The effect of psychiatric decision unit services on inpatient admissions and mental health presentations in emergency departments: an interrupted time series analysis from two cities and one rural area in England

AIMS

High-quality evidence is lacking for the impact on healthcare utilisation of short-stay alternatives to psychiatric inpatient services for people experiencing acute and/or complex mental health crises (known in England as psychiatric decision units [PDUs]). We assessed the extent to which changes in psychiatric hospital and emergency department (ED) activity were explained by implementation of PDUs in England using a quasi-experimental approach.

METHODS

We conducted an interrupted time series (ITS) analysis of weekly aggregated data pre- and post-PDU implementation in one rural and two urban sites using segmented regression, adjusting for temporal and seasonal trends. Primary outcomes were changes in the number of voluntary inpatient admissions to (acute) adult psychiatric wards and number of ED adult mental health-related attendances in the 24 months post-PDU implementation compared to that in the 24 months pre-PDU implementation.

RESULTS

The two PDUs (one urban and one rural) with longer (average) stays and high staff-to-patient ratios observed post-PDU decreases in the pattern of weekly voluntary psychiatric admissions relative to pre-PDU trend (Rural: -0.45%/week, 95% confidence interval [CI] = -0.78%, -0.12%; Urban: -0.49%/week, 95% CI = -0.73%, -0.25%); PDU implementation in each was associated with an estimated 35-38% reduction in total voluntary admissions in the post-PDU period. The (urban) PDU with the highest throughput, lowest staff-to-patient ratio and shortest average stay observed a 20% (-20.4%, CI = -29.7%, -10.0%) level reduction in mental health-related ED attendances post-PDU, although there was little impact on long-term trend. Pooled analyses across sites indicated a significant reduction in the number of voluntary admissions following PDU implementation (-16.6%, 95% CI = -23.9%, -8.5%) but no significant (long-term) trend change (-0.20%/week, 95% CI = -0.74%, 0.34%) and no short- (-2.8%, 95% CI = -19.3%, 17.0%) or long-term (0.08%/week, 95% CI = -0.13, 0.28%) effects on mental health-related ED attendances. Findings were largely unchanged in secondary (ITS) analyses that considered the introduction of other service initiatives in the study period.

CONCLUSIONS

The introduction of PDUs was associated with an immediate reduction of voluntary psychiatric inpatient admissions. The extent to which PDUs change long-term trends of voluntary psychiatric admissions or impact on psychiatric presentations at ED may be linked to their configuration. PDUs with a large capacity, short length of stay and low staff-to-patient ratio can positively impact ED mental health presentations, while PDUs with longer length of stay and higher staff-to-patient ratios have potential to reduce voluntary psychiatric admissions over an extended period. Taken as a whole, our analyses suggest that when establishing a PDU, consideration of the primary crisis-care need that underlies the creation of the unit is key.

Frailty assessment of older patients in the emergency department

An ageing population is leading to an increase in patients attending emergency departments (EDs) with comorbidities and age-related syndromes such as frailty. Frailty is a clinical syndrome defined as an increased vulnerability to age-related or disease-related insults in older adults due to diminishing physiological reserves. It also places increased demands on staff and hospital services. Screening for frailty early in the care pathway ensures goal-directed and timely care. This article provides an overview of frailty and its assessment in older people presenting to the ED. It discusses the most commonly used frailty assessment tool in the ED, the Clinical Frailty Scale, and identifies that the results of frailty assessment should be used to initiate appropriate individualised care in older patients.

Emergency nurses' preference for tools to identify frailty in major trauma patients: A prospective multi-centre cross-sectional study

BACKGROUND

Frailty is known to be a predictor of poor recovery following trauma and there is evidence that providing early frailty specific care can improve functional and health outcomes. Accurate assessment of frailty is key to its early identification and subsequent provision of specialist care. The aim of this study was to determine the feasibility and acceptability of different frailty screening tools to nurses administering them in the ED in patients admitted following traumatic injury.

METHODS

Patients aged 65 and over attending the Emergency Department of five major trauma centres following injury participated in the study between June 2019 and March 2020. Patients were assessed using the clinical frailty scale (CFS), Program of Research to Integrate Services for the Maintenance of Autonomy 7 (PRIMSA7), and the Trauma Specific Frailty Index (TSFI). Nurses were asked to rank ease of use and to state their preference for each of the tools from best to worst. If the tool was not able to be completed fully then free text responses were enabled to identify reasons. Accuracy of the tool in identifying if the patient was frail or not was determined by comparison with frailty determined by a geriatrician.

RESULTS

Data were analysed from 372 patients. Completion rates for each of the tools varied, with highest degree of compliance using the CFS (98.9%). TSFI was least likely to be completed with "lack of available information to complete questions" as the most cited reason. Nurses showed a clear preference for the CFS with 57.3% ranking this as first choice (PRISMA-7 32.16%; TSFI 10.54%). Both PRISMA-7 and CFS were both rated highly as 'extremely easy to complete' (PRISMA-7 58.5%, CFS 59.61%).

CONCLUSION

Our results suggest that nurses from five centres preferred to use the CFS to assess frailty in ED major trauma patients.

Investigating the effects of frailty on six-month outcomes in older trauma patients admitted to UK major trauma centres: a multi-centre follow up study

BACKGROUND

Pre-injury frailty is associated with adverse in-hospital outcomes in older trauma patients, but the association with longer term survival and recovery is unclear. We aimed to investigate post discharge survival and health-related quality of life (HRQoL) in older frail patients at six months after Major Trauma Centre (MTC) admission.

METHODS

This was a multi-centre study of patients aged ≥ 65 years admitted to five MTCs. Data were collected via questionnaire at hospital discharge and six months later. The primary outcome was patient-reported HRQoL at follow up using Euroqol EQ5D-5 L visual analogue scale (VAS). Secondary outcomes included health status according to EQ5D dimensions and care requirements at follow up. Multivariable linear regression analysis was conducted to evaluate the association between predictor variables and EQ-5D-5 L VAS at follow up.

RESULTS

Fifty-four patients died in the follow up period, of which two-third (64%) had been categorised as frail pre-injury, compared to 21 (16%) of the 133 survivors. There was no difference in self-reported HRQoL between frail and not-frail patients at discharge (Mean EQ-VAS: Frail 55.8 vs. Not-frail 64.1, p = 0.137) however at follow-up HRQoL had improved for the not-frail group but deteriorated for frail patients (Mean EQ-VAS: Frail: 50.0 vs. Not-frail: 65.8, p = 0.009). There was a two-fold increase in poor quality of life at six months (VAS ≤ 50) for frail patients (Frail: 65% vs. Not-frail: 30% p < 0.009). Frailty (β-13.741 [95% CI -25.377, 2.105], p = 0.02), increased age (β -1.064 [95% CI [-1.705, -0.423] p = 0.00) and non-home discharge (β -12.017 [95% CI [118.403, 207.203], p = 0.04) were associated with worse HRQoL at follow up. Requirements for professional carers increased five-fold in frail patients at follow-up (Frail: 25% vs. Not-frail: 4%, p = 0.01).

CONCLUSIONS

Frailty is associated with increased mortality post trauma discharge and frail older trauma survivors had worse HRQoL and increased care needs at six months post-discharge. Pre-injury frailty is a predictor of poor longer-term HRQoL after trauma and recognition should enable early specialist pathways and discharge planning.

Evaluating mental health decision units in acute care pathways (DECISION): a quasi-experimental, qualitative and health economic evaluation

Background

People experiencing mental health crises in the community often present to emergency departments and are admitted to a psychiatric hospital. Because of the demands on emergency department and inpatient care, psychiatric decision units have emerged to provide a more suitable environment for assessment and signposting to appropriate care.

Objectives

The study aimed to ascertain the structure and activities of psychiatric decision units in England and to provide an evidence base for their effectiveness, costs and benefits, and optimal configuration.

Design

This was a mixed-methods study comprising survey, systematic review, interrupted time series, synthetic control study, cohort study, qualitative interview study and health economic evaluation, using a critical interpretive synthesis approach.

Setting

The study took place in four mental health National Health Service trusts with psychiatric decision units, and six acute hospital National Health Service trusts where emergency departments referred to psychiatric decision units in each mental health trust.

Participants

Participants in the cohort study (n = 2110) were first-time referrals to psychiatric decision units for two 5-month periods from 1 October 2018 and 1 October 2019, respectively. Participants in the qualitative study were first-time referrals to psychiatric decision units recruited within 1 month of discharge (n = 39), members of psychiatric decision unit clinical teams (n = 15) and clinicians referring to psychiatric decision units (n = 19).

Outcomes

Primary mental health outcome in the interrupted time series and cohort study was informal psychiatric hospital admission, and in the synthetic control any psychiatric hospital admission; primary emergency department outcome in the interrupted time series and synthetic control was mental health attendance at emergency department. Data for the interrupted time series and cohort study were extracted from electronic patient record in mental health and acute trusts; data for the synthetic control study were obtained through NHS Digital from Hospital Episode Statistics admitted patient care for psychiatric admissions and Hospital Episode Statistics Accident and Emergency for emergency department attendances. The health economic evaluation used data from all studies. Relevant databases were searched for controlled or comparison group studies of hospital-based mental health assessments permitting overnight stays of a maximum of 1 week that measured adult acute psychiatric admissions and/or mental health presentations at emergency department. Selection, data extraction and quality rating of studies were double assessed. Narrative synthesis of included studies was undertaken and meta-analyses were performed where sufficient studies reported outcomes.

Results

Psychiatric decision units have the potential to reduce informal psychiatric admissions, mental health presentations and wait times at emergency department. Cost savings are largely marginal and do not offset the cost of units. First-time referrals to psychiatric decision units use more inpatient and community care and less emergency department-based liaison psychiatry in the months following the first visit. Psychiatric decision units work best when configured to reduce either informal psychiatric admissions (longer length of stay, higher staff-to-patient ratio, use of psychosocial interventions), resulting in improved quality of crisis care or demand on the emergency department (higher capacity, shorter length of stay). To function well, psychiatric decision units should be integrated into the crisis care pathway alongside a range of community-based support.

Limitations

The availability and quality of data imposed limitations on the reliability of some analyses.

Future work

Psychiatric decision units should not be commissioned with an expectation of short-term financial return on investment but, if appropriately configured, they can provide better quality of care for people in crisis who would not benefit from acute admission or reduce pressure on emergency department.

Study registration

The systematic review was registered on the International Prospective Register of Systematic Reviews as CRD42019151043.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/49/70) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 25. See the NIHR Funding and Awards website for further award information.

Non-medical practitioners in the staffing of emergency departments and urgent treatment centres in England: a mixed qualitative methods study of policy implementation

BACKGROUND

Patient demand, internationally, on emergency departments and urgent care treatment centres has grown. Shortages of staff, particularly of emergency medicine doctors, have compounded problems. Some countries are pursuing solutions of including non-medical practitioners e.g., nurse practitioners and physician associates/assistants in their emergency department workforces. This study investigated at the macro and meso level of the health system in England: what the rationale was and the factors influencing the current and future employment, or otherwise, of non-medical practitioners in emergency departments and urgent treatment centres.

METHODS

Mixed qualitative methods in the interpretative tradition were employed. We undertook, in 2021-2022, a documentary analysis of national, regional and subregional policy (2017-2021), followed by semi-structured interviews of a purposive sample (n = 18) of stakeholders from national, regional and subregional levels. The data were thematically analysed and then synthesised.

RESULTS

There was general national policy support for increasing the presence of non-medical practitioners as part of the solution to shortages of emergency medicine doctors. However, evidence of policy support dissipated at regional and subregional levels. There were no published numbers for non-medical practitioners in emergency departments, but stakeholders suggested they were relatively small in number, unevenly distributed and faced uncertain growth. While the experience of the COVID-19 pandemic and its aftermath were said to have made senior decision makers more receptive to workforce innovation, many factors contributed to the uncertain growth. These factors included: limited evidence on the relative advantage of including non-medical practitioners; variation in the models of service being pursued to address patient demand on emergency departments and the place of non-medical practitioners within them; the lack of a national workforce plan with clear directives; and the variation in training for non-medical practitioner roles, combined with the lack of regulation of that level of practice.

CONCLUSIONS

We identified many features of a system ready to introduce non-medical practitioners in emergency departments and urgent treatment centres but there were uncertainties and the potential for conflict with other professional groups. One area of uncertainty was evidence of relative advantage in including non-medical practitioners in staffing. This requires urgent attention to inform decision making for short- and long-term workforce planning. Further investigation is required to consider whether these findings are generalisable to other specialties, and to similar health systems in other countries.

Comparing Research Priority-Setting Partnerships for Older Adults Across International Health Care Systems: A Systematic Review

OBJECTIVES

Priority setting partnerships (PSPs) attempt to shape the research agenda to address the needs of local populations of interest. We reviewed the PSPs for older adults, with a focus on exemplar health care systems: United Kingdom (UK; publicly funded), United States (private health insurance-based), South Korea (national health insurance-based), and Africa (out-of-pocket).

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

We searched databases and sources (January 2011-October 202l; updated in February 2023) for PSPs of older adults' health care.

METHODS

Based on the British geriatric medicine curriculum, we extracted and categorized the PSP topics by areas and the research priorities by themes, and generated evidence maps depicting and comparing the research gaps across the systems. We evaluated PSP quality using the Nine Common Themes of Good Clinical Practice.

RESULTS

We included 32 PSPs (United Kingdom: n = 25; United States: n = 7; South Korea and Africa: n = 0) and identified priorities regarding 27 conditions or service arrangements in the United Kingdom and 9 in the United States (predominantly in neurology/psychiatry). The UK priorities focused on treatments and interventions whereas the US on prognostic/predictive factors. There were notable research gaps within the existing PSPs, including common geriatric conditions like continence and frailty. The PSP quality evaluation revealed issues around lacking inclusion of ethnic minorities.

CONCLUSIONS AND IMPLICATIONS

Research priorities for older adult health care vary internationally, but certain health care systems/countries have no available PSPs. Where PSPs are available, fundamental aspects of geriatric medicine have not been included. Future researchers should conduct prioritizations in different countries, focus on core geriatric syndromes, and ensure the inclusion of all relevant stakeholder groups.

Assessment and management of pelvic fractures from high-energy trauma in adults

Pelvic fractures caused by high-energy trauma such as falling from a height or road traffic collisions have a high mortality rate and patients are also at high risk of life-changing injuries. High-energy trauma to the pelvis is associated with major haemorrhage and injuries to the internal pelvic organs. Emergency nurses have a fundamental role in the initial assessment and management of patients, as well as in their ongoing care once the fracture has been stabilised and bleeding is controlled. This article describes the anatomy of the pelvis, discusses the initial assessment and management of patients who have sustained high-energy pelvic trauma, details the complications of pelvic fractures and explains patients' ongoing care in the emergency department.

AWAreness during REsuscitation - II: A multi-center study of consciousness and awareness in cardiac arrest

INTRODUCTION

Cognitive activity and awareness during cardiac arrest (CA) are reported but ill understood. This first of a kind study examined consciousness and its underlying electrocortical biomarkers during cardiopulmonary resuscitation (CPR).

METHODS

In a prospective 25-site in-hospital study, we incorporated a) independent audiovisual testing of awareness, including explicit and implicit learning using a computer and headphones, with b) continuous real-time electroencephalography(EEG) and cerebral oxygenation(rSO2) monitoring into CPR during in-hospital CA (IHCA). Survivors underwent interviews to examine for recall of awareness and cognitive experiences. A complementary cross-sectional community CA study provided added insights regarding survivors' experiences.

RESULTS

Of 567 IHCA, 53(9.3%) survived, 28 of these (52.8%) completed interviews, and 11(39.3%) reported CA memories/perceptions suggestive of consciousness. Four categories of experiences emerged: 1) emergence from coma during CPR (CPR-induced consciousness [CPRIC]) 2/28(7.1%), or 2) in the post-resuscitation period 2/28(7.1%), 3) dream-like experiences 3/28(10.7%), 4) transcendent recalled experience of death (RED) 6/28(21.4%). In the cross-sectional arm, 126 community CA survivors' experiences reinforced these categories and identified another: delusions (misattribution of medical events). Low survival limited the ability to examine for implicit learning. Nobody identified the visual image, 1/28(3.5%) identified the auditory stimulus. Despite marked cerebral ischemia (Mean rSO2 = 43%) normal EEG activity (delta, theta and alpha) consistent with consciousness emerged as long as 35-60 minutes into CPR.

CONCLUSIONS

Consciousness. awareness and cognitive processes may occur during CA. The emergence of normal EEG may reflect a resumption of a network-level of cognitive activity, and a biomarker of consciousness, lucidity and RED (authentic "near-death" experiences).

Real world safety of methoxyflurane analgesia in the emergency setting: a comparative hybrid prospective-retrospective post-authorisation safety study

BACKGROUND

Low-dose analgesic methoxyflurane (Penthrox®) was approved in Europe for emergency relief of moderate to severe pain in conscious adults with trauma in 2015. A comparative post-authorisation safety study (PASS) was conducted to assess the risk of hepatotoxicity and nephrotoxicity with methoxyflurane during routine clinical practice.

METHODS

This was a comparative hybrid prospective-retrospective cohort study. The comparative cohorts consisted of adults who were given methoxyflurane (methoxyflurane cohort) or another analgesic (concurrent cohort) routinely used for moderate to severe trauma and associated pain in the emergency setting (ambulance and Emergency Department) in the UK between December 2016 and November 2018. Hepatic and renal events were captured in the ensuing 12 weeks. A blinded clinical adjudication committee assessed events. A historical comparator cohort (non-concurrent cohort) was identified from patients with fractures in the English Hospital Episode Statistics (HES) accident and emergency database from November 2013 and November 2015 (before commercial launch of methoxyflurane). Hepatic and renal events were captured in the ensuing 12 weeks via linkage with the Clinical Practice Research Datalink (CPRD) and HES hospital admissions databases.

RESULTS

Overall, 1,236, 1,101 and 45,112 patients were analysed in the methoxyflurane, concurrent and non-concurrent comparator cohorts respectively. There was no significant difference in hepatic events between the methoxyflurane and concurrent cohorts (1.9% vs. 3.0%, P = 0.079) or between the methoxyflurane and non-concurrent cohorts (1.9% vs. 2.5%, P = 0.192). Renal events were significantly less common in the methoxyflurane cohort than in the concurrent cohort (2.3% vs. 5.6%, P < 0.001). For methoxyflurane versus non-concurrent cohort the lower occurrence of renal events (2.3% vs. 3.2%, P = 0.070) was not statistically significant. Multivariable adjustment did not change these associations.

CONCLUSIONS

Methoxyflurane administration was not associated with an increased risk of hepatotoxicity or nephrotoxicity compared with other routinely administered analgesics and was associated with a reduced risk of nephrotoxicity compared with other routinely administered analgesics.

TRIAL REGISTRATION

Study registered in the EU PAS Register (ENCEPP/SDPP/13040).

Screening patients for unintentional carbon monoxide exposure in the Emergency Department: a cross-sectional multi-centre study

BACKGROUND

Low-level exposure to carbon monoxide (CO) is a significant health concern but is difficult to diagnose. This main study aim was to establish the prevalence of low-level CO poisoning in Emergency Department (ED) patients.

METHODS

A prospective cross-sectional study of patients with symptoms of CO exposure was conducted in four UK EDs between December 2018 and March 2020. Data on symptoms, a CO screening tool and carboxyhaemoglobin were collected. An investigation of participants' homes was undertaken to identify sources of CO exposure.

RESULTS

Based on an ED assessment of 4175 participants, the prevalence of suspected CO exposure was 0.62% (95% CI; 0.41-0.91%). CO testing in homes confirmed 1 case of CO presence and 21 probable cases. Normal levels of carboxyhaemoglobin were found in 19 cases of probable exposure and in the confirmed case.

CONCLUSION

This study provides evidence that ED patients with symptoms suggestive of CO poisoning but no history of CO exposure are at risk from CO poisoning. The findings suggest components of the CO screening tool may be an indicator of CO exposure over and above elevated COHb. Clinicians should have a high index of suspicion for CO exposure so that this important diagnosis is not missed.

Establishing the research priorities for major trauma in the United Kingdom: A Delphi study of nurses and allied health professionals

BACKGROUND

Research prioritisation exercises are used to determine which areas of research are important. In major trauma care, nurses and allied health professionals are central to the delivery of evidence-based care but their opinions on research priorities are under-represented in the literature. We aimed to identify the research priorities of major trauma nurses and allied health professionals in the UK.

METHODS

A three-round electronic Delphi study was conducted in the UK between November 2019 and May 2021. Round one aimed to generate research questions with rounds two and three questions in order of priority. In stages two and three responses were analysed using descriptive statistics to compute frequencies and proportions for the ranking of each question.

RESULTS

Survey rounds were completed by 180, 100 and 91 respondents respectively. The first round generated 285 statements that were condensed into 71 research questions. Analysis of rankings in subsequent rounds prioritised 54 research questions across themes of adult / children's acute care, psychological care and workforce, training and education.

DISCUSSION

Nurses and AHPs are well-positioned to determine research priorities in major trauma care. Focusing on these priorities will guide future research and help to build an evidence-base in trauma care.

Configurations and outcomes of acute hospital care for frail and older patients with moderate to major trauma: a systematic review

OBJECTIVE

To systematically review research on acute hospital care for frail or older adults experiencing moderate to major trauma.

SETTING

Electronic databases (Medline, Embase, ASSIA, CINAHL Plus, SCOPUS, PsycINFO, EconLit, The Cochrane Library) were searched using index and key words, and reference lists and related articles hand-searched.

INCLUDED ARTICLES

Peer-reviewed articles of any study design, published in English, 1999-2020 inclusive, referring to models of care for frail and/or older people in the acute hospital phase of care following traumatic injury defined as either moderate or major (mean or median Injury Severity Score ≥9). Excluded articles reported no empirical findings, were abstracts or literature reviews, or referred to frailty screening alone.

METHODS

Screening abstracts and full text, and completing data extractions and quality assessments using QualSyst was a blinded parallel process. A narrative synthesis, grouped by intervention type, was undertaken.

OUTCOME MEASURES

Any outcomes reported for patients, staff or care system.

RESULTS

17 603 references were identified and 518 read in full; 22 were included-frailty and major trauma (n=0), frailty and moderate trauma (n=1), older people and major trauma (n=8), moderate or major trauma (n=7) 0r moderate trauma (n=6) . Studies were observational, heterogeneous in intervention and with variable methodological quality.Specific attention given to the care of older and/or frail people with moderate to major trauma in the North American context resulted in improvements to in-hospital processes and clinical outcomes, but highlights a relative paucity of evidence, particularly in relation to the first 48 hours post-injury.

CONCLUSIONS

This systematic review supports the need for, and further research into an intervention to address the care of frail and/or older patients with major trauma, and for the careful definition of age and frailty in relation to moderate or major trauma. INTERNATIONAL PROSPECTIVE REGISTER OF SYSTEMATIC REVIEWS PROSPERO: CRD42016032895.

Service use preceding and following first referral for psychiatric emergency care at a short-stay crisis unit: A cohort study across three cities and one rural area in England

BACKGROUND

Internationally, hospital-based short-stay crisis units have been introduced to provide a safe space for stabilisation and further assessment for those in psychiatric crisis. The units typically aim to reduce inpatient admissions and psychiatric presentations to emergency departments.

AIMS

To assess changes to service use following a service user's first visit to a unit, characterise the population accessing these units and examine equality of access to the units.

METHODS

A prospective cohort study design (ISCTRN registered; 53431343) compared service use for the 9 months preceding and following a first visit to a short-stay crisis unit at three cities and one rural area in England. Included individuals first visited a unit in the 6 months between 01/September/2020 and 28/February/2021.

RESULTS

The prospective cohort included 1189 individuals aged 36 years on average, significantly younger (by 5-13 years) than the population of local service users (<.001). Seventy percent were White British and most were without a psychiatric diagnosis (55%-82% across sites). The emergency department provided the largest single source of referrals to the unit (42%), followed by the Crisis and Home Treatment Team (20%). The use of most mental health services, including all types of admission and community mental health services was increased post discharge. Social-distancing measures due to the COVID-19 pandemic were in place for slightly over 50% of the follow-up period. Comparison to a pre-COVID cohort of 934 individuals suggested that the pandemic had no effect on the majority of service use variables.

CONCLUSIONS

Short-stay crisis units are typically accessed by a young population, including those who previously were unknown to mental health services, who proceed to access a broader range of mental health services following discharge.

1497 Methods to diagnose carbon monoxide exposure: A scoping review

Aims, Objectives and Background

Carbon-monoxide (CO) is a colourless, odourless gas produced from incomplete combustion of carbon-containing fuels. Measurement of CO levels to diagnose exposure is difficult due to its short half-life. The effects of exposure to CO range from mild symptoms, such as headache, to neurotoxicity and death.

In this scoping review we aimed to establish the existing methods used in clinical practice and research to determine CO exposure and map the diagnostic cut-off values used.

Method and design

We undertook a scoping review to establish methods used in clinical practice and research to measure CO exposure and to determine diagnostic thresholds in each. EMBASE, Medline and CINAHL databases were searched for published articles in English from 2002 onwards using keywords ‘carbon monoxide’, ‘poisoning’ and ‘diagnosis’. Two reviewers independently screened published abstracts for inclusion, with a third arbiter where there was lack of agreement between reviewers. Full text papers were then reviewed, and data extracted on methods used to measure CO level, diagnostic cut-off values, and whether CO exposure was from a known or unknown source.

Results and Conclusion

A total of 85 papers were identified meeting the inclusion and exclusion criteria. The most common methods identified for diagnosing CO exposure were measurement of carboxyhaemoglobin (COHb) in whole blood (50.5%) and CO-oximeter spectrophotometrics (20%). Diagnostic values were poorly reported and varied in non-smokers and smokers. Exhaled CO levels using breath analysers (8.2%) and ambient CO measurement (11.7%) were also documented. Diagnostic threshold values varied between 2–5% in non-smokers and 10–15% in smokers. Several methods are used in clinical practice and research to diagnose CO exposure. There is variation in the cut-off values used to make this diagnosis which is challenging for clinicians and makes comparison of research findings difficult.

1397 ’I don’t have time’: strategies for increasing research engagement in emergency department clinicians

Aims, Objectives and Background

Clinicians who engage in generating research knowledge are more likely to implement findings in practice leading to better patient outcomes. Having an emergency department (ED) culture that gives significance to research is an important factor in supporting clinicians to develop the skill and ability to participate and perform research.

In 2018 the ED at St George’s Hospital, London introduced an embedded research group with a dedicated leadership position, bringing together research delivery staff and clinical academics to increase the research culture in the department. This study aimed to investigate the impact of this model on research engagement amongst the ED clinical multi-disciplinary team.

Method and Design

A case study design approach was used involving:

A registry of the research-related initiatives undertaken in the department

Analysing the metrics of engagement in research activities by clinical staff, including number of publications and academic training uptake

Data were collected between April 2018 and March 2022.

Results and Conclusion

Registry data show 41 distinct initiatives established in the time period led or delivered by the research group. These included face-to-face teaching, publication writing support, a research internship program and small grant funding. Research outputs (publications or conference abstracts) showed a 23-fold increase from two in 2018 to 47 in 2021.

The project to develop a research culture in ED has had a positive effect on both type and number of research-related activities across all clinical staff groups. This case study illustrates how research activities delivered close to clinical practice under visible, focused clinical research leadership can increase research engagement. Challenges of a clinically complex context were overcome by embedding a multidisciplinary clinical research unit, linking research delivery with clinical academic development. This model could be replicated in other settings.

Provision of acute care pathways for older major trauma patients in the UK

BACKGROUND

The introduction of specific pathways of care for older trauma patients has been shown to decrease hospital length of stay and the overall rate of complications. The extent and scope of pathways and services for older major trauma patients in the UK is not currently known.

OBJECTIVE

The primary objective of this study was to map the current care pathways and provision of services for older people following major trauma in the UK.

METHODS

A cross-sectional survey of UK hospitals delivering care to major trauma patients (major trauma centres and trauma units). Data were collected on respondent and site characteristics, and local definitions of older trauma patients. To explore pathways for older people with major trauma, four clinical case examples were devised and respondents asked to complete responses that best illustrated the admission pathway for each.

RESULTS

Responses from 56 hospitals were included in the analysis, including from 25 (84%) of all major trauma centres (MTCs) in the UK. The majority of respondents defined 'old' by chronological age, most commonly patients 65 years and over. The specialty team with overall responsibility for the patient in trauma units was most likely to be acute medicine or acute surgery. Patients in MTCs were not always admitted under the care of the major trauma service. Assessment by a geriatrician within 72 hours of admission varied in both major trauma centres and trauma units and was associated with increased age.

CONCLUSIONS

This survey highlights variability in the admitting specialty team and subsequent management of older major trauma patients across hospitals in the UK. Variability appears to be related to patient condition as well as provision of local resources. Whilst lack of standardisation may be a result of local service configuration this has the potential to impact negatively on quality of care, multi-disciplinary working, and outcomes.

Cross-sectional study of carbon monoxide alarm use in patients attending the emergency department: a multicentre survey protocol

INTRODUCTION

The most common place for unintentional, non-fire-related carbon monoxide (CO) exposure to occur is in the home, but this is preventable if CO producing sources are properly maintained and CO alarms/detectors are in use. It is estimated that less than half of all homes have a CO alarm, but there is variation across countries, housing types and different demographic and socioeconomic groups. The purpose of this study is to provide up-to-date data on the use of CO alarms by surveying attendees to emergency departments using an online anonymous questionnaire.

METHODS AND ANALYSIS

A multicentre prospective, cross-sectional survey of 4000 patients or carers in three emergency departments will be used. A questionnaire comprising of a maximum of 14 items will be administered following completion of an informed consent process. Data collected include participant demographics, household information and CO alarm use. Statistical analyses will comprise descriptive techniques to present respondents' use of CO alarms and examine associations between alarm use and participant characteristics. The proportion of homes with CO alarms installed will be calculated for all subjects and for selected subgroups.

ETHICS AND DISSEMINATION

The study obtained ethical approval from the Westminster Research Ethics Committee (REC number 1/PR/1657). Informed consent will be obtained prior to the participant undergoing any activities that are specifically for the purposes of the study. Findings will be published in scientific journals, presented to national and international conferences and disseminated to CO safety groups.

TRIAL REGISTRATION NUMBER

ISRCTN registry 12562718.

Short-stay crisis units for mental health patients on crisis care pathways: systematic review and meta-analysis

BACKGROUND

Internationally, an increasing proportion of emergency department visits are mental health related. Concurrently, psychiatric wards are often occupied above capacity. Healthcare providers have introduced short-stay, hospital-based crisis units offering a therapeutic space for stabilisation, assessment and appropriate referral. Research lags behind roll-out, and a review of the evidence is urgently needed to inform policy and further introduction of similar units.

AIMS

This systematic review aims to evaluate the effectiveness of short-stay, hospital-based mental health crisis units.

METHOD

We searched EMBASE, Medline, CINAHL and PsycINFO up to March 2021. All designs incorporating a control or comparison group were eligible for inclusion, and all effect estimates with a comparison group were extracted and combined meta-analytically where appropriate. We assessed study risk of bias with Risk of Bias in Non-Randomized Studies - of Interventions and Risk of Bias in Randomized Trials.

RESULTS

Data from twelve studies across six countries (Australia, Belgium, Canada, The Netherlands, UK and USA) and 67 505 participants were included. Data indicated that units delivered benefits on many outcomes. Units could reduce psychiatric holds (42% after intervention compared with 49.8% before intervention; difference = 7.8%; P < 0.0001) and increase out-patient follow-up care (χ² = 37.42, d.f. = 1; P < 0.001). Meta-analysis indicated a significant reduction in length of emergency department stay (by 164.24 min; 95% CI -261.24 to -67.23 min; P < 0.001) and number of in-patient admissions (odds ratio 0.55, 95% CI 0.43-0.68; P < 0.001).

CONCLUSIONS

Short-stay mental health crisis units are effective for reducing emergency department wait times and in-patient admissions. Further research should investigate the impact of units on patient experience, and clinical and social outcomes.

1080 NURSES’ PREFERENCE FOR TOOLS TO IDENTIFY FRAILTY IN MAJOR TRAUMA PATIENTS: FINDINGS FROM THE FRAIL-T IN MAJOR TRAUMA STUDY

Introduction

Early assessment of frailty in older major trauma patients is important to providing appropriate care that goes beyond chronological age. Guidance exists that this assessment should be completed as early as possible in the Emergency Department (ED). To increase rates of frailty screening in this group the measurement tool needs to be quick to complete and easy to use. This study aimed to ascertain the preference of nursing staff completing frailty assessment in older major trauma patients in the ED.

Method

This prospective multi-centre study recruited from five UK MTCs between June 2019 and March 2020. Eligible patients were aged 65 or over requiring ‘trauma team activation’ and admitted to hospital. Patients were assessed for frailty by nurses trained to use three different frailty screening tools—the Clinical Frailty Scale (CFS), the PRISMA-7 tool, and the Trauma Specific Frailty Index (TSFI). Completion rates for each of the tools were calculated and nurses were asked to rate their preference for each of the tools and the reasons for non-completion if relevant.

Results

Data were analysed from 370 patients. Completion rates for each of the tools varied with highest degree of compliance using the CFS (98.9%). TSFI was least likely to be completed with ‘lack of available information to complete questions’ as the most cited reason. Nurses showed a clear preference for the CFS with 57.3% ranking this as first choice (PRISMA-7 32.16%; TSFI 10.54%). Both PRISMA-7 and CFS were both rated highly as ‘extremely easy to complete’ (PRISMA-7 58.5%, CFS 59.61%).

Conclusion

User acceptability is an important consideration in the selection of a frailty measurement tool for use in major trauma patients. Our study shows the Clinical Frailty Scale has high rates of completion and acceptability and can be implemented in practice for assessment of frailty in major trauma.

Migraine in the emergency department: A retrospective evaluation of the characteristics of attendances in a major city hospital in the United Kingdom

Introduction:

Detailed Emergency Department attendance data for migraine are needed for service redesign.

Methods:

A service evaluation was undertaken, classifying adult emergency department headache attendances using the International Classification of Headache Disorders migraine C-E criteria, evaluating attendance characteristics.

Results:

Migraine/Probable migraine diagnosis was documented in 58% but coded in 24% attendances by ED clinicians. 29% of patients used no analgesia before attending, 43% attended ≥4 days after onset and 19% arrived by ambulance.

Conclusion:

This evaluation highlights sub-optimal acute management and discrepancy between migraine coding and diagnosis contributing to underreporting. We recommend further evaluation of identified cohorts and headache proforma use.

803 QUALITY OF LIFE IN OLDER TRAUMA PATIENTS AFTER INJURY: FINDINGS FROM THE FRAILTY IN MAJOR TRAUMA STUDY (FRAIL-T)

Introduction

Major trauma is a substantial health burden for older patients with a significant proportion having ongoing functional and psychological difficulties long after their injury. Frailty impacts adversely on outcome after trauma but the longer term effects are unknown. This study aimed to determine differences in health related quality of life (HRQoL) and change in dependence for frail and non-frail patients aged 65 or over discharged from Major Trauma Centres (MTCs) following injury.

Methods

This prospective multi-centre study recruited from five UK MTCs between June 2019 and March 2020. Eligible patients were aged 65 or over requiring ‘trauma team activation’ and admitted to hospital. Follow-up data was collected via questionnaire at two time points: on day of hospital discharge and at 6 months. Primary outcome at follow-up was patient reported health-related quality of life (HRQoL) using the EQ-5D-5L measure.

Results

Data were analysed from 181 patients. 54 died in the follow-up period and HRQoL data was available for 127 patients. Of these 16% were identified as frail during the trauma hospital admission using the Clinical Frailty Scale. On average, frail patients were older (82 years) compared to non-frail (77 years). HRQoL was rated similarly at discharge in both groups (Non-Frail: 60, Frail: 65, p = 0.137), but at follow-up non-frail patients reported improvement whilst those who were frail had deteriorated from the discharge base-line (Non-Frail: 70, Frail: 50, p = 0.01). At 6 months post injury, half of the frail cohort (49%) were more dependent on care than pre-trauma compared to less than a third of non-frail patients (29%).

Conclusion

Patients who were frail in-hospital had worse HQRoL than non-frail patients 6 months after discharge from hospital, with increased dependence. Understanding the impact of injury on quality of life is important in planning for, and supporting, the ongoing care of frail older trauma patients.

734 ACUTE CARE PATHWAYS FOR OLDER MAJOR TRAUMA PATIENTS: A SURVEY OF UK PRACTICE

Introduction

Major trauma is a significant health burden for older patients, with worse clinical outcomes when compared to younger people. Various clinical models exist however it is not clear which have most benefit for older patients. This study aimed to map the current provision of clinical pathways and services for older people with major trauma in the United Kingdom (UK).

Methods

A cross-sectional online survey was undertaken. Case vignettes designed to reflect ‘typical’ older major trauma patients were embedded within the survey. The survey was distributed via trauma network managers and social media, inviting responses from all UK hospitals receiving trauma patients in 2020. Fixed choice questions were analysed with descriptive statistics and free text responses categorised into themes. The survey was not deemed to be research using the UK Health Regulatory Authority tool.

Results

Responses were received from 20/27 Major Trauma Centres (MTCs), 33 Trauma Units (TUs) and two local emergency hospitals. Older patients were defined by age (range 55 to 82 years) or frailty status. Frailty assessment was routinely performed in more than two-thirds (69.1%) of locations. Availability of trauma-specific guidance for older patients varied, and was greater in TUs than MTCs. Analysis of the vignettes showed wide variability in the admission and subsequent interventions for older major trauma patients across hospitals. Qualitative data showed pre-injury health status, staff availability, and day of the week were factors leading to variation within individual hospitals.

Conclusion

There is wide variation in the processes of care and pathways for older major trauma patients in the UK. Whilst lack of standardisation may be a result of local service configuration this has the potential to impact negatively on quality of care, multi-disciplinary working and outcomes. Understanding the range of variation in practice provides opportunity to identify good practice and areas for improvement.

791 The EDCO study: screening patients for unintentional carbon monoxide exposure in emergency department patients

Aims/Objectives/Background

Carbon monoxide (CO) is the most common cause of death by poisoning worldwide. Repeated low-level exposure to CO is significant health concern leading to long-term neurological sequelae but is difficult to diagnose due to non-specific symptoms such as headache. We aimed to establish the prevalence of low-level CO poisoning in patients presenting to the ED with symptoms suggestive of CO exposure.

Methods/Design

This prospective multi-centre observational study recruited from four UK EDs between December 2018 and March 2020. Eligible patients were those with symptoms suggestive of CO poisoning including headache, flu-like symptoms and cardiac chest pain. We collected data using the RCEM endorsed ‘COMA’ questions to detect CO poisoning and measured carboxyhaemoglobin (COHb). An investigation of the home was undertaken to identify sources of CO exposure. The proportion (exact 95% confidence interval) of probable CO poisoning in each symptom group was calculated.

Results/Conclusions

We analysed data from 4190 patients. 159 (3.8%) had suspected CO poisoning based on COHb level and/or COMA questions. Prevalence was highest in patients with flu-like symptoms 14.8% (7.9, 24.4).

Data linked to CO testing in the home confirmed 1 case of CO presence and 21 probable cases based on a possible CO source from gas appliances. 62% of probable cases had normal COHb level in ED and were identified using only the COMA questions. Only 7.5% of patients with raised COHb level were considered by ED clinicians to have been exposed to CO as a cause for their symptoms.

This study provides evidence that ED patients with non-specific symptoms and no clear history of CO exposure are at risk from CO poisoning from faulty appliances in the home. We advocate that the COMA tool is used in conjunction with testing of COHb levels at the earliest opportunity to ensure that patients with potential CO exposure are not missed.

Theory and conceptual frameworks: blame and credit/centralization and decentralization

In this presentation we will introduce the politics of blame-avoidance and credit taking. We will also conceptualize centralization between and within governments and lay out the conceptual frameworks which have guided this research. It is almost axiomatic in political science that politicians seek credit and avoid blame. If there is something that will be popular, they try to take credit for it; and if there is something unpopular, they will try to avoid blame and, if possible, cast blame for it onto opponents. If good or bad outcomes cannot be traced to their actions, they will try to change the subject and opt for ‘position-taking' in which they declare their fidelity to what they see as popular positions. This was the strategy adopted by many politicians of the populist radical right around the world during the pandemic, though as the pandemic wore on the ones out of power increasingly focused on blaming incumbent governments for public health measures. Centralization between governments means an increase in the power of the central government vis-a-vis other ‘subnational' governments such as regions, states, provinces, or municipalities. ‘Command and control' is a common recommendation in public health emergencies and central governments do often take powers over or away from subnational governments in crises. This is most politically contentious in federal states such Spain, Canada, or Germany, but can happen even in countries where there is a history of only local government (such as Ireland, Portugal, or the Nordic states).

The psychiatric decision unit as an emerging model in mental health crisis care: a national survey in England

Psychiatric decision units have been developed in many countries internationally to address the pressure on inpatient services and dissatisfactory, long waits people in mental health crisis can experience in emergency departments. Research into these units lags behind their development, as they are implemented by healthcare providers to address these problems. This is the first-ever national survey to identify their prevalence, structure, activities, and contextual setting within health services, in order to provide a robust basis for future research. The response rate was high (94%), and six PDUs in England were identified. The results indicated that PDUs open 24/7, accept only voluntary patients, provide recliner chairs for sleeping rather than beds, and limit stays to 12-72 hours. PDUs are predominantly staffed by senior, qualified mental health nurses and healthcare assistants, with psychiatry input. Staff:patient ratios are high (1:2.1 during the day shift). Differences in PDU structure and activities (including referral pathway, length of stay, and staff:patient ratios) were identified, suggesting the optimal configuration for PDUs has not yet been established. Further research into the efficacy of this innovation is needed; PDUs potentially have a role in an integrated crisis care pathway which provides a variety of care options to service users.

Screening and management of unintentional low-level carbon monoxide exposure in the emergency department

Unintentional carbon monoxide (CO) exposure, sometimes referred to as CO poisoning, is a serious threat to health and can have long-term effects on the neurological and respiratory systems. Patients who have been exposed can present to emergency departments (ED) with non-specific signs and symptoms, which makes it challenging to diagnose. This article describes the pathophysiology, signs and symptoms, and ED management of patients with possible or confirmed low-level CO exposure. It is important for emergency nurses to recognise patients with unintentional CO exposure so that treatment is provided and measures taken to prevent further exposure.

Feasibility and accuracy of ED frailty identification in older trauma patients: a prospective multi-centre study

BACKGROUND

The burden of frailty on older people is identifiable by its adverse effect on mortality, morbidity and long term functional and health outcomes. In patients suffering from a traumatic injury there is increasing evidence that it is frailty rather than age that impacts greatest on these outcomes and that early identification can guide frailty specific care. The aim of this study was to evaluate the feasibility of nurse-led assessment of frailty in older trauma patients in the ED in patients admitted to major trauma centres.

METHODS

Patients age 65 years and over attending the Emergency Departments (ED) of five Major Trauma Centres following traumatic injury were enrolled between June 2019 and March 2020. Patients were assessed for frailty whilst in the ED using three different screening tools (Clinical Frailty Scale [CFS], Program of Research to Integrate Services for the Maintenance of Autonomy 7 [PRIMSA7], and the Trauma Specific Frailty Index [TSFI]) to compare feasibility and accuracy. Accuracy was determined by agreement with geriatrician assessment of frailty. The primary outcome was identification of frailty in the ED using three different assessment tools.

RESULTS

We included 372 patients whose median age was 80, 53.8% of whom were female. The most common mechanism of injury was fall from less than 2 m followed by falls greater than 2 m. Completion rates for the tools were variable, 31.9% for TSFI, compared to 93% with PRISMA7 and 98.9% with the CFS. There was substantial agreement when using CFS between nurse defined frailty and geriatrician defined frailty. Agreement was moderate using PRISMA7 and slight using TSFI.

CONCLUSIONS

This prospective study has demonstrated that screening for frailty in older major trauma patients within the Emergency Department is feasible and accurate using CFS.

TRIAL REGISTRATION

ISRCTN, ISRCTN10671514 . Registered 22 October 2019.

251 The frailty in major trauma study (FRAIL-T): feasibility of nurse lead frailty assessment in elderly trauma and the impact on outcomes

Aims/Objectives/Background

Frailty screening for major trauma patients has recently become part of the best practice commissioning tariff within NHS England, yet there is no consensus as to who should carry out this assessment or which tool best identifies frailty in the Emergency Department (ED). As the trauma population ages there is a need for accurate early identification of frailty in the ED to underpin frailty specific major trauma pathways. The primary aim of this study was to determine the feasibility and accuracy of ED nurse-led frailty assessment in patients ≥ 65 years admitted to Major Trauma Centres (MTCs).

Methods/Design

A prospective observational study was conducted across five UK MTCs, enrolling 370 participants over nine months. Eligible patients were aged 65 or more requiring trauma team activation. Frailty was assessed in the ED using three different tools: Trauma Specific Frailty Index (TSFI); Clinical Frailty Scale (CFS); PRISMA-7. ED nurse frailty assessment was correlated with Geriatrician assessment within 72 hours of admission using Spearman’s correlation coefficient and kappa statistic for measuring the interrater agreement.

Results/Conclusions

Complete frailty assessments were calculated for CFS in 99.4% of patients, PRISMA7 in 95.9% and TSFI in 37.58%. Rates of frailty differed between tools: CFS 32%, PRISMA7 57% and TSFI 92% whilst Geriatrician determined frailty was 37%. In all tools frail patients were older (p<0.001) and falls <2 m were the leading mechanism of injury (p<0.05). CFS showed both strong correlation (rs 0.639,p<0.001) and substantial agreement (kappa 0.637,p<0.001) with Geriatrician assessment within 72 hours of admission.

ED nurses can accurately assess older major trauma patients for frailty using the Clinical Frailty Scale. These findings support assessment of frailty in the ED in order to identify patients who would benefit from early frailty specific care.

A nationwide initiative to increase nursing and midwifery research leadership: overview of year one programme development, implementation and evaluation

AIMS AND OBJECTIVES

To report on the development, implementation and evaluation of the first year of the National Institute for Health Research 70@70 Senior Nurse Research Leader Programme.

BACKGROUND

Internationally, there is a lack of nursing and midwifery research and policy contribution to healthcare sectors. To address this, funding was obtained for a Senior Nurse and Midwife Research Leader Programme in England. The programme aimed to increase nursing and midwifery research capacity and capability and support the development of future research leaders.

DESIGN

The programme had three phases: development, implementation and evaluation. The cohort study's evaluation phase consisted of a survey and qualitative written feedback.

METHODS

An online survey was sent to cohort members (n = 66). Quantitative survey data was analysed in Survey Monkey. Written feedback asked cohort members to summarise their activities and any challenges. Data were thematically analysed. The "Strengthening the Reporting of Observational Studies in Epidemiology" reporting checklist was used.

RESULTS

Thirty-nine (59%) cohort members responded to the survey. Responders valued being part of a network (46%), having protected time (22%) and having workplace autonomy (13%). Challenges reported included difficulties accessing online resources (32%), lack of collaborative opportunities (17%) and organisational barriers (10%). Fifty-six (85%) cohort members submitted the written report. The main themes were "relationship and profile building", "developing capability and capacity", "developing the workforce", "patient and public involvement and engagement" and "quality improvement."

CONCLUSIONS

The 70@70 programme has increased the research profile of the nursing and midwifery professions at a local and national level. International healthcare systems can learn from this, by considering optimal ways to provide nurses and midwives with the tools, resources and confidence to actively contribute to research policy and practice.

RELEVANCE TO CLINICAL PRACTICE

The initiatives undertaken through year 1 of the programme have created a platform through which research can be incorporated into clinical practice, education and teaching.

Pharmacokinetics of intramuscular tranexamic acid in bleeding trauma patients: a clinical trial

BACKGROUND

Intravenous tranexamic acid (TXA) reduces bleeding deaths after injury and childbirth. It is most effective when given early. In many countries, pre-hospital care is provided by people who cannot give i.v. injections. We examined the pharmacokinetics of intramuscular TXA in bleeding trauma patients.

METHODS

We conducted an open-label pharmacokinetic study in two UK hospitals. Thirty bleeding trauma patients received a loading dose of TXA 1 g i.v., as per guidelines. The second TXA dose was given as two 5 ml (0·5 g each) i.m. injections. We collected blood at intervals and monitored injection sites. We measured TXA concentrations using liquid chromatography coupled to mass spectrometry. We assessed the concentration time course using non-linear mixed-effect models with age, sex, ethnicity, body weight, type of injury, signs of shock, and glomerular filtration rate as possible covariates.

RESULTS

Intramuscular TXA was well tolerated with only mild injection site reactions. A two-compartment open model with first-order absorption and elimination best described the data. For a 70-kg patient, aged 44 yr without signs of shock, the population estimates were 1.94 h^-1 for i.m. absorption constant, 0.77 for i.m. bioavailability, 7.1 L h^-1 for elimination clearance, 11.7 L h^-1 for inter-compartmental clearance, 16.1 L volume of central compartment, and 9.4 L volume of the peripheral compartment. The time to reach therapeutic concentrations (5 or 10 mg L^-1) after a single intramuscular TXA 1 g injection are 4 or 11 min, with the time above these concentrations being 10 or 5.6 h, respectively.

CONCLUSIONS

In bleeding trauma patients, intramuscular TXA is well tolerated and rapidly absorbed.

CLINICAL TRIAL REGISTRATION

2019-000898-23 (EudraCT); NCT03875937 (ClinicalTrials.gov).

Frailty in major trauma study (FRAIL-T): a study protocol to determine the feasibility of nurse-led frailty assessment in elderly trauma and the impact on outcome in patients with major trauma

INTRODUCTION

The burden of frailty on older people is easily recognisable by increasing mortality and morbidity, longer hospital stays and adverse discharge locations. In the UK, frailty screening has recently become part of the best practice commissioning tariff within National Health Service England, yet there is no evidence or consensus as to who should carry out this assessment or within which time frame. As major trauma is an increasing burden for older people, there is a need to focus clinician's attention on early identification of frailty in the emergency department (ED) in patients with major trauma as a way to underpin frailty specific major trauma pathways, to optimise recovery and improve patient experience. Throughout the patient with major trauma pathway, nurses are perhaps best placed to conduct timely clinical assessments working with the patient, family and multidisciplinary team to influence ongoing care. This study aims to determine the feasibility of nurse-led assessment of frailty in patients aged 65 years or more admitted to major trauma centres (MTCs).

METHODS AND ANALYSIS

This is a prospective observational study conducted across five UK MTCs, enrolling 370 participants over 9 months. The primary aim is to determine the feasibility of nurse-led frailty assessment in MTC EDs in patients aged 65 years or more following traumatic injury. The prevalence of frailty and the best assessment tool for use in the ED will be determined. Other outcome measures include quality of life and frailty assessment 6 months after injury, mortality and discharge outcomes.

ETHICS AND DISSEMINATION

The study was given ethical approval by the Social Care Research Ethics Committee (REC no 19/IEC08/0006). Findings will be published in scientific journals and presented to national and international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN10671514.

Enhanced triage for patients with suspected cardiac chest pain: the History and Electrocardiogram-only Manchester Acute Coronary Syndromes decision aid

Supplemental Digital Content is available in the text.

Several decision aids can ‘rule in’ and ‘rule out’ acute coronary syndromes (ACS) in the Emergency Department (ED) but all require measurement of blood biomarkers. A decision aid that does not require biomarker measurement could enhance risk stratification at triage and could be used in the prehospital environment. We aimed to derive and validate the History and ECG-only Manchester ACS (HE-MACS) decision aid using only the history, physical examination and ECG.

Diagnostic accuracy of the Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid with a point-of-care cardiac troponin assay

OBJECTIVE

Point-of-care (POC) cardiac troponin (cTn) assays have a rapid turnaround time but are generally less sensitive than laboratory-based assays. Previous research found that the Abbott i-Stat cardiac troponin I (cTnI) assay has good diagnostic accuracy when used with the Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid and serial sampling over 3 hours. Accuracy of other assays may differ. We therefore evaluated the diagnostic accuracy of a different POC cTnI assay with serial sampling over 3 hours, both with T-MACS and when used alone.

METHODS

In a prospective diagnostic accuracy study at eight EDs in England (July 2015-October 2017), we collected clinical data from consenting adults with suspected ACS at the time of assessment in the ED. Blood samples were drawn on arrival and 3 hours later for POC cTnI (Cardio 3 Triage, Alere). The target condition was an adjudicated diagnosis of acute myocardial infarction (AMI), based on reference standard serial laboratory-based cTn testing. We calculated test characteristics for POC cTnI using the limit of detection (LoD, 0.01 µg/L) and the T-MACS decision aid.

RESULTS

Of 347 participants, 59 (14.9%) had AMI. With serial POC cTnI testing over 3 hours, POC cTnI at the LoD cut-off ruled out AMI in 193 (55.6%) patients with 98.1% sensitivity (95% CI 89.9% to 100.0%) and 99.5% negative predictive value (NPV, 95% CI 96.5% to 99.9%). T-MACS ruled out AMI in 117 (33.7%) patients with 98.1% sensitivity (95% CI 89.9% to 100%) and 99.2% NPV (95% CI 94.3% to 99.9%). T-MACS ruled in AMI with 97.9% specificity (95% CI 95.8% to 99.5%) and 83.7% positive predictive value (95% CI 70.6% to 91.7%).

CONCLUSIONS

With serial sampling over 3 hours, the Alere Cardio 3 Triage cTnI assay has relatively high NPV for AMI using either the LoD cut-off alone or the T-MACS decision aid. However, wide CIs around the measures of diagnostic accuracy mean that further prospective testing of this strategy is required before clinical implementation.

TRIAL REGISTRATION NUMBER

UKCRN 18000.

Confidence and willingness among laypersons in the UK to act in a head injury situation: a qualitative focus group study

OBJECTIVES

To explore factors influencing confidence and willingness among laypersons in the UK to act in a head injury situation, in order to inform first aid education offered by the British Red Cross.

DESIGN

Qualitative focus group study.

SETTING

South East England.

PARTICIPANTS

Forty-four laypersons (37 women, 7 men) were purposively recruited from the general public using snowball sampling, into one focus group each for six population groups: parents of young children (n=8), informal carers of older adults (n=7), school staff (n=7), sports coaches (n=2), young adults (n=9) and 'other' adults (n=11). The median (range) age group across the sample was 25-34 years (18-24, 84-95). Participants were from Asian (n=6), Black (n=6), Mixed (n=2) and White (n=30) ethnic backgrounds.

RESULTS

The majority of participants described being confident and willing to act in a head injury scenario if that meant calling for assistance, but did not feel sufficiently confident or knowledgeable to assist or make decisions in a more involved way. Individuals' confidence and willingness presented as fluid and dependent on an interplay of situational and contextual considerations, which strongly impacted decision-making: prior knowledge and experience, characteristics of the injured person, un/observed head injury, and location and environment. These considerations may be framed as enablers or barriers to helping behaviour, impacting decision-making to the same extent as-or even more so than-the clinical signs and symptoms of head injury. An individual conceptual model is proposed to illustrate inter-relationships between these factors.

CONCLUSIONS

Our findings show that confidence and willingness to act in a head injury scenario are dependent on several contextual and situational factors. It is important to address such factors, in addition to knowledge of clinical signs and symptoms, in first aid education and training to improve confidence and willingness to act.

The United States: A system built on fragmentation

Background

The United States is effectively a laboratory for ways to produce public goods, such as public health, on the cheap. Its c. 90,000 governments compete for residents, businesses, taxes, development, and jobs while also trying to compensate for the lack of universal health care coverage. They all have structural incentives to provide services as cheaply as possible. The effects are diverse and poorly mapped. They can mean innovation in organizational forms, a different and typically less expensive skill mix among the workers, poor quality, or simple under provision. The exact mix can often be hard to identify. It can also mean extreme responsiveness to funding from higher levels of government such as the states or federal government.

Methods

A comparative historical analysis (CHA) based on government documents, law, and secondary sources.

Results

The distinctively expansive scope of US public health actions is largely due to the country’s failure to establish a universal health care system, and the diversity of US public health tasks reflects local adaptation of tens of thousands of governments. This means that public health in the United States retains much of the activity it had in, for example, the UK before the establishment of the US. In particular, and even in states that accepted the Medicaid expansion in the Affordable Care Act (ACA), local public health departments provide a substantial amount of direct care and fill in for gaps in health care provision.

Conclusions

The US public health system is highly fragmented like the governments that run it, and therefore diverse. Reflecting the failures of the US health care system, it carries out many more tasks that in other countries are seen as health, especially primary, care.

The migrant health workforce in European countries: does anybody care?

Background

Data and knowledge on the migrant health workforce are poorly developed, and we do not understand which institutional contexts may foster responsible governance. This introduction seeks to set the scene for critical debate by placing the structure and composition of the migrant health workforce in the context of health systems and policy. The aim is to confront growing nationalism and populism with the important contribution of migrant carers to health system performance and the health of the population.

Methods

A comparative approach was applied and a rapid review of available data and research undertaken. Five EU countries were selected which represent different healthcare systems, health workforce patterns and political contexts in high-income countries, comprising Austria, Denmark, Germany, Italy, UK.

Results

The migrant workforce pattern show high variation. The number of physicians is highest (around 28%) in the UK, and low in Austria, Denmark and Italy (below 5%) while Germany is in a middle position (around 10%). The picture turns when looking at nurses and carers, where Italy and Germany for instance are placed in higher ranks. The results suggest three things: no coherent patterns of health system types and composition of the migrant care workforce can be identified. There is also no clear connection between the size of the migrant health workforce and the relevance of populist movements. And finally, the migrant carers remain largely absent in the policy debates; none of the health systems has develop a comprehensive governance model that ‘cares’ for the migrant carers and that could help to highlight their contribution against the threats of growing nationalism and populism.

Conclusions

There is a need for comprehensive European monitoring and research to develop more inclusive health workforce governance and to identify institutional conditions that improve capacity and capability for ‘care’ ‘of the migrant health workforce.

PP24 Lay understanding of head injury and when an ambulance might be needed: a mixed methods study

Background

Head injury results in a high use of emergency services, although most people with head injuries do not require hospitalisation. Conversely, some evidence suggests that lay recognition of the seriousness of head injury can be problematic, for example in sports settings.

Aim

To investigate how members of the public - parents of young children, school staff, sports coaches, informal carers of older adults, young adults and other adults - understood head injury terminology and when an emergency ambulance/999 call was required for head injury, against UK public guidance.

Methods

A mixed methods exploratory study, comprising of electronic and paper self-completion surveys across the UK and focus groups or interviews. Survey data were analysed statistically against the outcomes of understanding of terms and selection of the correct action by symptom. Focus group/interview data were analysed thematically.

Results

We received 520 survey responses, with respondents from across gender, age group, ethnicity and first aid experience. Out of 19 given signs and symptoms of head injury, participants could differentiate the most serious (e.g. unconsciousness 92% call 999) from those that could be observed (e.g. nausea 5%, and altered behaviour 5–30% call 999). The proportion of ‘correct’ actions ranged from just below half to almost 100%. Those aged 18–24 had a lower percentage of correct answers. Focus groups and/or interviews were held with 44 participants. Hypothetical scenarios elicited a range of responses, from calling 999 in any instance, to not calling in serious situations. Participants described ‘life experience’ as influential in the decision whether to call 999 or feel confident to observe.

Conclusion

Distinguishing severity of head injury was reported as difficult and confidence about the best course of action was low. The study was limited by regional recruitment biases, but supports the need for public health guidance in head injury.

Diagnostic Accuracy of a High-Sensitivity Cardiac Troponin Assay with a Single Serum Test in the Emergency Department

OBJECTIVES

We sought to evaluate diagnostic accuracy of a high-sensitivity cardiac troponin I (hs-cTnI) assay for acute coronary syndromes (ACS) in the emergency department (ED). The assay has high precision at low concentrations and can detect cTnI in 96.8% of healthy individuals.

METHODS

In successive prospective multicenter studies (“testing” and “validation”), we included ED patients with suspected ACS. We drew blood for hs-cTnI [Singulex Clarity® cTnI; 99th percentile, 8.67 ng/L; limit of detection (LoD), 0.08 ng/L] on arrival. Patients also underwent hs-cTnT (Roche Elecsys) testing over ≥3 h. The primary outcome was an adjudicated diagnosis of ACS, defined as acute myocardial infarction (AMI; prevalent or incident), death, or revascularization within 30 days.

RESULTS

The testing and validation studies included 665 and 2470 patients, respectively, of which 94 (14.1%) and 565 (22.9%) had ACS. At a 1.5-ng/L cutoff, hs-cTnI had good sensitivity for AMI in both studies (98.7% and 98.1%, respectively) and would have “ruled out” 40.1% and 48.9% patients. However, sensitivity was lower for ACS (95.7% and 90.6%, respectively). At a 0.8-ng/L cutoff, sensitivity for ACS was higher (97.5% and 97.9%, ruling out 28.6% patients in each cohort). The hs-cTnT assay had similar performance at the LoD (24.6% ruled out; 97.2% sensitivity for ACS).

CONCLUSIONS

The hs-cTnI assay could immediately rule out AMI in 40% of patients and ACS in &gt;25%, with similar accuracy to hs-cTnT at the LoD. Because of its high precision at low concentrations, this hs-cTnI assay has favorable characteristics for this clinical application.

Diagnostic accuracy of the T-MACS decision aid with a contemporary point-of-care troponin assay

Objectives

The rapid turnaround time of point-of-care (POC) cardiac troponin (cTn) assays is highly attractive for crowded emergency departments (EDs). We evaluated the diagnostic accuracy of the Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid with a POC cTn assay.

Methods

In a prospective diagnostic accuracy study at eight EDs, we included patients with suspected acute coronary syndromes (ACS). Blood drawn on arrival and 3 hours later was analysed for POC cTnI (i-Stat, Abbott Point of Care). The primary outcome was a diagnosis of ACS, which included both an adjudicated diagnosis of acute myocardial infarction (AMI) based on serial laboratory cTn testing and major adverse cardiac events (death, AMI or coronary revascularisation) within 30 days.

Results

Of 716 patients included, 105 (14.7%) had ACS. Using serial POC cTnI concentrations over 3 hours could have ‘ruled out’ ACS in 198 (31.2%) patients with a sensitivity of 99.0% (95% CI 94.4% to 100.0%) and negative predictive value 99.5% (95% CI 96.5% to 99.9%). No AMIs were missed. T-MACS ‘ruled in’ ACS for 65 (10.4%) patients with a positive predictive value of 91.2% (95% CI 82.1% to 95.9%) and specificity 98.9% (97.6% to 99.6%).

Conclusion

With a POC cTnI assay, T-MACS could ‘rule out’ ACS for approximately one-third of patients within 3 hours while ‘ruling in’ ACS for another 10%. The rapid turnaround time and portability of the POC assay make this an attractive pathway for use in crowded EDs or urgent care centres. Future work should also evaluate use in the prehospital environment.

Optimising antiplatelet utilisation in the acute care setting: a novel threshold for medical intervention in suspected acute coronary syndromes

OBJECTIVES

To construct a model to optimise and personalise recommendations for antiplatelet prescription for patients with suspected acute coronary syndrome (ACS). Acknowledging that emergency physicians work with diagnostic uncertainty, we sought to identify the point at which the probability of ACS is sufficiently high that the benefits of antiplatelet treatment outweigh the risks. Second, we evaluated the projected clinical impact of this approach by using a clinical prediction model (Troponin-only Manchester Acute Coronary Syndromes (T-MACS)) to calculate the probability of ACS.

METHODS

We conducted three systematic reviews, quantifying the effects of ticagrelor, clopidogrel or aspirin-alone treatment strategies for ACS (November 2017). We extracted data for (a) clinical outcomes and (b) weighted patient preferences (utilities) for each outcome. We then constructed utilitarian models, simulating the probability of clinical outcomes with different treatment strategies. This identified the threshold probability of ACS at which each treatment strategy became superior.We validated this approach in a prospective diagnostic study including patients with suspected ACS that was conducted at two large UK teaching hospitals (St George's Hospital London recruited October 2015 to June 2017 and Manchester Royal Infirmary: February 2015 to August 2017). We calculated the probability of ACS using T-MACS. The diagnosis of ACS was adjudicated based on serial high-sensitivity troponin testing and 30-day follow-up.

RESULTS

We constructed three models using data from six studies. Prescribing ticagrelor had greatest overall benefit when the probability of ACS exceeded 8.0%. Below that threshold, aspirin alone yielded greater benefit. The validation study included 660 patients, of which 87 (13.2%) had ACS. Prescription of combined antiplatelet strategy to patients with >8% probability of ACS had greater utility than aspirin alone.

CONCLUSION

Treatment with ticagrelor appears to yield greater net benefit for patients when the probability of ACS >8%. The clinical and cost-effectiveness of this 'precision medicine' approach warrants further study.

Adjunctive clindamycin for cellulitis: a clinical trial comparing flucloxacillin with or without clindamycin for the treatment of limb cellulitis

OBJECTIVE

To compare flucloxacillin with clindamycin to flucloxacillin alone for the treatment of limb cellulitis.

DESIGN

Parallel, double-blinded, randomised controlled trial.

SETTING

Emergency department attendances and general practice referrals within 20 hospitals in England.

INTERVENTIONS

Flucloxacillin, at a minimum of 500 mg 4 times per day for 5 days, with clindamycin 300 mg 4 times per day for 2 days given orally versus flucloxacillin given alone.

MAIN OUTCOME MEASURES

The primary outcome was improvement at day 5. This was defined as being afebrile with either a reduction in affected skin surface temperature or a reduction in the circumference of the affected area. Secondary outcomes included resolution of systemic features, resolution of inflammatory markers, recovery of renal function, reduction in the affected area, decrease in pain, return to work or normal activities and the absence of increased side effects.

RESULTS

410 patients were included in the trial. No significant difference was seen in improvement at day 5 for flucloxacillin with clindamycin (136/156, 87%) versus flucloxacillin alone (140/172, 81%)-OR 1.55 (95% CI 0.81 to 3.01), p=0.174. There was a significant difference in the number of patients with diarrhoea at day 5 in the flucloxacillin with clindamycin allocation (34/160, 22%) versus flucloxacillin alone (16/176, 9%)-OR 2.7 (95% CI 1.41 to 5.07), p=0.002. There was no clinically significant difference in any secondary outcome measures. There was no significant difference in the number of patients stating that they had returned to normal activities at the day 30 interview in the flucloxacillin with clindamycin allocation (99/121, 82%) versus flucloxacillin alone (104/129, 81%)-adjusted OR 0.90 (95% CI 0.44 to 1.84).

CONCLUSIONS

The addition of a short course of clindamycin to flucloxacillin early on in limb cellulitis does not improve outcome. The addition of clindamycin doubles the likelihood of diarrhoea within the first few days.

TRIAL REGISTRATION NUMBER

NCT01876628, Results.

London Trauma Conference 2015

I1: Trauma, Pre-hospital and Cardiac Arrest Care 2015

Pascale Avery, Leopold Salm, Flora Bird

A1: Retrospective evaluation of HEMS ‘Direct to CT’ protocol

Anja Hutchinson, Ashley Matthies, Anthony Hudson, Heather Jarman

A2 Rush hour – Crush hour: temporal relationship of cyclist vs. HGV trauma admissions. A single site observational study

Maria Bergman Nilsson, Tom Konig, Nigel Tai

A3 Semiprone position endotracheal intubation during continuous cardiopulmonary resuscitation in drowned children with regurgitation: a case report and experimental manikin study

Espen Fevang, Børge Hognestad, Håkon B. Abrahamsen

A4 An audit of CO2 A-a gradient in non-trauma patients receiving pre-hospital anaesthesia

Olivia V Cheetham, Matthew JC Thomas, Kieron D Rooney

A5 Can the use of c-spine immobilisation collars be avoided in non-trauma patients presenting to the Emergency Department?

Josephine Murray, Malcolm Tunnicliff

A6 Curriculum mapping in ED point of care simulation

Joseph W Collinson, Thomas Brown, Christopher Pritchett

A7 Point of care multidisciplinary trauma team simulation & participant satisfaction in a geographically remote trauma unit in Cornwall

Christopher SA Pritchett, Mark Jadav, Gareth Meredith, Jamie Plumb, Steve Harris, Roger Langford

A8 Conservative management of head injury inpatients - the challenge of simplifying injury management in a non-neurosurgical hospital

JG Hunter, A Sage, R Madden, O Flamank, B Broadbent, S Marsh, H Lewis, E Daniels, N Roberts

A9 Improving the care of traumatic brain injury at non-neurosurgical hospitals: Introducing a head injury pathway and single place of care is associated with significant improvements in neurological observation

JG Hunter, A Sage, R Madden, O Flamank, B Broadbent, S Marsh, H Lewis, E Daniels, N Lin, N Roberts

A10 The experience of inter-disciplinary students undertaking cardiac arrest moulage training

Samuel Bulford, Silas Houghton-Budd, Sam Pearson, Megan Clear-Hill

A11 Impact brain apnoea – nine cases

David J Menzies, James P Leonard, Conor Keogh, Ray Quinn, John D Hinds

A12 Time well spent? Improving the performance improvement programme in a busy Trauma Unit

N Roberts, D Ashton-Cleary, M Jadav

A14 Clinical significant and outcome of pulmonary contusions in patients with blunt chest trauma

Ismail Mahmood, Ayman El-Menyar, Basil Younis, Ahmed Khalid, Syed Nabir, Mohamed Nadeem Ahmed, Omer Al-Yahri, Hassan Al-Thani

A15 Plastics operative workload in major trauma centres: a national prospective survey

Katie Young, Susan A. Hendrickson, Georgina Phillips, Matthew D. Gardiner, Shehan Hettiaratchy

A16 A survey to assess the accuracy of estimating height by pre-hospital clinicians: can we reliably predict those most at risk of serious injury?

Alexandra Alice Crossland, Anthony Hudson

A17 An audit of the cause, outcome and adherence to treatment Standard Operating Procedure (SOP) for all traumatic cardiac arrests at a Helicopter Emergency Medical Service over a 12-month period

Nicholas C Brassington, Anthony Hudson, Emily McWhirter

A18 Should we “stay-and-play? A study of patient physiology in Norwegian Helicopter Emergency Services

Bjørn O Reid, Marius Rehn, Oddvar Uleberg, Andreas J Krüger

A19 Training in resuscitative thoracotomy: have we cracked it? A survey of higher Emergency Medicine trainees in London

Cara Jennings, Yasmin Kapadia, Duncan Bew

A20 London’s Air Ambulance (LAA): 25-years of drownings in an urban environment

Jenny Townsend, Tom P Hurst, Elizabeth A Foster

A21 Live patients in trauma simulation – more than just simulation on a shoestring?

Thomas B Brown, Joseph Collinson, Christopher Pritchett, Toby Slade

A22 Collecting core data in pre-hospital critical care using a consensus based template

Kristin Tønsager, Marius Rehn, Kjetil G.Ringdal, Andreas J.Krüger

A23 Prehospital interventions before and after implementation of a physician staffed helicopter

Rasmus Hesselfeldt, Sandra Wulffeld, Asger Sonne, Lars S. Rasmussen, Jacob Steinmetz

A24 Duration of ventilation following prehospital drug assisted intubation; a retrospective review

Thomas J Renninson, Nadine Thomson, Harvey Pynn, Timothy J Hooper

A25 Non-haemorrhagic shock in trauma: a novel guideline for management in ED

Anthony Hudson, Jacinta Dawson, Ashley Matthies

A26 Patient-tailored triage decisions by anaesthetist-staffed pre-hospital critical care teams

Morten Langfeldt Friberg, Leif Rognås

A27 Anatomical accuracy and appropriate sizing of pre-hospital thoracostomies

Jessica FG Wills, Anthony Hudson

A28 Pre-hospital management of mass casualty civilian shootings

Conor DA Turner, Marius Rehn

A30 The prevalence of alcohol-related trauma recidivism: a systematic review

James Nunn, Mete Erdogan, Robert S. Green

A31 Development of a hospital-wide program for simulation-based training in trauma care and management

Samuel Minor, Mete Erdogan, Kathy Hartlen, Robert S. Green

A32 Out of Hospital Cardiac Arrests (OOHCA); lessons from Hollywood

Ruth Bird, Rachael L. Grupping

A33 Mechanism of injury as a predictor of severity of injury in road traffic collisions: a literature review

Amelia M. Stacey, Marius Rehn, David J. Lockey

A34 Lessons to be learned from prehospital airway intervention documentation? Are airway intervention documentation templates as successful in-hospital as prehospitally?

S. Abiks, L. Cutler, K. Monaghan, A. Al-Rais, C. Hymers, R. Bloomer, Y. Kapadia

A35 Novel biomarkers in prehospital management of traumatic brain injury (the PreTBI study protocol)

Sophie-Charlott Seidenfaden, Ingunn S. Riddervold, Hans Kirkegaard, Niels Juul, Morten T. Bøtker

A36 Hospital outcomes of traumatic railway incidents: a seven-year observational retrospective study of a major trauma centre

Alice Gao, Zane Perkins; Gareth Grier, Alex Tzannes

A37 Does taking a third crew member affect the on-scene time of HEMS jobs?

Nathan Hudson-Peacock, Quentin Otto, Laurie Phillipson, Rik Thomas, Ainsley Heyworth

A38 Does pre-hospital rapid sequence induction affect on-scene time of HEMS jobs?

Quentin Otto, Nathan Hudson-Peacock, Laurie Phillipson, Ainsley Heyworth, Erica Ley

A39 Code red: shock index as a prehospital indicator of massive haemorrhage

Daniel Banner, Ainsley Heyworth, Erica Ley

A40 Air ambulance tasking: how accurate are our current methods?

Madeleine Benson, Nathan Hudson-Peacock, Tony Stone, Erica Ley, Louise Rousson, Ainsley Heyworth

A41 Modern trauma burden in a district general hospital

Beth A Lineham, Matthew J Lee, Martin Gough

A42 Establishing a legal service for major trauma patients in two UK major trauma centres

William H Seligman, Hannah E Thould, Andrew Dinsmore, Charlotte Tan, Julian Thompson, C Andy Eynon, David J Lockey

A43 Prehospital assessment and care of patients – a study of the use of guidelines when assessing head trauma

Rebecka M Rubenson Wahlin, Veronica Lindström, Sari Ponzer, Veronica Vicente

A44 An audit of pre-hospital blood pressure management resulting from head injury

Pamela Eligio, Anthony Hudson

A45 The surgical contribution of surface shading volumetric rendering techniques in rib fracture management

Robert Young, Dimitri Amiras, Ian Sinha

Private practice — An advanced practice option

Currently there is considerable debate on the role and function of nurses in Australia and internationally. This debate stems from developments within the nursing profession itself from political and economic issues in health platforms, due to restructuring of the health care system, consumer expectations of health care and nurses' expectations of a career. This paper provides the opportunity to reflect on the development of the role of the private practice (independent nurse) and where that role is situated in the nursing profession. This forms the basis for discussion of the development of specialty practice at an advanced level in Australia and to demonstrate its relationship with the nurse practitioner movement in Australia.

Support for nurses who are new to emergency care

Starting work as a newly registered nurse in an emergency department can be a daunting experience. Some studies suggest there is a gap between what such nurses learn and how they put it into practice. This article examines the implementation of a practice-based learning programme, the Foundations of Emergency Practice, at four trusts across London to equip inexperienced nurses with the skills to practise safely and effectively.