Inequalities in birth before arrival at hospital in South West England: a multimethods study of neonatal hypothermia and emergency medical services call-handler advice

OBJECTIVES

To examine inequalities in birth before arrival (BBA) at hospitals in South West England, understand which groups are most likely to experience BBA and how this relates to hypothermia and outcomes (phase A). To investigate opportunities to improve temperature management advice given by emergency medical services (EMS) call-handlers during emergency calls regarding BBA in the UK (phase B).

DESIGN

A two-phase multimethod study. Phase A analysed anonymised data from hospital neonatal records between January 2018 and January 2021. Phase B analysed anonymised EMS call transcripts, followed by focus groups with National Health Service (NHS) staff and patients.

SETTING

Six Hospital Trusts in South West England and two EMS providers (ambulance services) in South West and North East England.

PARTICIPANTS

18 multidisciplinary NHS staff and 22 members of the public who had experienced BBA in the UK.

RESULTS

35% (64/184) of babies conveyed to hospital were hypothermic on arrival. When compared with national data on all births in the South West, we found higher percentages of women with documented safeguarding concerns at booking, previous live births and 'late bookers' (booking their pregnancy >13 weeks gestation). These women may, therefore, be more likely to experience BBA. Preterm babies, babies to first-time mothers and babies born to mothers with disability or safeguarding concerns at booking were more likely to be hypothermic following BBA. Five main themes emerged from qualitative data on call-handler advice: (1) importance placed on neonatal temperature; (2) advice on where the baby should be placed following birth; (3) advice on how to keep the baby warm; (4) timing of temperature management advice and (5) clarity and priority of instructions.

CONCLUSIONS

Findings identified factors associated with BBA and neonatal hypothermia following BBA. Improvements to EMS call-handler advice could reduce the number of babies arriving at hospital hypothermic.

Which elements of hospital-based clinical decision support tools for the assessment and management of children with head injury can be adapted for use by paramedics in prehospital care? A systematic mapping review and narrative synthesis

OBJECTIVE

Hospital-based clinical decision tools support clinician decision-making when a child presents to the emergency department with a head injury, particularly regarding CT scanning. However, there is no decision tool to support prehospital clinicians in deciding which head-injured children can safely remain at scene. This study aims to identify clinical decision tools, or constituent elements, which may be adapted for use in prehospital care.

DESIGN

Systematic mapping review and narrative synthesis.

DATA SOURCES

Searches were conducted using MEDLINE, EMBASE, PsycINFO, CINAHL and AMED.

ELIGIBILITY CRITERIA

Quantitative, qualitative, mixed-methods or systematic review research that included a clinical decision support tool for assessing and managing children with head injury.

DATA EXTRACTION AND SYNTHESIS

We systematically identified all in-hospital clinical decision support tools and extracted from these the clinical criteria used in decision-making. We complemented this with a narrative synthesis.

RESULTS

Following de-duplication, 887 articles were identified. After screening titles and abstracts, 710 articles were excluded, leaving 177 full-text articles. Of these, 95 were excluded, yielding 82 studies. A further 14 studies were identified in the literature after cross-checking, totalling 96 analysed studies. 25 relevant in-hospital clinical decision tools were identified, encompassing 67 different clinical criteria, which were grouped into 18 categories.

CONCLUSION

Factors that should be considered for use in a clinical decision tool designed to support paramedics in the assessment and management of children with head injury are: signs of skull fracture; a large, boggy or non-frontal scalp haematoma neurological deficit; Glasgow Coma Score less than 15; prolonged or worsening headache; prolonged loss of consciousness; post-traumatic seizure; amnesia in older children; non-accidental injury; drug or alcohol use; and less than 1 year old. Clinical criteria that require further investigation include mechanism of injury, clotting impairment/anticoagulation, vertigo, length of time of unconsciousness and number of vomits.

How do emergency department staff respond to behaviour that challenges displayed by people living with dementia? A mixed-methods study

OBJECTIVES

To investigate staff experiences of, and approaches to behaviour that challenges displayed by patients with dementia in the emergency department (ED). Behaviour that challenges is defined as 'actions that detract from the well-being of individuals due to the physical or psychological distress they cause within the settings they are performed', and can take many forms including aggressive physical actions, shouting and verbal aggression and non-aggressive behaviour including repetitive questioning, inappropriate exposure and resistance to care.

DESIGN

Mixed-methods study consisting of an online survey and semistructured telephone interviews. Quantitative data were analysed and presented using descriptive statistics. Qualitative data were analysed thematically.

SETTING

The EDs of three National Health Service (NHS) Hospital Trusts in Southwest England.

PARTICIPANTS

Multidisciplinary NHS staff working in the ED.

RESULTS

Fifty-two online survey responses and 13 telephone interviews were analysed. Most (24/36, 67%) survey respondents reported that they had received general training in relation to dementia in the last 2-5 years, however, less than a fifth (4/23, 17%) had received any ED-specific dementia training. All (48/48) felt that behaviour that challenges could potentially be prevented, though resource constraints and practice variation were identified. Four main themes emerged from the qualitative data: (1) the 'perfect storm' of the ED; (2) behaviour that challenges is preventable with the right resources; (3) improvisation and (4) requirement for approaches that are specific to the ED.

CONCLUSIONS

The findings of this study suggest that ED staff do not feel that they are prepared to respond effectively to behaviour that challenges displayed by people living with dementia. Future work could adapt or develop an intervention to support ED staff in responding to behaviour that challenges.

Factors that influence the administration of tranexamic acid (TXA) to trauma patients in prehospital settings: a systematic review

OBJECTIVE

In the UK there are around 5400 deaths annually from injury. Tranexamic acid (TXA) prevents bleeding and has been shown to reduce trauma mortality. However, only 5% of UK major trauma patients who are at risk of haemorrhage receive prehospital TXA. This review aims to examine the evidence regarding factors influencing the prehospital administration of TXA to trauma patients.

DESIGN

Systematic literature review.

DATA SOURCES

AMED, CENTRAL, CINAHL, Cochrane Database of Systematic Reviews, Conference Proceedings Citation Index-Science, Embase and MEDLINE were searched from January 2010 to 2020; searches were updated in June 2022.

CLINICALTRIALS

gov and OpenGrey were also searched and forward and backwards citation chasing performed.

ELIGIBILITY CRITERIA

All primary research reporting factors influencing TXA administration to trauma patients in the prehospital setting was included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers performed the selection process, quality assessment and data extraction. Data were tabulated, grouped by setting and influencing factor and synthesised narratively.

RESULTS

Twenty papers (278 249 participants in total) were included in the final synthesis; 13 papers from civilian and 7 from military settings. Thirteen studies were rated as 'moderate' using the Effective Public Health Practice Project Quality Assessment Tool. Several common factors were identified: knowledge and skills; consequences and social influences; injury type (severity, injury site and mechanism); protocols; resources; priorities; patient age; patient sex.

CONCLUSIONS

This review highlights an absence of high-quality research. Preliminary evidence suggests a host of system and individual-level factors that may be important in determining whether TXA is administered to trauma patients in the prehospital setting.

FUNDING AND REGISTRATION

This review was supported by Research Capability Funding from the South Western Ambulance Service NHS Foundation Trust and the National Institute for Health Research Applied Research Collaboration South West Peninsula.

PROSPERO REGISTRATION NUMBER

CRD42020162943.

Do general practitioners working in or alongside the emergency department improve clinical outcomes or experience? A mixed-methods study

OBJECTIVES

To examine the effect of general practitioners (GPs) working in or alongside the emergency department (GPED) on patient outcomes and experience, and the associated impacts of implementation on the workforce.

DESIGN

Mixed-methods study: interviews with service leaders and NHS managers; in-depth case studies (n=10) and retrospective observational analysis of routinely collected national data. We used normalisation process theory to map our findings to the theory's four main constructs of coherence, cognitive participation, collective action and reflexive monitoring.

SETTING AND PARTICIPANTS

Data were collected from 64 EDs in England. Case site data included: non-participant observation of 142 clinical encounters; 467 semistructured interviews with policy-makers, service leaders, clinical staff, patients and carers. Retrospective observational analysis used routinely collected Hospital Episode Statistics alongside information on GPED service hours from 40 hospitals for which complete data were available.

RESULTS

There was disagreement at individual, stakeholder and organisational levels regarding the purpose and potential impact of GPED (coherence). Participants criticised policy development and implementation, and staff engagement was hindered by tensions between ED and GP staff (cognitive participation). Patient 'streaming' processes, staffing and resource constraints influenced whether GPED became embedded in routine practice. Concerns that GPED may increase ED attendance influenced staff views. Our quantitative analysis showed no detectable impact on attendance (collective action). Stakeholders disagreed whether GPED was successful, due to variations in GPED model, site-specific patient mix and governance arrangements. Following statistical adjustment for multiple testing, we found no impact on: ED reattendances within 7 days, patients discharged within 4 hours of arrival, patients leaving the ED without being seen; inpatient admissions; non-urgent ED attendances and 30-day mortality (reflexive monitoring).

CONCLUSIONS

We found a high degree of variability between hospital sites, but no overall evidence that GPED increases the efficient operation of EDs or improves clinical outcomes, patient or staff experience.

TRIAL REGISTRATION NUMBER

ISCRTN5178022.

Trends and associated factors for Covid-19 hospitalisation and fatality risk in 2.3 million adults in England

The Covid-19 mortality rate varies between countries and over time but the extent to which this is explained by the underlying risk in those infected is unclear. Using data on all adults in England with a positive Covid-19 test between 1st October 2020 and 30th April 2021 linked to clinical records, we examined trends and risk factors for hospital admission and mortality. Of 2,311,282 people included in the study, 164,046 (7.1%) were admitted and 53,156 (2.3%) died within 28 days of a positive Covid-19 test. We found significant variation in the case hospitalisation and mortality risk over time, which remained after accounting for the underlying risk of those infected. Older age groups, males, those resident in areas of greater socioeconomic deprivation, and those with obesity had higher odds of admission and death. People with severe mental illness and learning disability had the highest odds of admission and death. Our findings highlight both the role of external factors in Covid-19 admission and mortality risk and the need for more proactive care in the most vulnerable groups.

Does the presence of general practitioners in emergency departments affect quality and safety in English NHS hospitals? A retrospective observational study

OBJECTIVES

Emergency departments (EDs) in NHS hospitals in England have faced considerable increases in demand over recent years. Most hospitals have developed general practitioner services in emergency departments (GPEDs) to treat non-emergency patients, aiming to relieve pressure on other staff and to improve ED efficiency and patient experience. We measured the impact of GPED services on patient flows, health outcomes and ED workload.

DESIGN

Retrospective observational study. Differences in GPED service availability across EDs and time of day were used to identify the causal effect of GPED, as patients attending the ED at the same hour of the day are quasi-randomly assigned to treatment or control groups based on their local ED's service availability.

PARTICIPANTS

Attendances to 40 EDs in English NHS hospitals from April 2018 to March 2019, 4 441 349 observations.

PRIMARY AND SECONDARY OUTCOMES MEASURED

Outcomes measured were volume of attendances, 'non-urgent' attendances, waiting times over 4 hours, patients leaving without being treated, unplanned reattendances within 7 days, inpatient admissions and 30-day mortality.

RESULTS

We found a small, statistically significant reduction in unplanned reattendances within 7 days (OR 0.968, 95% CI 0.948 to 0.989), equivalent to 302 fewer reattendances per year for the average ED. The clinical impact of this was judged to be negligible. There was no detectable impact on any other outcome measure.

CONCLUSIONS

We found no adverse effects on patient outcomes; neither did we find any evidence of the hypothesised benefits of placing GPs in emergency settings beyond a marginal reduction in reattendances that was not considered clinically significant.

Potential impacts of general practitioners working in or alongside emergency departments in England: initial qualitative findings from a national mixed-methods evaluation

OBJECTIVES

To explore the potential impacts of introducing General Practitioners into Emergency Departments (GPED) from the perspectives of service leaders, health professionals and patients. These 'expectations of impact' can be used to generate hypotheses that will inform future implementations and evaluations of GPED.

DESIGN

Qualitative study consisting of 228 semistructured interviews.

SETTING

10 acute National Health Service (NHS) hospitals and the wider healthcare system in England. Interviews were undertaken face to face or via telephone. Data were analysed thematically.

PARTICIPANTS

124 health professionals and 94 patients and carers. 10 service leaders representing a range of national organisations and government departments across England (eg, NHS England and Department of Health) were also interviewed.

RESULTS

A range of GPED models are being implemented across the NHS due to different interpretations of national policy and variation in local context. This has resulted in stakeholders and organisations interpreting the aims of GPED differently and anticipating a range of potential impacts. Participants expected GPED to affect the following areas: ED performance indicators; patient outcome and experience; service access; staffing and workforce experience; and resources. Across these 'domains of influence', arguments for positive, negative and no effect of GPED were proposed.

CONCLUSIONS

Evaluating whether GPED has been successful will be challenging. However, despite uncertainty surrounding the direction of effect, there was agreement across all stakeholder groups on the areas that GPED would influence. As a result, we propose eight domains of influence that will inform our subsequent mixed-methods evaluation of GPED.

TRIAL REGISTRATION NUMBER

ISRCTN51780222.

Limit of detection of troponin discharge strategy versus usual care: randomised controlled trial

Introduction

The clinical effectiveness of a ‘rule-out’ acute coronary syndrome (ACS) strategy for emergency department patients with chest pain, incorporating a single undetectable high-sensitivity cardiac troponin (hs-cTn) taken at presentation, together with a non-ischaemic ECG, remains unknown.

Methods

A randomised controlled trial, across eight hospitals in the UK, aimed to establish the clinical effectiveness of an undetectable hs-cTn and ECG (limit of detection and ECG discharge (LoDED)) discharge strategy. Eligible adult patients presented with chest pain; the treating clinician intended to perform investigations to rule out an ACS; the initial ECG was non-ischaemic; and peak symptoms occurred <6 hours previously. Participants were randomised 1:1 to either the LoDED strategy or the usual rule-out strategy. The primary outcome was discharge from the hospital within 4 hours of arrival, without a major adverse cardiac event (MACE) within 30 days.

Results

Between June 2018 and March 2019, 632 patients were randomised; 3 were later withdrawn. Of 629 patients (age 53.8 (SD 16.1) years, 41% women), 7% had a MACE within 30 days. For the LoDED strategy, 141 of 309 (46%) patients were discharged within 4 hours, without MACE within 30 days, and for usual care, 114 of 311 (37%); pooled adjusted OR 1.58 (95% CI 0.84 to 2.98). No patient with an initial undetectable hs-cTn had a MACE within 30 days.

Conclusion

The LoDED strategy facilitates safe early discharge in >40% of patients with chest pain. Clinical effectiveness is variable when compared with existing rule-out strategies and influenced by wider system factors.

Trial registration number

ISRCTN86184521.

Cost-effectiveness of advanced life support and prehospital critical care for out-of-hospital cardiac arrest in England: a decision analysis model

OBJECTIVES

This research aimed to answer the following questions: What are the costs of prehospital advanced life support (ALS) and prehospital critical care for out-of-hospital cardiac arrest (OHCA)? What is the cost-effectiveness of prehospital ALS? What improvement in survival rates from OHCA would prehospital critical care need to achieve in order to be cost-effective?

SETTING

A single National Health Service ambulance service and a charity-funded prehospital critical care service in England.

PARTICIPANTS

The patient population is adult, non-traumatic OHCA.

METHODS

We combined data from previously published research with data provided by a regional ambulance service and air ambulance charity to create a decision tree model, coupled with a Markov model, of costs and outcomes following OHCA. We compared no treatment for OHCA to the current standard of care of prehospital ALS, and prehospital ALS to prehospital critical care. To reflect the uncertainty in the underlying data, we used probabilistic and two-way sensitivity analyses.

RESULTS

Costs of prehospital ALS and prehospital critical care were £347 and £1711 per patient, respectively. When costs and outcomes of prehospital, in-hospital and postdischarge phase of OHCA care were combined, prehospital ALS was estimated to be cost-effective at £11 407/quality-adjusted life year. In order to be cost-effective in addition to ALS, prehospital critical care for OHCA would need to achieve a minimally economically important difference (MEID) in survival to hospital discharge of 3%-5%.

CONCLUSION

This is the first economic analysis to address the question of cost-effectiveness of prehospital critical care following OHCA. While costs of either prehospital ALS and/or critical care per patient with OHCA are relatively low, significant costs are incurred during hospital treatment and after discharge in patients who survive. Knowledge of the MEID for prehospital critical care can guide future research in this field.

TRIAL REGISTRATION NUMBER

ISRCTN18375201.

General practitioners and emergency departments (GPED)-efficient models of care: a mixed-methods study protocol

INTRODUCTION

Pressure continues to grow on emergency departments in the UK and throughout the world, with declining performance and adverse effects on patient outcome, safety and experience. One proposed solution is to locate general practitioners to work in or alongside the emergency department (GPED). Several GPED models have been introduced, however, evidence of effectiveness is weak. This study aims to evaluate the impact of GPED on patient care, the primary care and acute hospital team and the wider urgent care system.

METHODS AND ANALYSIS

The study will be divided into three work packages (WPs). WP-A; Mapping and Taxonomy: mapping, description and classification of current models of GPED in all emergency departments in England and interviews with key informants to examine the hypotheses that underpin GPED. WP-B; Quantitative Analysis of National Data: measurement of the effectiveness, costs and consequences of the GPED models identified in WP-A, compared with a no-GPED model, using retrospective analysis of Hospital Episode Statistics Data. WP-C; Case Studies: detailed case studies of different GPED models using a mixture of qualitative and quantitative methods including: non-participant observation of clinical care, semistructured interviews with staff, patients and carers; workforce surveys with emergency department staff and analysis of available local routinely collected hospital data. Prospective case study sites will be identified by completing telephone interviews with sites awarded capital funding by the UK government to implement GPED initiatives. The study has a strong patient and public involvement group that has contributed to study design and materials, and which will be closely involved in data interpretation and dissemination.

ETHICS AND DISSEMINATION

The study has been approved by the National Health Service East Midlands-Leicester South Research Ethics Committee: 17/EM/0312. The results of the study will be disseminated through peer-reviewed journals, conferences and a planned programme of knowledge mobilisation.

TRIAL REGISTRATION NUMBER

ISRCTN51780222.

Randomised controlled trial of the Limit of Detection of Troponin and ECG Discharge (LoDED) strategy versus usual care in adult patients with chest pain attending the emergency department: study protocol

INTRODUCTION

Observational data suggest a single high-sensitivity troponin blood test taken at emergency department (ED) presentation could be used to rule out major adverse cardiac events (MACE) in 10%-60% of ED patients with chest pain. This is done using an 'undetectable' cut-off (the Limit of Detection: LoD). We combined the LoD cut-off with ECG findings to create the LoDED strategy. We aim to establish whether the LoDED strategy works under real-life conditions, when compared with existing strategies, in a way that is cost-effective and acceptable to patients.

METHODS AND ANALYSIS

This is a parallel-group pragmatic randomised controlled trial across UK EDs. Adults presenting to ED with suspected cardiac chest pain will be randomised 1:1. Existing rule-out strategies in current use across study centres, using serial high-sensitivity troponin testing, will be compared with the LoDED strategy. The primary outcome is successful early discharge (discharge from hospital within 4 hours of arrival) without MACE occurring within 30 days. Secondary outcomes include initial length of hospital stay; comparative costs; patient satisfaction and acceptability to patients. To detect a 9% difference between the early discharge rates (assuming an 8% rate in the standard care group) with 90% power, 594 patients need to be recruited, assuming a 95% follow-up rate.

ETHICS AND DISSEMINATION

The study has been approved by the Frenchay Research Ethics Committee (reference 18/SW/0038). Results will be published in an international peer-reviewed journal. Lay summaries will be made available to patients.

TRIAL REGISTRATION NUMBER

ISRCTN86184521; Pre-results.

How do people with dementia use the ambulance service? A retrospective study in England: the HOMEWARD project

OBJECTIVES

An increasing number of older people are calling ambulances and presenting to accident and emergency departments. The presence of comorbidities and dementia can make managing these patients more challenging and hospital admission more likely, resulting in poorer outcomes for patients. However, we do not know how many of these patients are conveyed to hospital by ambulance. This study aims to determine: how often ambulances are called to older people; how often comorbidities including dementia are recorded; the reason for the call; provisional diagnosis; the amount of time ambulance clinicians spend on scene; the frequency with which these patients are transported to hospital.

METHODS

We conducted a retrospective cross-sectional study of ambulance patient care records (PCRs) from calls to patients aged 65 years and over. Data were collected from two ambulance services in England during 24 or 48 hours periods in January 2017 and July 2017. The records were examined by two researchers using a standard template and the data were extracted from 3037 PCRs using a coding structure.

RESULTS

Results were reported as percentages and means with 95% CIs. Dementia was recorded in 421 (13.9%) of PCRs. Patients with dementia were significantly less likely to be conveyed to hospital following an emergency call than those without dementia. The call cycle times were similar for patients regardless of whether or not they had dementia. Calls to people with dementia were more likely to be due to injury following a fall. In the overall sample, one or more comorbidities were reported on the PCR in over 80% of cases.

CONCLUSION

Rates of hospital conveyance for older people may be related to comorbidities, frailty and complex needs, rather than dementia. Further research is needed to understand the way in which ambulance clinicians make conveyance decisions at scene.

A systematic review to identify and assess the effectiveness of alternatives for people over the age of 65 who are at risk of potentially avoidable hospital admission

BACKGROUND/OBJECTIVES

There are some older patients who are 'at the decision margin' of admission. This systematic review sought to explore this issue with the following objective: what admission alternatives are there for older patients and are they safe, effective and cost-effective? A secondary objective was to identify the characteristics of those older patients for whom the decision to admit to hospital may be unclear.

DESIGN

Systematic review of controlled studies (April 2005-December 2016) with searches in Medline, Embase, Cinahl and CENTRAL databases. The protocol is registered at PROSPERO (CRD42015020371). Studies were assessed using Cochrane risk of bias criteria, and relevant reviews were assessed with the AMSTAR tool. The results are presented narratively and discussed.

SETTING

Primary and secondary healthcare interface.

PARTICIPANTS

People aged over 65 years at risk of an unplanned admission.

INTERVENTIONS

Any community-based intervention offered as an alternative to admission to an acute hospital.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Reduction in secondary care use, patient-related outcomes, safety and costs.

RESULTS

Nineteen studies and seven systematic reviews were identified. These recruited patients with both specific conditions and mixed chronic and acute conditions. The interventions involved paramedic/emergency care practitioners (n=3), emergency department-based interventions (n=3), community hospitals (n=2) and hospital-at-home services (n=11). Data suggest that alternatives to admission appear safe with potential to reduce secondary care use and length of time receiving care. There is a lack of patient-related outcomes and cost data. The important features of older patients for whom the decision to admit is uncertain are: age over 75 years, comorbidities/multi-morbidities, dementia, home situation, social support and individual coping abilities.

CONCLUSIONS

This systematic review describes and assesses evidence on alternatives to acute care for older patients and shows that many of the options available are safe and appear to reduce resource use. However, cost analyses and patient preference data are lacking.

Effects of storage at -20°C on ischaemia-modified albumin results

Background: Ischaemia-modified albumin (IMA) is being studied as a new marker for reversible ischaemia in patients presenting with possible cardiac chest pain. The conditions under which samples are stored prior to analysis may be critical in influencing the analytical result and hence the cut-off used in any particular study.

Methods: Sixty-eight samples taken during a study assessing the performance of IMA for risk stratification in patients presenting with possible cardiac chest pain were analysed both within 2.5 h of collection and after periods of storage at -20°C.

Results: Samples stored at -20°C yielded IMA values on average 3 units higher than those analysed within 2.5 h (mean 90.5 vs. 87.5; P < 0.00001). A Bland-Altman plot showed that the difference was not concentration dependent.

Conclusions: These results indicate that decision cut-offs will be influenced by conditions of sample storage prior to IMA analysis, and that these should be stated in detail for each study.

A randomised trial comparing the cost effectiveness of different emergency department healthcare professionals in soft tissue injury management

OBJECTIVES

To evaluate the cost effectiveness of soft tissue injury management by emergency nurse practitioners (ENPs) and extended scope physiotherapists (ESPs) compared with the routine care provided by doctors in an emergency department (ED).

DESIGN

Randomised, pragmatic trial of equivalence.

SETTING

A single ED in England.

PARTICIPANTS

372 patients were randomised, 126 to the ESP group, 123 to the ENP group and 123 to the doctor group. Participants were adults (16 years and older) presenting to the ED with a peripheral soft tissue injury eligible for management by any of the three professional groups.

INTERVENTIONS

Patients were randomised to treatment by an ESP, ENP or routine care provided by doctors (of all grades).

MAIN OUTCOME MEASURES

Economic cost-minimisation evaluation from a funder perspective of the National Health Service, England incorporating analysis of the direct, indirect and tangible costs of care in primary and secondary settings.

RESULTS

From a funder perspective in primary and secondary care, ESPs and ENPs are at best equivalent and could not cost less than routine care. Uncertainty in cost arises from ESPs and ENPs incurring greater indirect costs, such as those associated with follow-up appointments and subsequent primary care visits. Comparison from a funder perspective in secondary care, that is, considering those costs incurred in secondary care alone, demonstrates that ENPs are equivalent in cost to routine care, while ESPs are either equivalent or possibly cheaper than routine care.

CONCLUSIONS

These results question the notion that training the healthcare workforce to undertake extensions of their role is generally cost effective. While the randomised trial indicated that the three professional groups have equivalent clinical outcomes, this economic analysis suggests that substitution of routine care with a predominantly ESP or ENP workforce could prove more expensive. Further research is required to understand the underlying reasons for this. The trial has been registered with ISRCTN-ISRCTN 70891354.

Randomised comparison of the effectiveness of the laryngeal mask airway supreme, i-gel and current practice in the initial airway management of prehospital cardiac arrest (REVIVE-Airways): a feasibility study research protocol

INTRODUCTION

Effective cardiopulmonary resuscitation with appropriate airway management improves outcomes following out-of-hospital cardiac arrest (OHCA). Historically, tracheal intubation has been accepted as the optimal form of OHCA airway management in the UK. The Joint Royal Colleges Ambulance Liaison Committee recently concluded that newer supraglottic airway devices (SADs) are safe and effective devices for hospital procedures and that their use in OHCA should be investigated. This study will address an identified gap in current knowledge by assessing whether it is feasible to use a cluster randomised design to compare SADs with current practice, and also to each other, during OHCA.

METHODS AND ANALYSIS

The primary objective of this study is to assess the feasibility of a cluster randomised trial to compare the ventilation success of two newer SADs: the i-gel and the laryngeal mask airway supreme to usual practice during the initial airway management of OHCA. The secondary objectives are to collect data on ventilation success, further airway interventions required, loss of a previously established airway during transport, airway management on arrival at hospital (or termination of the resuscitation attempt), initial resuscitation success, survival to intensive care admission, survival to hospital discharge and patient outcome at 3 months. Ambulance paramedics will be randomly allocated to one of the three methods of airway management. Adults in medical OHCA attended by a trial paramedic will be eligible for the study.

ETHICS AND DISSEMINATION

Approval for the study has been obtained from a National Health Service Research Ethics Committee with authority to review proposals for trials of a medical device in incapacitated adults. The results will be made publicly available on an open access website, and we will publish the findings in appropriate journals and present them at national and international conferences relevant to the subject field.

TRIAL REGISTRATION

ISRCTN: 18528625.

PAin SoluTions In the Emergency Setting (PASTIES); a protocol for two open-label randomised trials of patient-controlled analgesia (PCA) versus routine care in the emergency department

INTRODUCTION

Pain is the commonest reason that patients present to an emergency department (ED), but it is often not treated effectively. Patient controlled analgesia (PCA) is used in other hospital settings but there is little evidence to support its use in emergency patients. We describe two randomised trials aiming to compare PCA to nurse titrated analgesia (routine care) in adult patients who present to the ED requiring intravenous opioid analgesia for the treatment of moderate to severe pain and are subsequently admitted to hospital.

METHODS AND ANALYSIS

Two prospective multi-centre open-label randomised trials of PCA versus routine care in emergency department patients who require intravenous opioid analgesia followed by admission to hospital; one trial involving patients with traumatic musculoskeletal injuries and the second involving patients with non-traumatic abdominal pain. In each trial, 200 participants will be randomised to receive either routine care or PCA, and followed for the first 12 h of their hospital stay. The primary outcome measure is hourly pain score recorded by the participant using a visual analogue scale (VAS) over the 12 h study period, with the primary statistical analyses based on the area under the curve of these pain scores. Secondary outcomes include total opioid use, side effects, time spent asleep, patient satisfaction, length of hospital stay and incremental cost effectiveness ratio.

ETHICS AND DISSEMINATION

The study is approved by the South Central-Southampton A Research Ethics Committee (REC reference 11/SC/0151). Data collection will be completed by August 2013, with statistical analyses starting after all final data queries are resolved. Dissemination plans include presentations at local, national and international scientific meetings held by relevant Colleges and societies. Publications should be ready for submission during 2014. A lay summary of the results will be available to study participants on request, and disseminated via a publically accessible website.

REGISTRATION DETAILS

The study is registered with the European Clinical Trials Database (EudraCT Number: 2011-000194-31) and is on the ISCRTN register (ISRCTN25343280).

A randomised trial comparing the clinical effectiveness of different emergency department healthcare professionals in soft tissue injury management

OBJECTIVES

To evaluate the clinical effectiveness of soft tissue injury management by emergency nurse practitioners (ENPs) and extended scope physiotherapists (ESPs) compared to the routine care provided by doctors in a UK emergency department (ED).

DESIGN

Randomised, pragmatic trial of equivalence.

SETTING

One adult ED in England.

PARTICIPANTS

372 patients were randomised; 126 to the ESP group, 123 to the ENP group and 123 to the doctor group. Participants were adults (older than 16 years) presenting to the ED with a peripheral soft tissue injury eligible for management by any of the three professional groups. Patients were excluded if they had any of the following: injury greater than 72 hours old; systemic disease; dislocated joints; recent surgery; unable to give informed consent (eg, dementia), open wounds; major deformities; opiate analgesia required; concurrent chest/rib injury; neurovascular deficits and associated fracture.

INTERVENTIONS

Patients were randomised to treatment by ESPs, ENPs or routine care provided by doctors (of all grades).

MAIN OUTCOME MEASURES

Upper-limb and lower-limb functional scores, quality of life, physical well-being, preference-based health measures and the number of days off work.

RESULTS

The clinical outcomes of soft tissue injury treated by ESPs and ENPs in the ED were equivalent to routine care provided by doctors.

CONCLUSIONS

As all groups were clinically equivalent it is other factors such as cost, workforce sustainability, service provision and skill mix that become important. This result validates the role of the ENP, which is becoming established as an integral part of minor injuries care, and demonstrates that the ESP should be considered as part of the clinical skill mix without detriment to outcomes. ISRCTN-ISRCTN TRIALS REGISTER NUMBER: 70891354.

Why are we here? A study of patient actions prior to emergency hospital admission

INTRODUCTION

Emergency department (ED) attendances and subsequent hospital admissions are rising in the United Kingdom. The reasons for this are unclear but may relate to recent changes in primary care and public perception. The actions taken by patients or their relatives before emergency hospital admission, the reasons for these actions and their outcome were determined.

METHODS

Adult patients admitted to an inner city teaching hospital with a medical or surgical illness were interviewed using a semistructured questionnaire. Data were collected and analyzed regarding the actions taken before arrival at hospital, the reasons for taking these actions, their outcome and future intentions. 200 patients were interviewed.

RESULTS

Direct attendance at the ED was more common when help was sought by bystanders or persons known only slightly to the patient (p = 0.03). 57 patients (28.5%) attended the ED directly, 45 of whom dialled 999 for an emergency ambulance. Most patients who attended the ED directly did so as a result of the perceived severity or urgency of their condition and there was incomplete awareness of the out-of-hours GP service.

CONCLUSION

The majority of adult patients who are admitted to hospital with an acute illness seek professional help from primary care in the first instance. Those who attend the ED generally perceive their problem as more urgent or severe, or have an ambulance called on their behalf. The shift towards ED care appears partly driven by changes in general practice and unfamiliarity with the new arrangements for out-of-hours primary care provision.

Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children

OBJECTIVE

To determine whether full elbow extension as assessed by the elbow extension test can be used in routine clinical practice to rule out bony injury in patients presenting with elbow injury.

DESIGN

Adults: multicentre prospective interventional validation study in secondary care. Children: multicentre prospective observational study in secondary care.

SETTING

Five emergency departments in southwest England.

PARTICIPANTS

2127 adults and children presenting to the emergency department with acute elbow injury.

INTERVENTION

Elbow extension test during routine care by clinical staff to determine the need for radiography in adults and to guide follow-up in children.

MAIN OUTCOME MEASURES

Presence of elbow fracture on radiograph, or recovery with no indication for further review at 7-10 days.

RESULTS

Of 1740 eligible participants, 602 patients were able to fully extend their elbow; 17 of these patients had a fracture. Two adult patients with olecranon fractures needed a change in treatment. In the 1138 patients without full elbow extension, 521 fractures were identified. Overall, the test had sensitivity and specificity (95% confidence interval) for detecting elbow fracture of 96.8% (95.0 to 98.2) and 48.5% (45.6 to 51.4). Full elbow extension had a negative predictive value for fracture of 98.4% (96.3 to 99.5) in adults and 95.8% (92.6 to 97.8) in children. Negative likelihood ratios were 0.03 (0.01 to 0.08) in adults and 0.11 (0.06 to 0.19) in children.

CONCLUSION

The elbow extension test can be used in routine practice to inform clinical decision making. Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.

The PRIMA study: presentation ischaemia-modified albumin in the emergency department

OBJECTIVES

To investigate the diagnostic accuracy of presentation ischaemia-modified albumin (IMA), in addition to cardiac troponin I (TnI), as a strategy to rapidly ascribe low risk to patients with chest pain attending an emergency department, and to determine whether IMA has the potential to reduce transit time in emergency departments.

METHODS

A prospective observational study was carried out in two emergency departments (belonging to the John Radcliffe Hospital, Oxford, UK; and the Frenchay Hospital, Bristol, UK) of similar size. Consecutive adult patients presenting with features of possible ischaemic cardiac chest pain and a normal electrocardiogram were eligible. The index test (measurement of IMA and TnI at presentation) and reference standard (delayed TnI measurement, taken at least 8 h after pain onset) were applied to all recruited patients. All clinicians were blinded to the results of the index test. Assays were carried out in a single laboratory using standard techniques.

RESULTS

399 patients were recruited; 277 patients had a result for both the index test and reference standard. The sensitivity was 97.6% (95% confidence interval (CI) 87.4 to 99.9), negative predictive value 97% (95% CI 84.2 to 99.9) and specificity 13.6% (95% CI 9.5 to 18.7). Sensitivity analysis showed similar findings in three alternative scenarios. Receiver operating characteristic analysis indicated that a different "cut-off" value for IMA would not improve the properties of the test. The median potential time saved (n = 268) was 6 h and 10 min.

CONCLUSION

The diagnostic accuracy of presentation IMA in this study does not support its use as an effective risk stratification tool for patients with chest pain in the emergency department. The sensitivity is insufficiently high, with a small number of false negatives undermining the safety of the test. Frequent false positives produce a low specificity that limits the practical value of the test.

Effect of an extended scope physiotherapy service on patient satisfaction and the outcome of soft tissue injuries in an adult emergency department

OBJECTIVES

To evaluate the effect of introducing an extended scope physiotherapy (ESP) service on patient satisfaction, and to measure the functional outcome of patients with soft tissue injuries attending an adult emergency department (ED), comparing management by ESPs, emergency nurse practitioners (ENPs), and all grades of ED doctor.

METHODS

The ESP service operated on four days out of every seven in a week in an urban adult ED. A satisfaction questionnaire was sent to all patients with a peripheral soft tissue injury and fractures (not related to the ankle) within one week of attending the ED. Patients with a unilateral soft tissue ankle injury were sent the acute Short Form 36 (SF-36) functional outcome questionnaire, with additional visual analogue scales for pain, at 4 and 16 weeks after their ED attendance. Waiting times and time spent with individual practitioners was also measured.

RESULTS

The ESP service achieved patient satisfaction that was superior to either ENPs or doctors. Overall 55% of patients seen by the ESP service strongly agreed that they were satisfied with the treatment they received, compared with 39% for ENPs and 36% for doctors (p = 0.048). Assessment of long-term outcome from ankle injury was undermined by poor questionnaire return rates. There was a trend towards improved outcomes at four weeks in those patients treated by an ESP, but this did not achieve statistical significance.

CONCLUSION

Adding an ESP service to the interdisciplinary team achieves higher levels of patient satisfaction than for either doctors or ENPs. Further outcomes research, conducted in a wider range of emergency departments and integrated with an economic analysis, is recommended.

Randomised controlled trial of combined paracetamol and ibuprofen for fever

A randomised open label study of the combined use of paracetamol and ibuprofen to rapidly reduce fever is reported. The advantage of using both medications is less than half a degree centigrade in the first hour, and insufficient to warrant routine use.

Patient satisfaction in emergency medicine

A systematic review was undertaken to identify published evidence relating to patient satisfaction in emergency medicine. Reviewed papers were divided into those that identified the factors influencing overall satisfaction in emergency department patients, and those in which a specific intervention was evaluated. Patient age and race influenced satisfaction in some, but not all, studies. Triage category was strongly correlated with satisfaction, but this also relates to waiting time. The three most frequently identified service factors were: interpersonal skills/staff attitudes; provision of information/explanation; perceived waiting times. Seven controlled intervention studies were found. These suggested that increased information on ED arrival, and training courses designed to improve staff attitudes and communication, are capable of improving patient satisfaction. None of the intervention studies looked specifically at the effect of reducing the perceived waiting time. Key interventions to improve patient satisfaction will be those that develop the interpersonal and attitudinal skills of staff, increase the information provided, and reduce the perceived waiting time. Future research should use a mixture of quantitative and qualitative methods to evaluate specific interventions.

What is the effect of reporting all emergency department radiographs?

OBJECTIVES

To evaluate the effect of formal radiological reporting of all emergency department (ED) radiographs on clinical practice and patient outcome, and to consider whether a selective reporting policy might prove safe and effective.

METHODS

All radiographs taken in a single ED over a six month period were prospectively studied simultaneously in both the emergency and radiology departments to detect cases where a radiograph that was considered normal by ED staff was then reported as abnormal by the reporting radiologist. Whenever such a discrepancy occurred the patient's records were scrutinised to ascertain the source of the discrepancy, with a gold standard interpretation derived from senior clinical review and additional investigations where indicated. The clinical impact of the radiologist's formal report was then assessed. Accuracy of interpretation was considered in relation to the grade of ED staff and the radiographic examination obtained.

RESULTS

During the study period, 19468 new patient attendances to the ED generated 11749 radiographic examinations. Discrepancies were detected in 175 patients (1.5% of all radiographic examinations). Of these, 136 (1.2%) were subsequently shown to have been incorrectly interpreted in the ED (ED false negatives), with 40 patients (0.3%) undergoing a change in management as a result. In the remaining 39 the ED interpretation was judged to be correct (radiology false positives), with 16 patients undergoing further investigations or visits to the ED to confirm this.

CONCLUSIONS

The formal reporting of ED radiographs by the radiology department detects a number of clinically important abnormalities that have been overlooked. However, this formal reporting also generates a number of incorrect interpretations that may lead to further unnecessary investigations. Some groups of ED radiographs (such as those interpreted by an ED consultant and films of the fingers and toes) may not require formal radiological reporting. The adoption of a selective reporting policy may reduce the reporting workload of the radiology department without compromising patient care.

Prehospital thrombolysis: lessons from Sweden and their application to the United Kingdom

OBJECTIVE

To study the successful implementation of paramedic administered prehospital thrombolysis in Sweden, and to consider the implications of this for the UK.

METHODS

A series of research visits were undertaken, including visits to Uppsala Hospital and dispatch centre, ambulance stations in several counties of Sweden and Dalarna County, which has one of the longest experiences of telemedicine supported prehospital thrombolysis in Europe. Data relating to prehospital thrombolysis, stages in successful implementation, and potential barriers to change were identified.

RESULTS

Two thirds of the hospitals in Sweden now have some form of prehospital thrombolysis. A nationally agreed and standardised training programme and the fact that many ambulance paramedics are also qualified nurses has facilitated successful introduction, but Sweden's low population density is also an important factor. Data from Dalarna County indicate that the median "pain to needle" time has been reduced by 45 minutes with a concurrent reduction in complications from 50% to 25% (p=0.018). Inhospital mortality has also reduced from 12% to 6%, but with the small numbers involved this improvement does not achieve statistical significance (p=0.36).

CONCLUSION

If the outcome of acute myocardial infarction in the United Kingdom is to be improved, and National Service Framework targets met, then prehospital thrombolysis is an important development. Several technical solutions already exist, and a single bolus thrombolytic agent is now available, but the main barriers to full implementation are related to the establishment of an effective training programme and the organisational changes that will facilitate this new practice. High quality research is urgently needed to guide the implementation of prehospital thrombolysis in a clinically and cost effective way.

The case for urban prehospital thrombolysis

This is the first part in a debate on the benefits and disadvantages of urban prehospital thrombolysis. I put the case for prehospital thrombolysis in the urban environment and argue that it is a rational development that will save lives and reduce long term morbidity.

Can nurses working in remote units accurately request and interpret radiographs?

OBJECTIVE

Recent changes in the NHS have seen nurses take on roles that are traditionally filled by doctors, leading to the development of emergency nurse practitioners (ENPs). In addition to this, increasing interest has focused on telemedicine (literally, medicine at a distance) as a way of supporting remote emergency departments and minor injuries units from larger centres. The vast majority of these consultations are related to peripheral limb trauma and require a radiograph to be viewed as an integral part of the telemedical consultation. The aim of this study was therefore to determine whether nurses working alone in a peripheral unit are able to appropriately request, and accurately interpret, peripheral limb radiographs.

METHODS

In this prospective study the four qualified nurses working in a peripheral unit were permitted to request a defined set of radiographs after limb trauma. A written protocol for nurse requested radiographs was supported by individual teaching sessions. At the time that the radiograph was requested basic demographic details were recorded and the patient was also assessed by two senior doctors in emergency medicine, one in person and one via a telemedicine link, both of whom independently considered whether the radiograph requested by the nurse was appropriate in that patient. Nursing staff were also asked to provide a provisional interpretation of each film, and this was compared with a gold standard derived from the interpretations of the two emergency physicians who had seen the patient and the final radiologist's report.

RESULTS

The first 300 patients who had a radiograph requested by a member of the nursing staff were studied over a period of 12 months. Altogether 93 radiographs (31%) were positive for recent bony trauma or radio-opaque foreign body. Eleven radiographs (3.7%) were judged by both emergency physicians to be inappropriate. Three radiographs (1%) were requested outside the limits of the protocol, but all three were judged to be appropriate and occurred within the first two months of the study. A total of 32 (10.7%) of the radiographs were incorrectly interpreted by nursing staff with 26 false positives, four false negatives and two cases where the nurse observed an abnormality but failed to identify it correctly. The sensitivity of nurse interpretation was therefore 96%, with a specificity of 87%.

CONCLUSION

Experienced nurses, working without continuous medical supervision in a remote unit, are able to request appropriate radiographs of the peripheral limbs. Nurses requesting radiographs in this way can also interpret these films to a high standard, though with a tendency to err on the side of caution, generating many more false positive results than false negatives.

Burns and scalds in pre-school children attending accident and emergency: accident or abuse?

OBJECTIVES

To assess how frequently and adequately information relating to the possibility of non-accidental injury (NAI) is documented and considered by doctors assessing pre-school children with burns and scalds in the accident and emergency (A&E) department, and to determine the effect of introducing a routine reminder mechanism into the A&E notes, coupled with an improved programme of NAI education and awareness.

METHODS

The records of 100 pre-school children attending an A&E department with a burn or scald were reviewed against nine pre-determined standards. Changes in policy were instituted, through a programme of education and the use of a reminder checklist, and the next 100 cases re-audited against the same checklist.

RESULTS

Groups one and two were similar in their demographic characteristics. The reminder checklist was included in 60% of group two notes, and when included was completed in 97%. The child protection register was rarely consulted. There was a statistically significant increase in recording the following: time that the injury had occurred, the consistency of the history, the compatibility of the injury with the history given, the consideration of the possibility of NAI, the general state and behaviour of the child and the presence or absence of any other injuries. The rate of referral for a further opinion regarding the possibility of NAI increased from 0 to 3%, but failed to reach statistical significance.

CONCLUSIONS

Prevailing awareness and documentation regarding the possibility of NAI was found to be poor, but a programme of intervention combining education and the use of a reminder checklist improved both awareness and documentation of NAI, as well as referral rates for further assessment. This strategy may prove applicable to children of all ages and injury types, reducing the number of cases of child abuse that are overlooked in the A&E department.

Cholecystectomy, conversion and complications

BACKGROUND

Faced with a difficult laparoscopic cholecystectomy the surgeon may feel that conversion to open operation would risk greater complications because of the laparotomy. Information on the effect of conversion is lacking. The purpose of this study is to measure the complications of laparoscopic cholecystectomy and observe the effect of the conversion rate.

METHODS

A total of 957 patients were studied. There were three consecutive series of patients; the first undergoing open cholecystectomy (384 patients), the second laparoscopic cholecystectomy with a 5.8% conversion rate (412 patients) and the third laparoscopic cholecystectomy with a 1.3% conversion rate (161 patients). Data was collected prospectively using a continuous audit, and the complication rate compared on an intention to treat basis. In addition a panel of experienced surgeons was asked to score the complications depending on their severity and a composite complication score calculated. Comparison between the 3 groups was then undertaken.

RESULTS

Open cholecystectomy produced a post-operative complication rate of 6%. Initially this appeared to fall to 3.1% with the introduction of laparoscopic cholecystectomy, but when the complications occurring in the converted patients were included (i.e., on an intention to treat basis) the rate increased to 5.6% in the first group of laparoscopically-treated patients and 3.1% in the second. These differences were not statistically significant. A similar pattern emerged when scoring the severity of the complications as judged by the expert panel. The inclusion of intra-operative complications appears to remove any small advantage for laparoscopic cholecystectomy. The reduction in the conversion rate between the two laparoscopic groups from 5.8% to 1.2% was statistically significant.

CONCLUSION

When considered on an intention to treat basis laparoscopic cholecystectomy offers no advantage over open operation in terms of the frequency or severity of complications. Reducing the frequency of conversion from a laparoscopic to an open procedure also has no significant effect on the complications encountered. We conclude, therefore, that the complication rate is independent of the conversion rate and that the surgeon, when faced with difficulty at laparoscopic cholecystectomy, should not be deterred from converting to open operation for fear of the post-operative consequences.

A useful form of glue ear

Children and adults commonly present to the emergency department with a foreign body lodged in the ear. Over the past 15 years techniques for cyanoacrylate ("superglue") assisted foreign body removal have been described, but are not widely employed. Two cases of successful and one of unsuccessful removal using this technique are reported, and some advice is offered to aid others.

Does early wound infection after elective orthopaedic surgery lead on to chronic sepsis?

Infection is an uncommon, but occasionally devastating, complication of orthopaedic surgery. The definition of post-operative infection remains problematic. A high rate of early post-operative sepsis has previously been reported using a clinical definition of wound infection as recommended by the Surgical Infection Study Group. The purposes of this study is to determine the rate of ongoing wound problems and deep sepsis 1 year after these early wound infections. Of 1131 consecutive orthopaedic procedures, there were 70 wound infections occurring within 30 days of surgery. Adequate follow-up data were obtained in 67 (97%) of the 69 patients alive at 1 year. Of these 67, three had definite evidence and two possible evidence of ongoing wound problems and/or deep sepsis. It is concluded that early post-operative wound infection as defined by the Surgical Infection Study Group is a poor predictor (4-10%) of ongoing wound problems and deep sepsis at 1 year. All of the confirmed cases of late sepsis were found to be associated with revision arthroplasty and/or pin tract sepsis.

Annular pancreas and obstructive jaundice

Annular pancreas is a rare abnormality which, in some cases, will be an incidental finding. Recently, two case reports have highlighted the possibility that annular pancreas is responsible for extrahepatic biliary obstruction in the absence of pancreatitis. We present a case of obstructive jaundice in which an annular pancreas was noted at both ERCP and CT scanning, but in which the cause of the obstruction was a carcinoma of the ampulla of Vater. Obstructive jaundice should not be attributed to an annular pancreas until the alternative differential diagnoses have been positively excluded.

Persistent spermatozoa after vasectomy: a survey of British urologists

OBJECTIVES

To determine the rate of, and main indications for, repeat vasectomy in our department, and to assist in policy-making procedures by determining how urologists in England and Wales manage those men who show small but persistent quantities of motile or non-motile spermatozoa in their ejaculate after vasectomy.

SUBJECTS AND METHODS

A retrospective review of all of the vasectomies and repeat vasectomies performed by the Urology Department at Southmead Hospital during a 14-month period was undertaken to determine the rate of and indications for repeat vasectomy. Subsequently, every consultant urologist in England and Wales was canvassed with a questionnaire to determine whether they repeated vasectomy in the presence of persistent motile or non-motile sperms and if so, after what time interval. Any experience of pregnancies arising from these groups was also assessed, and any relevant comments invited.

RESULTS

The local review revealed that 5% of all vasectomies were repeated within 6-36 months. Of these, 87% were performed because of persistent sperms in post-vasectomy semen samples, the majority of which showed sperm concentrations of one in 50 to one in 100 high-power fields. A response of 56% was obtained to the questionnaire and of those responding, 23% never repeated a vasectomy where there were presistent non-motile sperms, but almost all urologists would eventually repeat vasectomy where motile sperms were present. The median interval between the first and second vasectomies was 6 months and 12 months for motile and non-motile sperm, respectively. Apart from those cases already published, there was little experience of pregnancy arising from men with persistently few motile or non-motile sperms.

CONCLUSIONS

The risk of pregnancy occurring in the presence of non-motile sperms was estimated to be less than the established risk of late recanalization, and this survey provides both logical and medico-legal support for issuing a 'special clearance' to men with few persistent non-motile sperm after vasectomy, providing the risks of pregnancy are properly discussed and documented. For motile sperm, however, there appears to be a stronger precedent for repeating the vasectomy. The technique used for post-vasectomy semen analysis was also an important consideration when determining any policy regarding such cases.