standard defining major trauma patients with the potential to benefit from MTC care was determined. In the subsequent meeting triage tools were developed to select appropriate injured patients meeting this reference standard.

Results

Three tools were produced with a different diagnostic accuracy focus:

Sensitive – Maximising major trauma identification.

Specific – Preserving MTC care for the most severely injured patients

Balanced – A tool balancing sensitivity and specificity

Conclusion

The reference standard will form the basis of data analysis in Phase 2 of the project. The performance of the 3 differing tools will be tested in a dataset of routine ambulance service and TARN data. Following this, the most optimal triage tool will be assessed in clinical practice across 4 ambulance services.

01 Major trauma triage tools study (MATTS) triage tools summary

Introduction

The aim of this project is to identify major trauma triage tools currently in use by ambulance services in England, Wales and internationally and subsequently complete a detailed document analysis of these tools. The review will aim to detect the most commonly used predictors of major trauma whilst identifying the evidence behind them.

Methods

A variety of triage tools used internationally were acquired through analysis of systematic reviews freely available on PubMed. The 46 identified tools included: 40 adult/general, 4 paediatric-specific and 2 geriatric-specific tools. Following the acquisition of all triage tools, they were analysed by diagnostic criteria and a detailed spreadsheet produced. Each row of the spreadsheet represented a different triage criterion and each cell was colour coded to suggest the correct course of action for patient management.

Results

In total, 63 separate clinical features and triaging criteria were identified. These were categorised into five major groups (most common variables):

Physiology (GCS, Low BP).

Anatomy (Chest trauma, traumatic amputation).

Mechanism of injury (Falls, high speed RTC).

Modifiers for high risk groups (Age >55/65, pregnant)

Time limit to the nearest MTC (>45 minutes).

Additionally, crew concern is a potential predictor in 14 tools. Despite many tools using similar predictors, their respective predictor cut-points varied widely (e.g. from GCS ≤14 to <9).

From the tools assessed, two basic tool structures were discerned:

A flowchart style format (34 tools)

A points-based scoring system (7 tools)

Conclusions

The various major trauma triaging tools currently in use in the NHS and worldwide are highly varied. Although there are commonly used domains variable cut-points often varied. Given this significant difference between services’ tools, and variability of clinician interpretation of those criteria, large variations in standards of major trauma triaging are likely.

Risk of significant traumatic brain injury in adults with minor head injury taking direct oral anticoagulants: a cohort study and updated meta-analysis

BACKGROUND

Patients taking direct oral anticoagulants (DOACs) commonly undergo CT head imaging after minor head injury, regardless of symptoms or signs. However, the risk of intracranial haemorrhage (ICH) in such patients is unclear, and further research has been recommended by the UK National Institute for Health and Care Excellence head injury guideline group.

METHODS

An observational cohort study was performed in the UK South Yorkshire major trauma centre between 26 June and 3 September 2018. Adult patients taking DOACs with minor head injury were prospectively identified, with case ascertainment supplemented by screening of radiology and ED information technology systems. Clinical and outcome data were subsequently collated from patient records. The primary endpoint was adverse outcome within 30 days, comprising: neurosurgery, ICH or death due to head injury. A previously published meta-analysis was updated with the current results and the findings of other recent studies.

RESULTS

148 patients with minor head injury were included (GCS 15, n=107, 72%; GCS 14, n=41, 28%). Patients were elderly (median 82 years) and most frequently injured from ground level falls (n=142, 96%). Overall risk of adverse outcome was 3.4% (5/148, 95% CI 1.4% to 8.0%). Five patients had ICH, of whom one died within 30 days. One patient was treated with prothrombin complex concentrate but no patient received critical care management or underwent neurosurgical intervention. Updated random effects meta-analysis, including the current results and two further recent studies, showed a weighted overall risk of adverse outcome of 3.2% (n=29/787, 95% CI 2.0% to 4.4%).

CONCLUSIONS

The risk of adverse outcome following mild head injury in patients taking DOACs appears low. These findings would support shared patient-clinician decision making, rather than routine imaging, following minor head injury while taking DOACs.

Harnessing inter-disciplinary collaboration to improve emergency care in low- and middle-income countries (LMICs): results of research prioritisation setting exercise

BACKGROUND

More than half of deaths in low- and middle-income countries (LMICs) result from conditions that could be treated with emergency care - an integral component of universal health coverage (UHC) - through timely access to lifesaving interventions.

METHODS

The World Health Organization (WHO) aims to extend UHC to a further 1 billion people by 2023, yet evidence supporting improved emergency care coverage is lacking. In this article, we explore four phases of a research prioritisation setting (RPS) exercise conducted by researchers and stakeholders from South Africa, Egypt, Nepal, Jamaica, Tanzania, Trinidad and Tobago, Tunisia, Colombia, Ethiopia, Iran, Jordan, Malaysia, South Korea and Phillipines, USA and UK as a key step in gathering evidence required by policy makers and practitioners for the strengthening of emergency care systems in limited-resource settings.

RESULTS

The RPS proposed seven priority research questions addressing: identification of context-relevant emergency care indicators, barriers to effective emergency care; accuracy and impact of triage tools; potential quality improvement via registries; characteristics of people seeking emergency care; best practices for staff training and retention; and cost effectiveness of critical care - all within LMICs.

CONCLUSIONS

Convened by WHO and facilitated by the University of Sheffield, the Global Emergency Care Research Network project (GEM-CARN) brought together a coalition of 16 countries to identify research priorities for strengthening emergency care in LMICs. Our article further assesses the quality of the RPS exercise and reviews the current evidence supporting the identified priorities.

The effect of exercise on baseline SCAT5 performance in male professional Rugby players

Background

Rugby Union requires annual baseline testing using the Sports Concussion Assessment Tool (SCAT5) as part of its head injury assessment protocols. Scores achieved during baseline testing are used to guide return-to-play decisions at the time of head impact events during matches, and concussion diagnosis during subsequent diagnostic screens. Baseline values must be valid, accurate representations of a player’s capability in the various SCAT5 sub-modes, including symptom report, cognitive function and balance. The extent to which prior exercise may affect performance is an important consideration, and the present cross-sectional study aimed to explore how SCAT5 performance differs when assessed at rest (RSCAT) compared to after 30 min of exercise (EXSCAT) in 698 male professional rugby players for whom paired exercise and rest SCAT5 data were available.

Results

Symptom endorsement was greater when assessed after exercise than at rest. Fatigue/Low energy was 1.5 times more likely to be reported when assessed during EXSCAT. Orientation score was improved during SCAT5s performed after exercise, but only when rest and exercise SCAT5s were conducted on the same day, suggesting a learning effect. Concentration score was impaired during EXSCAT. No other cognitive sub-modes were affected by exercise. Total errors during Modified Balance Error Scoring System (MBESS) increased during EXSCAT, as a result of increased errors made during single leg balance, irrespective of testing sequence, with 42% of players making more errors in EXSCAT, compared to 28% making more errors in RSCAT.

Conclusions

Symptoms, cognitive sub-modes and balance sub-modes are all affected by exercise. These may be the result of learning effects that improve cognitive performance, and the direct effects of exercise on sub-mode performance. The clinical implications of these changes may be assessed in the future through a study of diagnostic screens in players after head impact events, to confirm whether an exercise baseline screen is required annually, or whether specific sub-modes of the SCAT5 should be obtained at rest and after exercise.

Effect of a concussion on subsequent baseline SCAT performance in professional rugby players: a retrospective cohort study in global elite Rugby Union

OBJECTIVES

This study assessed whether concussion affects subsequent baseline performance in professional rugby players. Annual baseline screening tests are used to guide return-to-play decisions and concussion diagnosis during subsequent screens. It is important that baseline performances are appropriate and valid for the duration of a season and unaffected by factors unrelated to the current head impact event. One such factor may be a concussion following baseline assessment.

SETTING

The World Rugby concussion management database for global professional Rugby Union.

PARTICIPANTS

501 professional rugby players with two baseline Sports Concussion Assessment Tools (SCATs) and an intervening concussion (CONC) were compared with 1190 control players with successive annual SCAT5s and no diagnosed concussion (CONT).

PRIMARY AND SECONDARY OUTCOME MEASURES

Symptom endorsement, cognitive and balance performance during annual SCAT baseline assessments.

RESULTS

Players with a diagnosed concussion (CONC) endorsed fewer symptoms (change -0.42, 95% CI -0.75 to -0.09), and reported lower symptom severity scores during their second assessment (T2, p<0.001) than non-concussed players (CONT). Concussed players also improved Digits Backward and Final Concentration scores in T2 (p<0.001). Tandem gait time was improved during T2 in CONT. No other sub-mode differences were observed in either group.

CONCLUSIONS

Reduced symptom endorsement and improved cognitive performance after concussion may be the result of differences in the motivation of previously concussed players to avoid exclusion from play, leading to under-reporting of symptoms and greater effort in cognitive tests. Improved cognitive performance may be the result of familiarity with the tests as a result of greater exposure to concussion screening. The changes are small and unlikely to have clinical significance in most cases, though clinicians should be mindful of possible reasons, possibly repeating sub-modes and investigating players whose baseline scores change significantly after concussion. The findings do not necessitate a change in the sport's concussion management policy.

Is a definitive trial of prehospital continuous positive airway pressure versus standard oxygen therapy for acute respiratory failure indicated? The ACUTE pilot randomised controlled trial

OBJECTIVES

To determine the feasibility of a large-scale definitive multicentre trial of prehospital continuous positive airway pressure (CPAP) in acute respiratory failure.

DESIGN

A single-centre, open-label, individual patient randomised, controlled, external pilot trial.

SETTING

A single UK Ambulance Service, between August 2017 and July 2018.

PARTICIPANTS

Adults with respiratory distress and peripheral oxygen saturations below British Thoracic Society target levels despite controlled oxygen treatment.

INTERVENTIONS

Patients were randomised to prehospital CPAP (O-Two system) versus standard oxygen therapy in a 1:1 ratio using simple randomisation.

PRIMARY AND SECONDARY OUTCOME MEASURES

Feasibility outcomes comprised recruitment rate, adherence to allocated treatment, retention and data completeness. The primary clinical outcome was 30-day mortality.

RESULTS

77 patients were enrolled (target 120), including 7 cases with a diagnosis where CPAP could be ineffective or harmful. CPAP was fully delivered in 74% (target 75%). There were no major protocol violations. Full data were available for all key outcomes (targets ≥90%). Overall 30-day mortality was 27.3%. Of these deceased patients, 14/21 (68%) either did not have a respiratory condition or had ceiling of treatment decisions implemented excluding hospital non-invasive ventilation and critical care.

CONCLUSIONS

Recruitment rate was below target and feasibility was not demonstrated. Limited compliance with CPAP, and difficulty in identifying patients who could benefit from CPAP, indicate that prehospital CPAP is unlikely to materially reduce mortality. A definitive effectiveness trial of CPAP is therefore not recommended.

TRIAL REGISTRATION NUMBER

ISRCTN12048261; Post-results.

Relationship between the Injury Severity Score and the need for life-saving interventions in trauma patients in the UK

INTRODUCTION

Major trauma is the third leading cause of avoidable mortality in the UK. Defining which patients require care in a major trauma centre is a critical component of developing, evaluating and enhancing regional major trauma systems. Traditionally, trauma patients have been classified using the Injury Severity Score (ISS), but resource-based criteria have been proposed as an alternative. The aim of this study was to investigate the relationship between ISS and the use of life-saving interventions (LSI).

METHODS

Retrospective cohort study using the Trauma Audit Research Network database for all adult patients (aged ≥18 years) between 2006 and 2014. Patients were categorised as needing an LSI if they received one or more interventions from a previously defined list determined by expert consensus.

RESULTS

193 290 patients met study inclusion criteria: 56.9% male, median age 60.0 years (IQR 41.2-78.8) and median ISS 9 (IQR 9-16). The most common mechanism of injury was falls <2 m (52.1%), followed by road traffic collisions (22.2%). 15.1% received one or more LSIs. The probability of a receiving an LSI increased with increasing ISS, but only a low to moderate correlation was evident (0.334, p<0.001). A clinically significant number of cases (5.3% and 7.6%) received an LSI despite having an ISS ≤8 or <15, respectively.

CONCLUSIONS

A clinically significant number of adult trauma patients requiring LSIs have an ISS below the traditional definition of major trauma. The traditional definition should be reconsidered and either lowered, or an alternative metric should be used.

Accuracy of PE rule-out strategies in pregnancy: secondary analysis of the DiPEP study prospective cohort

Objective

Recent studies suggest that combinations of clinical probability assessment (the YEARS algorithm or Geneva score) and D-dimer can safely rule out suspected pulmonary embolism (PE) in pregnant women. We performed a secondary analysis of the DiPEP (Diagnosis of Pulmonary Embolism in Pregnancy) study data to determine the diagnostic accuracy of these strategies.

Methods

The DiPEP study prospectively recruited and collected data and blood samples from pregnant/postpartum women with suspected PE across 11 hospitals and retrospectively collected data from pregnant/postpartum women with diagnosed PE across all UK hospitals (15 February 2015 to 31 August 2016). We selected prospectively recruited pregnant women who had definitive diagnostic imaging for this analysis. We used clinical data and D-dimer results to determine whether the rule out strategies would recommend further investigation. Two independent adjudicators used data from imaging reports, treatments and adverse events up to 30 days to determine the reference standard.

Results

PEs were diagnosed in 12/219 (5.5%) women. The YEARS/D-dimer strategy would have ruled out PE in 96/219 (43.8%) but this would have included 5 of the 12 with PEs. Sensitivity for PE was 58.3% (95% CI 28.6% to 83.5%) and specificity 44.0% (37.1% to 51.0%). The Geneva/D-dimer strategy would have ruled out PE in 46/219 (21.0%) but this would have included three of the 12 with PE. Sensitivity was 75.0% (95% CI 42.8% to 93.3%) and specificity 20.8% (95% CI 15.6% to 27.1%). Administration of anticoagulants prior to blood sampling may have reduced D-dimer sensitivity for small PE.

Conclusion

Strategies using clinical probability and D-dimer have limited diagnostic accuracy and do not accurately rule out all PE in pregnancy. It is uncertain whether PE missed by these strategies lead to clinically important consequences.

043 Should adults with mild head injury taking direct oral anticoagulants undergo CT scanning? A systematic review

Background

Patients taking direct oral anticoagulant medications (DOACs) commonly undergo computed tomography (CT) head scanning following mild head injury, regardless of symptoms or signs. International guidelines have noted a lack of evidence to support management decisions in such patients.

Methods

A systematic review, pre-registered (CRD42017071411) and following Cochrane Collaboration recommendations, was performed. Studies of adults with mild head injury (GCS 13–15) taking DOACs, which reported the risk of adverse outcome following the head injury, were eligible for inclusion. A comprehensive range of bibliographic databases and grey literature were examined using a sensitive search strategy. Selection of eligible studies, data extraction, and risk of bias was evaluated independently by separate reviewers. A random effects meta-analysis was used to provide a pooled estimate of the risk of adverse outcome. The overall quality of evidence was assessed using the Grades of Recommendation, Assessment, Development and Evaluation Working Group approach.

Results

4,185 articles were screened for inclusion, of which 7 cohort studies, including 346 patients, met inclusion criteria. All studies were at high or unclear risk of bias secondary to selection and information bias. Estimates of adverse outcome (any death, intracranial hematoma (ICH), or neurosurgery) ranged from 0% to 8%. A random effects meta-analysis showed a weighted composite outcome risk of 4% (95% CI 2–6%, I2=3%). The overall quality of the body of evidence was low secondary to imprecision, indirectness and risk of bias.

Conclusions

There is limited data available to characterize the risk of adverse outcome in patients taking DOACs following mild head injury. A sufficiently powered prospective cohort study is required to validly define this risk, identify clinical features predictive of adverse outcome, and inform future head injury guidelines.

051 The ACUTE (ambulance CPAP: use, treatment effect and economics) feasibility study: a pilot randomised controlled trial of prehospital CPAP for acute respiratory failure

Background

Acute respiratory failure (ARF) is a common and life-threatening medical emergency. Continuous positive airway pressure (CPAP) is a potentially beneficial prehospital treatment, but it is uncertain whether this could improve important outcomes in NHS ambulance services.

Methods

An individually randomised, external pilot study was conducted to test the feasibility of a definitive pragmatic trial. Adults with respiratory distress and peripheral oxygen saturations below British Thoracic Society target levels were recruited from the West Midlands Ambulance Service between August 2017 and July 2018. Participants were randomised 1:1 to prehospital CPAP or standard oxygen therapy. Feasibility objectives estimated the: incidence of eligible patients; proportion recruited and allocated to treatment appropriately; adherence to allocated treatment; retention and data completeness; and 30-day mortality, as a potential primary outcome for a definitive trial.

Results

Over 12 months, 77 patients were enrolled (CPAP arm 42, standard oxygen arm 35 cases, target 120). CPAP was fully delivered as planned in 74% (target 75%). There were no major protocol violations/non-compliances (target 0%). Full data were available for key outcomes (target ≥90%). Mortality was higher than expected (overall 27.3%, CPAP arm 28.6% n=12/42, standard care arm 25.7% n=9/35). Of deceased patients, 14/21 (68%) either did not have a respiratory condition or had ceiling of treatment decisions excluding hospital non-invasive ventilation and critical care. Two patients required emergency department treatment for a pneumothorax, neither having received prehospital CPAP. There were no other serious adverse events.

Conclusions

The lower than expected recruitment rate, limited compliance with CPAP, and the difficulty in identifying patients who could benefit from CPAP, indicate limited potential for prehospital CPAP to reduce mortality. A definitive effectiveness trial is therefore not recommended. These findings also argue against routine implementation of CPAP into NHS ambulance services.

03 Opioid overdose death in wales from 2012 to 2015: a linked data autopsy study

Background

Opioids account for more fatalities by overdose than any other drug. Fatal opioid overdose is a growing public health problem, with incidence rising in western countries especially. We sought to describe the deaths, sociodemographic characteristics, and service usage patterns of decedents of opioid overdose in Wales.

Methods

We carried out a retrospective cross-sectional analysis of opioid related deaths in Wales identified from Office for National Statistics data between 01/01/2012 and 31/12/2015, in Wales, UK.

Routine data were captured from Office of National Statistics (ONS), the Welsh Demographic Service and National Health Service datasets for the preceding three years and linked using a deterministic algorithm. Demographic, socioeconomic, clinical and service use characteristics were detailed using descriptive statistics.

Results

The majority of opioid overdose deaths (n=312) occurred at home (n=253, 81.09%) and were accidental (n=262, 83.97%). A third (31.09%) involved heroin as the main object of injury (n=97). Decedents were mostly male (n=228, 73.1%) and lived in socioeconomically deprived (lacking in material and social opportunities and/or resources) areas at the time of their death (n=199, 63.75%). The majority of decedents changed address at least once during the 36 month observation period prior to death (n=169, 53.85%), but rarely moved far geographically (e.g. were resident in more than two postcode areas). The majority of decedents visited the emergency department (n=227, 72.76%), were admitted to hospital (n=199, 63.78%) – usually for mental health problems – and were recorded at least one General Practitioner episode (n=258, 82.69%) during the observation period. A minority of decedents used drug treatment services (n=72, 23.08%).

Conclusions

Opioid overdose deaths occur most commonly secondary to heroin use. Decedents demonstrate a peripatetic lifestyle and are rarely engaged with drug treatment services. Frequent contact with unscheduled care providers might present a target for preventative interventions.

PP22 Box randomisation- a novel method for allocation in pre-hospital randomised controlled trials: the ACUTE study experience

Background

Allocation concealment is essential to avoid selection bias in randomised trials. The ACUTE pilot trial compared the effectiveness of pre-hospital CPAP vs standard oxygen therapy for acute respiratory failure (ARF). The randomisation schedule was implemented, and treatment allocation concealed, with a novel method using identical boxes.

Methods

Investigation of allocation concealment in the ACUTE trial proceeded in 4 stages. Firstly, the characteristics of recruited ACUTE trial patients were compared across arms. Secondly, the findings of a weekly trial box audit log were examined. Thirdly, allocation concealment was explored in paramedic focus groups and survey. Finally, a convenience sample of West Midlands and Yorkshire Ambulance Service paramedics were presented with a random pair of ACUTE boxes from each trial arm, and asked to identify any differences. If a difference was noted, they were asked to indicate which box contained CPAP and why.

Results

The ACUTE study enrolled 77 participants (42 CPAP, 35 control). Baseline characteristics were similar, although patients in the CPAP arm appeared to have slightly more severe ARF. In week 10, audit of trial boxes revealed that intervention arm boxes were ‘rattling’, secondary to deflation of CPAP masks packaged under tension. All boxes were consequently re-packaged and resupplied. No comments in the paramedic survey, but a focus group participant stated that one box had appeared different when shaken. 278 paramedics participated in the observational study. 115 participants (41.4%) felt they were able to tell which box contained CPAP, predominantly due to weight difference. Of these, 81 paramedics (70%, p<0.05) were correct.

Conclusions

Although the majority of paramedics were unable to determine box contents, a significant minority correctly determined the CPAP arm. Taken together with the development of a ‘rattle’ during the trial, and slight baseline imbalance in characteristics of trial participants, loss of allocation concealment cannot be excluded.

PP26 Incidence of acute respiratory failure cases in west midlands ambulance service (WMAS) – sub-study of ACUTE (ambulance CPAP: use, treatment effect and economics) trial

Background

Acute respiratory failure (ARF) is a life-threatening emergency and pre-hospital CPAP may improve outcomes. A CPAP cost-effectiveness determinant is the incidence of eligible patients with ARF. This sub-study of the ACUTE trial aimed to determine the number of adults with ARF potentially suitable for CPAP, presenting to WMAS.

Methods

This observational study was conducted between 1stAugust 2017 and 31st July 2018. Adult patients presenting with SpO2 <94% were identified from WMAS electronic patient records. Electronic filters applied ACUTE trial inclusion and exclusion criteria, with subsequent manual clinical review by a research paramedic. A second research paramedic checked a sub-sample for inter-rater agreement. Overall and monthly incidence rates were calculated, census data provided the population denominator.

Results

108,391 potential patients were identified from electronic patient records (EPR), after filter application 4,526 cases were eligible for review (Figure 1). After review, 1017 cases were considered CPAP candidates. Inter-rater agreement was 86%. Overall incidence was 17.35 per 100,000 population per year (95%CI 16.3–18.5). Marked seasonal variation was present, increasing over winter (Figure 2). Urban areas had the highest proportion of eligible patients (67.6% v 18.3% Rural v 14.2% semi-rural); and 53.0% of all eligible were male.

Conclusions

The incidence of eligible ARF patients impacts on the cost-effectiveness of pre-hospital CPAP, but previous reports have been variable, using sub-optimal methods or from non-UK settings. We report a valid NHS estimate of 17 patients per 100,000 who do not respond to current pre-hospital ARF management and could be candidates for CPAP.

PP28 ‘They are not silly people – they know the difference’: clinician focus group views on a pilot randomised controlled trial of prehospital continuous positive airway pressure (CPAP)

Background

Continuous positive airway pressure (CPAP) is not in widespread use in UK ambulance services, but could benefit patients with acute respiratory failure (ARF). As a new treatment in this context, clinician acceptability is an important factor in the feasibility of conducting definitive research in the prehospital arena.

Methods

As part of a pilot randomised controlled trial (the ACUTE study), nine trial-trained paramedics took part in three semi-structured focus groups. 204 trained staff had been given the opportunity to take part. The sample included six staff who had recruited to the trial, one who had not, and two who had withdrawn from it. Audio-recordings were transcribed and analysed thematically.

Results

Participants described facilitators to trial participation including: clear eligibility criteria and patient documentation, access to demonstration equipment, training away from the work environment, and repeated patient recruitment. Barriers to taking part included: the lack of protected time for training, inadequate workplace facilities for the electronic learning package used, adverse responses by receiving hospital staff, and infrequent patient exposure. Both paramedics who withdrew cited the inconvenience of carrying packs each shift. Some participants described anxiety and distress when opening packs to find a standard-care mask, and reported patients having similar reactions.

Conclusions

Future researchers could promote improved workplace computing facilities and increased provision of face-to-face training days, which were praised by participants in these focus groups, but limited to a single event distant from some staff. Greater stakeholder engagement by researchers could reduce the difficulties at hospital handover reported by some ambulance staff. Where blinding is not possible, the perceptions of clinicians and patients should be considered carefully, as this study shows both may have adverse emotional responses to being treated with standard care, particularly when prospective consent discussions describe the trial intervention as potentially beneficial.

PP25 ‘I wish there was CPAP in every box’: internet-based survey responses of clinicians recruiting to a pilot randomised controlled trial of continuous positive airway pressure (CPAP) for patients with acute respiratory failure

Background

Continuous positive airway pressure (CPAP) is not in widespread use in UK ambulance services, but could benefit patients with acute respiratory failure (ARF). As a new treatment in this context, clinician acceptability is an important factor in the feasibility of conducting definitive research in the prehospital arena.

Methods

As part of a pilot randomised controlled trial (the ACUTE study), recruiting clinicians were emailed after enrolling patients to either the CPAP or standard-care arm, and were asked to complete an optional, anonymous, internet-based survey. The survey used a mixture of closed questions, Likert-scaled answers and free text to explore staff views on both the treatment and the trial procedures. Quantitative responses were analysed descriptively, and qualitative answers thematically.

Results

Recruiting clinicians for all 77 patients were sent survey links, with 40 email responses received. Respondents felt confident diagnosing ARF and determining trial eligibility. CPAP-arm respondents found the equipment easy-to-use and felt it did not delay transport to hospital. Most standard-care respondents said they would have liked CPAP to be available to their patients. Respondents described varying responses from receiving hospital staff.

Conclusions

Prehospital CPAP seems acceptable to clinicians. Limitations of this survey are that it was targeted only at clinicians who have already opted to take part in the trial, and so may exclude a body of staff who find the treatment unacceptable at face value. Not all clinicians who enrolled patients completed the survey, which could suggest a response bias or simply a reflection of its optional nature within the trial. Future pilot studies could mandate an acceptability survey, and also seek the views of staff not taking part in the interventional study. Trial teams may need to better explain the rationale of comparing a new intervention with standard care, and offer more widespread hospital staff awareness sessions.

Selecting pregnant or postpartum women with suspected pulmonary embolism for diagnostic imaging: the DiPEP diagnostic study with decision-analysis modelling

BACKGROUND

Pulmonary embolism (PE) is a leading cause of death in pregnancy and post partum, but the symptoms of PE are common in normal pregnancy. Simple diagnostic tests are needed to select women for diagnostic imaging.

OBJECTIVE

To estimate the accuracy, effectiveness and cost-effectiveness of clinical features, decision rules and biomarkers for selecting pregnant or postpartum women with a suspected PE for imaging.

DESIGN

An expert consensus study to develop new clinical decision rules, a case-control study of women with a diagnosed PE or a suspected PE, a biomarker study of women with a suspected PE or diagnosed deep-vein thrombosis (DVT) and decision-analysis modelling.

SETTING

Emergency departments and consultant-led maternity units.

PARTICIPANTS

Pregnant/postpartum women with a diagnosed PE from any hospital reporting to the UK Obstetric Surveillance System research platform and pregnant/postpartum women with a suspected PE or diagnosed DVT at 11 prospectively recruiting sites.

INTERVENTIONS

Clinical features, decision rules and biomarkers.

MAIN OUTCOME MEASURES

Sensitivity, specificity, area under receiver operating characteristic (AUROC) curve, quality-adjusted life-years (QALYs) and health-care costs.

RESULTS

The primary analysis involved 181 women with PE and 259 women without PE in the case-control study and 18 women with DVT, 18 with PE and 247 women without either in the biomarker study. Most clinical features showed no association with PE. The AUROC curves for the clinical decision rules were as follows: primary consensus, 0.626; sensitive consensus, 0.620; specific consensus, 0.589; PE rule-out criteria, 0.621; simplified Geneva score, 0.579; Wells's PE criteria (permissive), 0.577; and Wells's PE criteria (strict), 0.732. The sensitivities and specificities of the D-dimer measurement were 88.4% and 8.8%, respectively, using a standard threshold, and 69.8% and 32.8%, respectively, using a pregnancy-specific threshold. Previous venous thromboembolism, long-haul travel, multiple pregnancy, oxygen saturation, recent surgery, temperature and PE-related chest radiograph abnormality were predictors of PE on multivariable analysis. We were unable to derive a rule through multivariable analysis or recursive partitioning with adequate accuracy. The AUROC curves for the biomarkers were as follows: activated partial thromboplastin time - 0.669, B-type natriuretic peptide - 0.549, C-reactive protein - 0.542, Clauss fibrinogen - 0.589, enzyme-linked immunosorbent assay D-dimer - 0.668, Innovance D-dimer (Siemens Healthcare Diagnostics Products GmbH, distributed by Sysmex UK Ltd, Milton Keynes, UK) - 0.651, mid-regional pro-atrial natriuretic peptide (MRproANP) - 0.524, prothrombin fragment 1 + 2 - 0.562, plasmin-antiplasmin - 0.639, Prothombin time - 0.613, thrombin generation lag time - 0.702, thrombin generation endogenous potential - 0.559, thrombin generation peak - 0.596, thrombin generation time to peak - 0.655, tissue factor - 0.531 and troponin - 0.597. The repeat analysis excluding women who had received anticoagulation was limited by the small number of women with PE (n = 4). The health economic analysis showed that a strategy of scanning all women with a suspected PE accrued more QALYs and incurred fewer costs than any selective strategy based on a clinical decision rule and was therefore the dominant strategy.

LIMITATIONS

The findings apply specifically to the diagnostic assessment of women with a suspected PE in secondary care.

CONCLUSIONS

Clinical features, decision rules and biomarkers do not accurately, effectively or cost-effectively select pregnant or postpartum women with a suspected PE for diagnostic imaging.

FUTURE WORK

New diagnostic technologies need to be developed to detect PE in pregnancy.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN21245595.

FUNDING DETAILS

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 47. See the NIHR Journals Library website for further project information.

PP19 Opioid poisoning deaths: a national picture

Background

The factors associated with opioid poisoning death are poorly understood. We performed a retrospective autopsy study of decedents of opioid poisoning in Wales in 2015. Using anonymised linked data, we describe demographic characteristics, patterns of emergency service utilisation, and clinical presentation prior to death.

Methods

Decedents of opioid poisoning in Wales in 2015 were identified from Office of National Statistics (ONS) mortality data. Records were linked with the Emergency Department Dataset (EDDS) by the National Welsh Informatics Service (NWIS); and held in the Secure Anonymised Information Linkage (SAIL) databank. Data were accessed and analysed in the SAIL gateway.

Results

Age at death ranged from eighteen to seventy-eight years, with a mean of forty-two years. Average male age was forty-one years and average female age was forty-four and a half years. Seventy-six percent of decedents were men (n=98/112).

Eight-seven percent of decedents (n=112/129) attended the emergency department in the three years prior to death; eighty-nine in the previous year, ninety-nine in the previous two years and 112 in the previous three years. Eighty-four percent of male and ninety-three percent of female decedents attended the ED in the three years prior to death.

In total 665 attendances were made, half of which involved conveyance by ambulance. Attendances per individual ranged from one to sixty, with over half of decedents attending more than three times.

Diagnostic codes were mostly missing or non-specific, with only six and a half percent of attendances representing twenty seven decedents, coded as drug related.

Conclusions

Matching previously published data, we found that fatal opioid poisoning is preceded by a period of high emergency health service utilisation. On average decedents were in their fifth decade and more likely to be male than female. Attendances varied widely, with men less likely to attend than women.

PP24 Time: take-home naloxone in multicentre emergency settings: protocol for a feasibility study

Background

Opioids such as heroin kill more people worldwide than any other drug. Death rates associated with opioid poisoning in the UK are at record levels. Naloxone is an opioid agonist which can be distributed in take home ‘kits’. This intervention is known as Take Home Naloxone (THN).

Methods

We propose to carry out a randomised controlled feasibility trial (RCT) of THN distributed in emergency settings clustered by Emergency Department (ED) catchment area, and local ambulance service; with anonymised linked data outcomes. This will include distribution of THN by paramedics and ED staff to patients at risk of opioid overdose. Existing linked data will be used to develop a discriminant function to retrospectively identify people at high risk of overdose death based on observable predictors of overdose to include in outcome follow up.

Results

We will gather outcomes up to one year including; deaths (and drug related); emergency admissions; intensive care admissions; ED attendances (and overdose related); 999 attendances (and for overdose); THN kits issued; and NHS resource usage. We will agree progression criteria following consultation with research team members related to sign up of sites; successful identification and provision of THN to eligible participants; successful follow up of eligible participants and opioid decedents; adverse event rate; successful data matching and data linkage; and retrieval of outcomes within three months of projected timeline.

Conclusions

THN programmes are currently run by some drug services in the UK. However, saturation is low. There has been a lack of experimental research in to THN, and so questions remain: Does THN reduce deaths? Are there unforeseen harms associated with THN? Is THN cost effective? This feasibility study will establish whether a fully powered cluster RCT can be used to answer these questions.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

The DiPEP study: an observational study of the diagnostic accuracy of clinical assessment, D-dimer and chest x-ray for suspected pulmonary embolism in pregnancy and postpartum

Objective

To identify clinical features associated with pulmonary embolism (PE) diagnosis and determine the accuracy of decision rules and D‐dimer for diagnosing suspected PE in pregnant/postpartum women

Design

Observational cohort study augmented with additional cases.

Setting

Emergency departments and maternity units at eleven prospectively recruiting sites and maternity units in the United Kingdom Obstetric Surveillance System (UKOSS)

Population

324 pregnant/postpartum women with suspected PE and 198 pregnant/postpartum women with diagnosed PE

Methods

We recorded clinical features, elements of clinical decision rules, D‐dimer measurements, imaging results, treatments and adverse outcomes up to 30 days

Main outcome measures

Women were classified as having PE on the basis of imaging, treatment and adverse outcomes by assessors blind to clinical features and D‐dimer. Primary analysis was limited to women with conclusive imaging to avoid work‐up bias. Secondary analyses included women with clinically diagnosed or ruled out PE.

Results

The only clinical features associated with PE on multivariate analysis were age (odds ratio 1.06; 95% confidence interval 1.01–1.11), previous thrombosis (3.07; 1.05–8.99), family history of thrombosis (0.35; 0.14–0.90), temperature (2.22; 1.26–3.91), systolic blood pressure (0.96; 0.93–0.99), oxygen saturation (0.87; 0.78–0.97) and PE‐related chest x‐ray abnormality (13.4; 1.39–130.2). Clinical decision rules had areas under the receiver‐operator characteristic curve ranging from 0.577 to 0.732 and no clinically useful threshold for decision‐making. Sensitivities and specificities of D‐dimer were 88.4% and 8.8% using a standard threshold and 69.8% and 32.8% using a pregnancy‐specific threshold.

Conclusions

Clinical decision rules and D‐dimer should not be used to select pregnant or postpartum women with suspected PE for further investigation. Clinical features and chest x‐ray appearances may have counter‐intuitive associations with PE in this context.

Tweetable abstract

Clinical decision rules and D‐dimer are not helpful for diagnosing pregnant/postpartum women with suspected PE

Clinical decision rules and D‐dimer are not helpful for diagnosing pregnant/postpartum women with suspected PE.

Normosmic idiopathic hypogonadotrophic hypogonadism due to a rare KISS1R gene mutation

Hypogonadotrophic hypogonadism is due to impaired or reduced gonadotrophin secretion from the pituitary gland. In the absence of any anatomical or functional lesions of the pituitary or hypothalamic gland, the hypogonadotrophic hypogonadism is referred to as idiopathic hypogonadotrophic hypogonadism (IHH). We present a case of a young lady born to consanguineous parents who was found to have IHH due to a rare gene mutation.