Emergency Medicine Journal

BackgroundAmbulance clinicians use pre-alerts to inform receiving hospitals of the imminent arrival of a time-critical patient considered to require immediate attention, enabling the receiving Emergency Department or other clinical area to prepare. Pre-alerts are key to ensuring immediate access to appropriate care, but unnecessary pre-alerts can divert resources from other patients and fuel pre-alert fatigue amongst ED staff. This research aims to provide a better understanding of pre-alert decision-making practice. MethodsSemi-structured interviews were conducted with 34 ambulance clinicians from three ambulance services and 40 ED staff from six receiving EDs. Observation (162 hours) of responses to pre-alerts (n=143, call-to-handover) was also conducted in the six EDs. Interview transcripts and observation notes were imported into NVIVO and analysed using thematic analysis. FindingsPre-alert decisions involve rapid assessment of clinical risk based on physiological observations, clinical judgement, and perceived risk of deterioration, with reference to pre-alert guidance. Clinical experience (pattern recognition and intuition) and confidence helped ambulance clinicians to understand which patients required immediate ED care upon arrival or were at highest risk of deterioration. Ambulance clinicians primarily learned to pre-alert on the job and via informal feedback mechanisms, including the ED response to previous pre-alerts. Availability and access to clinical decision support was variable, and clinicians balanced the use of guidance and protocols with concerns about retention of clinical judgement and autonomy. Differences in pre-alert criteria between ambulance services and EDs created difficulties in deciding whether to pre-alert and was particularly challenging for less experienced clinicians. ConclusionWe identified potentially avoidable variation in decision-making, which has implications for patient care and emergency care resources, and can create tension between the services. Consistency in practice may be improved by greater standardisation of guidance and protocols, training and access to performance feedback, and cross-service collaboration to minimise potential sources of tension.

ObjectiveAmbulance clinicians use pre-alert calls to advise emergency departments (EDs) of the arrival of patients requiring immediate review or intervention. Consistency of pre-alert practice is important in ensuring appropriate EDs response. We used routine data to describe pre-alert practice and explore factors affecting variation in practice. MethodsWe undertook an observational study using a linked dataset incorporating 12 months ambulance patient records, ambulance clinician data and emergency call data for three UK ambulance services. We used LASSO regression to identify candidate variables for multivariate logistic regression models to predict variation in pre-alert use, analysing clinician factors (role, experience, qualification, time of pre-alert during shift), patient factors (NEWS2 score, clinical working impression, age, sex) and hospital factors (receiving ED, ED handover delay status). ResultsFrom the dataset of 1,363,274 patients conveyed to ED, 142,795 (10.5%) were pre-alerted, of whom only a third were for conditions with clear pre-alert pathways (e.g. sepsis, STEMI, major trauma). Casemix (illness acuity score, clinical diagnostic impression) was the strongest predictor of pre-alert use but male patient gender, clinician role, receiving hospital, and hospital turnaround delay at receiving hospitals were also statistically significant predictors, after adjusting for casemix. There was no evidence of higher pre-alert rates in the final hour of shift. ConclusionsPre-alert decisions are determined by factors other than illness acuity and clinical diagnostic impression. Research is required to determine whether our findings are reproducible elsewhere and why non-clinical factors (e.g. patient gender) may influence pre-alert practice.

IntroductionTriage is a key principle in the effective management of major incidents, yet there is a paucity of evidence surrounding the optimal method of paediatric major incident triage (MIT). This study aimed to derive consensus on key components of paediatric MIT among healthcare professionals involved in the management of paediatric major incidents. MethodsThis modified two-round online Delphi consensus study, delivered between July and October 2021, included participants from pre-hospital and hospital specialities involved in managing a paediatric major incident. Statements were derived iteratively based on review of MIT tools, and extant literature. A 5-point Likert agreement scale was used to determine consensus, which was set a priori at 70%. Results111 clinicians completed both rounds, with 13 of 17 statements reaching consensus. Positive consensus was reached on the use of rescue breaths in mechanisms associated with hypoxia or asphyxiation, use of mobility assessment as a crude discriminator of injury, and use of adult physiology for older children. Whilst positive consensus was reached on the benefits of a single MIT tool for use across the entire adult and paediatric age range, there was negative consensus in relation to the clinical implementation of such a tool. Consensus could not be reached regarding the use of a single tool across the whole paediatric age range specifically, nor on the use of rescue breaths in blunt or penetrating trauma. ConclusionThis Delphi study has established consensus among a large group of subject matter experts on several key elements of paediatric MIT. Further work is required to develop a triage tool that can be implemented based on emerging and ongoing research, and which is acceptable to clinicians. What this paper adds?O_ST_ABSSection 1: What is already known on this subject?C_ST_ABS{circ} Whilst triage is a key principle in the effective management of a major incident, there is limited evidence surrounding the use of existing paediatric major incident triage (MIT) tools {circ}Paediatric MIT tools currently used in the UK are associated with high rates of under-triage, failing to identify those in need of life-saving interventions {circ}Existing paediatric MIT tools differ from adult tools, including approach to physiological ranges, and recommendation for initiation of rescue breaths Section 2: What this study adds{circ} Consensus was reached supporting use of rescue breaths for mechanisms associated with hypoxia or asphyxiation, mobility as a crude discriminator for serious injury, and adult physiology for older children {circ}Whilst consensus was reached on benefits related to use of a single tool across all age ranges (adult and paediatric), the expert panel did not support this approach for actual clinical practice {circ}There was no consensus on use of rescue breaths in blunt or penetrating trauma, or use of a single triage tool for the entire paediatric age group {circ}Further work is required to develop and implement a MIT tool that accurately identifies children needing life-saving interventions, and that is acceptable to clinicians

BackgroundSince December 2022, the NHS has experienced large-scale strikes over pay by staff. Strikes heavily impact elective care delivery. The NHS cancels approximately 12 million elective care appointments each year. One million appointments have been cancelled due to strikes between 2022 and 2024. During this time emergency care is prioritised, and in a recent opinion piece, the president of the Royal College of Emergency medicine claimed the Emergency Department ran better than usual. The aim of this paper was to investigate changes in patient flow into hospitals through the ED during the strike periods. MethodologyData from two different emergency departments (EDs) in the North West of England is analysed using Cox-regression to model time between patient arrival at the ED, and subsequent admission. Various systematic and patient-level factors are controlled for. The impact of different striking groups (nurses, junior doctors etc.) on patient time to admission is analysed. ResultsFor the Type 1 ED, hazard ratios indicate that patients are admitted through the ED more quickly on strike days where any single group of staff were striking compared to non-strike days (HRs: 1.16-1.39, all p [≤] 0.003). This increased flow was only seen for consultant strikes in the smaller ED. InterpretationThese findings for all strike types indicate that improved patient flow on strike days is likely due to the increased inpatient capacity from elective care postponement. This result may indicate that there is room for change in NHS hospital systems to improve turnaround time and reduce ED crowding. Key MessagesO_ST_ABSWhat is already known on this topicC_ST_ABSExit block is a primary issue for NHS Emergency Departments (EDs), increasing patient time spent in ED. The president of the Royal College of Emergency Medicine claimed that NHS EDs run better than usual during strikes. There is little quantitative evidence to support this claim. What this study addsThis study identifies significant increases in flow of admitted patients into the hospital during the strikes, when accounting for differences in admission patterns. How this study might affect research, practice or policyThe improvement in flow indicates that, although strike day service is unsustainable, elements of strike preparation can have a positive impact on the running of the emergency departments - demonstrating scope to improve patient flow through NHS EDs.

BackgroundPressures on hospital emergency care services have led to increasing interest in new models of acute care provision. One such model is a medical emergency department where medical patients are triaged directly to acute internal medicine, without assessment by emergency medicine. The evidence for this model of care is unclear. DesignSystematic review. MethodsStudies included direct referral pathways to acute internal medicine. The protocol was registered prospectively (Prospero: CRD42023495786). Databases searched included MEDLINE (Ovid), The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE in process, Web of Science, CINAHL, and Embase. Studies had no time or language restrictions. Studies were selected based on inclusion and exclusion criteria, assessed by at least two independent researchers. ROBINS I risk of bias assessment was applied to the selected studies and a narrative synthesis was performed. ResultsFrom 4405 abstracts, 89 full text articles were screened and 4 were selected for data extraction. Two studies assessed tools to predict the need for a medical admission and two studies assessed the impact of direct referral pathways to medicine. Risk of bias was mixed, and studies were heterogeneous. However, the studies reported a good ability to appropriately select patients for direct referral to medicine and a reduced length of time to medical assessment. There were no differences in other outcomes such as mortality or overall length of stay. DiscussionThe current evidence to support direct admission to medicine, effectively a medical ED, is limited with studies being heterogeneous and of varying quality. Models for patient selection varied, but there was evidence to support accurate, early identification of medical patients and of reduced delays in medical assessment and care. ConclusionGiven these positive early signs of benefit, more studies are needed to design and evaluate care models such as medical EDs. RegistrationProspero Registration Number: CRD42023495786. What is already known on this topicDirect admission pathways to acute medicine services are used in some centres in the UK with significant variation in how this pathway is provided. What this study addsThis systematic review is the first comprehensive synthesis of published research on direct admission pathways to internal medicine services. The limited number of studies were heterogenous and of variable quality. Different models for patient selection were included but were assessed, studies demonstrated the ability to identify patients likely to require medical admission, and a reduction in the time to medical admission. More studies are needed to assess how to structure and operationalize a direct admission pathway in the United Kingdom and internationally. How this study might affect research, practice or policyOur study highlights the need for further research to help develop optimal pathways to enable patients with acute medical conditions requiring treatment to be reviewed by acute medical teams as soon as possible after presentation, to improve patient care in the context of growing demand for these services. Strengths and Limitations- This is the first systematic review of direct admission pathways to medicine. - The systematic review was conducted using standardised methodology with the protocol prospectively registered on an open access database. There were no date or language restrictions applied. - The main limitation of the systematic review is the limited number and quality of studies available for inclusion.

ObjectiveThe 21st century has seen an unexpected rise in numbers of patients with severe injuries caused by low energy transfer mechanisms such as low falls. Our objective was to determine whether this increasing "low energy transfer major trauma" disease burden is more strongly associated with population ageing, better detection or registry reporting between 2000 and 2019. DesignLongitudinal series of annual cross-sectional studies from the Trauma Audit Research Network (TARN). SettingEngland and Wales. ParticipantsPatients with an Injury Severity score (ISS) >15, admitted to English or Welsh hospitals from January 2000 until December 2019. Main outcome measuresThe primary outcome was the strength of association of changes in annual rates of; major trauma patients receiving three-dimensional imaging (CT/MRI scans), registry reporting, and proportion of the population aged over seventy-five with changes in the annual proportion of patients injured via low energy transfer mechanisms. ResultsThe annual proportion of major trauma patients injured by low energy transfer mechanisms rose more than four-fold from 12.5% in 2000 to 52.6% in 2019 (+40.1%, 95% CI 38.8 to 41.4, p<0.0001). This rise in the prevalence of low energy major trauma was more strongly associated with case ascertainment improvements over the study period - indicated by a 60% increase in the proportion of major trauma patients receiving CT/MRI (+60%), and 47% increase in registry reporting rates than a one percent rise in the prevalence of people aged 75 years and over in England and Wales. ConclusionBetween 2000 and 2019 changes in major trauma imaging and reporting have revealed the previously hidden burden of injury resulting from low energy transfer mechanisms, potentially explaining significant increases in major trauma patient numbers. Future research should recognise low energy and high energy major trauma patients are distinct groups and require different interventions to improve patient outcomes. Section 1: What is already known on this topicO_LIFalls from standing height or less than two metres are causing an increasing major injury disease burden across Europe. C_LIO_LIInternationally trauma systems have focussed on patients with injuries caused by high energy transfer mechanisms, such as road traffic collisions. C_LI Section 2: What this study addsO_LIBetter detection and reporting of low energy transfer major trauma - rather than population ageing - appear to be are driving the increase in lower energy major trauma. C_LIO_LILow energy transfer major trauma - characterised by older age, less abnormal physiology, but a high prevalence of traumatic brain and thoracic injuries - is now the dominant major trauma (ISS>15) presentation in England and Wales. C_LIO_LILow energy transfer major trauma patients wait longer for CT scan, are less likely to receive the care in the highest-level trauma centre, to undergo surgery or be admitted to critical care. C_LI Section 3: How this study might affect research, policy and practiceO_LIFuture research should recognise high energy and low energy trauma patients are distinct groups, which require different interventions to improve care processes and outcomes. C_LI

BackgroundPulmonary embolism is a common, time critical condition care requiring multidisciplinary care. Interhospital transport is a high-risk period in the patients care, but offers an opportunity for expedited risk stratification, resuscitation and transport to definitive care. Patients who require interhospital transfer to specialist centres for pulmonary embolism management have worse outcomes. Despite this, literature surrounding the medical retrieval practice and experience of pulmonary embolism is limited. MethodsA retrospective cohort study over a 10-year period from January 2014-September 2024 from the database of a high-volume aeromedical retrieval service in New South Wales, Australia will be performed. The study aims to describe the experience in this service in the care of critically ill pulmonary embolism patients requiring interhospital transport.

BackgroundThe need to better manage frequent attenders or high-impact users (HIUs) in hospital emergency departments (EDs) is widely recognised. These patients often have complex medical needs and are also frequent users of other health and care services. The West of England Academic Health Science Network launched its Supporting High impAct useRs in Emergency Departments (SHarED) quality improvement programme to spread a local HIU intervention across six other EDs in five Trusts. AimSHarED aimed to reduce ED attendance and hospital admissions by 20% for enrolled HIUs. To evaluate the implementation of SHarED, we sought to learn about the experience of staff with HIU roles and their ED colleagues, and assess the impact on HIU attendance and admissions. MethodsWe analysed a range of data including semi-structured interviews with 10 HIU staff; ED staff training; an ED staff experience survey; and ED attendances and hospital admissions for 148 HIUs enrolled in SHarED. ResultsStaff with HIU roles were unanimously positive about the benefits of SHarED for both staff and patients. SHarED contributed to supporting ED staff with patient-centred recommendations and provided the basis for more integrated case management across the health and care system. 55% of ED staff received training. There were improvements in staff views relating to confidence, support, training, and HIUs receiving more appropriate care. The mean monthly ED attendance per HIU reduced over time. Follow-up data for 86% (127/148) of cases showed a mean monthly ED attendances per HIU reduced by 33%, from 2.1 to 1.4, between the six months pre- and post-enrolment (p<0.001). ConclusionSHarED illustrates the considerable potential for a quality improvement programme to promote more integrated case management by specialist teams across the health and care system for particularly vulnerable individuals and improve working arrangements for hard-pressed staff. What is already known on this topicFrequent attendance in hospital emergency departments is a worldwide problem that, despite the national recognition of the rationale for better management of high-impact users, has relied on the local efforts of clinicians to change working practices. What this study addsThe Supporting High impAct useRs in Emergency Departments (SHarED) quality improvement programme was successful in spreading a model of high-impact user management based on the identification, proactive management, monitoring and review of these patients, with clear benefits to emergency department staff, and potential benefits to patients and resource use. How this study might affect research, practice or policySHarED illustrates the considerable potential for a quality improvement programme to promote more integrated case management by specialist teams across the health and care system for particularly vulnerable individuals and improve working arrangements for hard-pressed staff.

BackgroundThe early identification of deterioration in suspected COVID-19 patients managed at home enables a more timely clinical intervention, which is likely to translate into improved outcomes. We undertook an analysis of COVID-19 patients conveyed by ambulance to hospital to investigate how oxygen saturation and measurements of other vital signs correlate to patient outcomes, to ascertain if clinical deterioration can be predicted with simple community physiological monitoring. MethodsA retrospective analysis of routinely collected clinical data relating to patients conveyed to hospital by ambulance was undertaken. We used descriptive statistics and predictive analytics to investigate how vital signs, measured at home by ambulance staff from the South Central Ambulance Service, correlate to patient outcomes. Information on patient comorbidities was obtained by linking the recorded vital sign measurements to the patients electronic health record at the Hampshire Hospitals NHS Foundation Trust. ROC analysis was performed using cross-validation to evaluate, in a retrospective fashion, the efficacy of different variables in predicting patient outcomes. ResultsWe identified 1,080 adults with a COVID-19 diagnosis who were conveyed by ambulance to either Basingstoke & North Hampshire Hospital or the Royal Hampshire County Hospital (Winchester) between March 1st and July 31st and whose diagnosis was clinically confirmed at hospital discharge. Vital signs measured by ambulance staff at first point of contact in the community correlated with patient short-term mortality or ICU admission. Oxygen saturations were the most predictive of mortality or ICU admission (AUROC 0.772 (95 % CI: 0.712-0.833)), followed by the NEWS2 score (AUROC 0.715 (95 % CI: 0.670-0.760), patient age (AUROC 0.690 (95 % CI: 0.642-0.737)), and respiration rate (AUROC 0.662 (95 % CI: 0.599-0.729)). Combining age with the NEWS2 score (AUROC 0.771 (95 % CI: 0.718-0.824)) or the measured oxygen saturation (AUROC 0.820 (95 % CI: 0.785-0.854)) increased the predictive ability but did not reach significance. ConclusionsInitial oxygen saturation measurements (on air) for confirmed COVID-19 patients conveyed by ambulance correlated with short-term (30-day) patient mortality or ICU admission, AUROC: 0.772 (95% CI: 0.712-0.833). We found that even small deflections in oxygen saturations of 1-2% below 96% confer an increased mortality risk in those with confirmed COVID at their initial community assessments.

ObjectiveTo investigate the association between patient time spent in Type 1 emergency departments (EDs) and all-cause mortality 30 days after leaving the department alive. DesignCross-sectional, retrospective, observational study using national linked data. SettingAll NHS Type 1 emergency departments in England. Participants6,721,179 individuals (mean age 41.3 years, 52.6% female, 81.4% White ethnicity) attended an ED at least once between 21st March 2021 and 31st March 2022; had a record populated with a "non-immediate" acuity level and a chief complaint at arrival; and survived to either discharge from the ED or admission to hospital for inpatient care. Main outcome measuresAll-cause mortality within 30 days of the ED attendance. ResultsWithin the study population, 88,657 patients (1.3%) died within 30 days of ED attendance. A positive non-linear relationship was observed between time spent in the ED and post-discharge mortality, with the probability of death increasing after two hours. The marginal probabilities of death (controlling for socio-economic characteristics, clinical factors such as chief complaint, and comorbidities) at two hours in the ED were 0.02% for patients aged 20 years, rising to 0.1% at 40 years, 0.3% at 60 years, and 0.8% at 80 years. Compared with patients who spent two hours in the ED, the adjusted odds of post-discharge death were: 1.1 times higher (1.07 to 1.14) for three hours; 1.6 times (1.48 to 1.68) for six hours; 1.9 times (1.80 to 2.03) for nine hours; and 2.1 times (2.02 to 2.28) for 12 hours. ConclusionsLonger time spent in the ED for non-immediate care is associated with increased risk of all-cause mortality within 30 days of discharge or admission, in a non-linear manner. Our findings suggest that time in the ED may be a risk factor for death after discharge, not just during the visit. These findings could inform policy makers and health professionals when setting ED time targets. Further research is needed to understand causal drivers of post-discharge mortality and confirm whether our findings generalise to more recent periods. Summary boxO_ST_ABSSection 1: What is already known on this topicC_ST_ABSO_LISmall, single-centre studies have suggested that there is an increased mortality rate among patients who experience delays between arrival at the emergency department and admission to an inpatient bed. C_LIO_LIA larger study of over five million individual admitted patients in England, using data from between 2016 and 2018, found an increase in all-cause 30-day mortality that was associated with delays to hospital admission. The quantifiable increase in mortality started as early as five hours after arrival at the emergency department (ED) and increased in a linear "dose-related" fashion. C_LI Section 2: What this study addsO_LIOur study suggests that longer ED stays for non-immediate care are associated with an increased risk of all-cause mortality within 30 days of both discharge or admission. C_LIO_LIOur study builds on previous research by incorporating more recent data, treating time spent in the ED as a continuous rather than a discrete variable; controlling for a broad range of socio-economic variables recorded in England and Wales National Census; and including all patients who attended emergency departments, for both those that were admitted and those that were discharged (rather than just those who were subsequently admitted to hospital for inpatient care). C_LI

BackgroundCardiopulmonary resuscitation (CPR) and defibrillation at least doubles survival to hospital discharge following out-of-hospital cardiac arrest. Members of the public can perform both before the ambulance service arrives. However, bystanders use a public-access Automated External Defibrillator (AED) in around 5% of cases. Using Unmanned Aerial Vehicles ( drones) to deliver AEDs may overcome many of the barriers preventing public-access AED use. We investigated how quickly and easily bystanders performing CPR could use drone-delivered AEDs. MethodsWe developed an AED-capable drone between May and November 2020. In July and September 2021, we conducted eighteen out-of-hospital cardiac arrest simulations. A single participant found a simulated patient inside a building and made a 999-call to a Welsh Ambulance Services NHS Trust call-handler. Once cardiac arrest was confirmed during the 999-call a nearby drone launched, reached hovering altitude and delivered the AED immediately outside the building. The participant retrieved the AED when instructed to do so, attached it to the patient and delivered a single shock. The primary outcome was hands-off CPR time. We investigated ease of AED retrieval via a questionnaire adapted from the System Usability Scale and explored participant behaviours via brief post-simulation interviews and reviews of audio (999-call) and video recordings of the simulation. ResultsHands-off CPR time was (median) 109s (interquartile range 87-130s). Participants spent 19s (16-22s) away from the patients side when retrieving the AED. They found it easy to use the AED but often sought reassurance from the call-handler that it was appropriate for them to retrieve it. ConclusionParticipants found it easy to retrieve and use an AED delivered by drone in simulated out-of-hospital cardiac arrests. Hands-off CPR time was potentially clinically relevant in this lone bystander simulation, but there was only a small increase in hands-off time caused by retrieval of the drone-delivered AED. O_TEXTBOXWhat is already known on this topic - summarise the state of scientific knowledge on this subject before you did your study and why this study needed to be doneDrones have been used to deliver AEDs in simulation studies across the world and in a real-life pilot in Sweden. Real-world success is so far limited, and no functioning system for this to happen in real-world out-of-hospital cardiac arrests in the UK. What this study adds - summarise what we now know as a result of this study that we did not know beforeWe have demonstrated a feasible drone-delivered AED system. Lone bystanders spent a median of 19 seconds away from the patient to retrieve the drone-delivered AED. Interaction with the drone and AED was not difficult, and the 999 call-handler has a vital role in facilitating safe and timely retrieval of the drone-delivered AED. How this study might affect research, practice or policy - summarise the implications of this studyLone bystanders are currently not instructed by ambulance services to leave a patient to retrieve a nearby public-access AED, but collecting an AED delivered directly to them may be appropriate. The next step in developing a drone-delivered AED system for real-world use in the UK is to integrate a drone-delivered AED system into an ambulance services Emergency Operations Centre system and to test the out-of-hospital cardiac arrests response in prolonged beyond visual-line-of-sight drone flights. C_TEXTBOX

BackgroundThe English National Health Service (NHS) 111 telephone service aims to assist members of the public with urgent medical care needs. However, each year nearly 18% of the 20.6 million calls to 111 are abandoned prior to speaking to a health advisor. There are concerns that callers who are not triaged may not appropriately seek the correct level of care for their needs. The aim of this study was to explore the patient journey for callers who contact NHS 111 but end the call prior to speaking to a health advisor. The primary objective was to determine whether callers to NHS 111 who end the call prior to triage attend an ED with a non-avoidable cause sooner than who are triaged by an NHS 111 health advisor. MethodsWe obtained routine data pertaining to all NHS 111 calls made by adult patients registered with a General Practitioner (GP) in the Bradford region of Yorkshire, UK, between the 1st January 2022 and 30th June 2023. Subsequent healthcare access in the 72 hours following each callers first (index) call was identified using the Connected Yorkshire research database. We conducted a time-to-event analysis comparing the two cohorts: those whose index call was triaged by an NHS 111 health advisor vs. callers who ended the index call prior to triage. The event was defined as an Emergency Department (ED) attendance within 72 hours for a non-avoidable cause. We utilised Kaplan-Meier (KM) curves and conducted log-rank tests to compare the time to first non-avoidable ED attendance between cohorts, and a Cox proportional hazards model adjusted for baseline characteristics. From this, we calculated the adjusted hazard ratio (aHR) of attending an ED with a non-avoidable cause. ResultsThere were 19,056 index non-triaged and 168,609 triaged calls made to NHS 111 by an adult registered with a Bradford GP. A lower proportion of ED attendances in the non-triaged call cohort were non-avoidable compared with the triaged cohort (80.0% compared to 84.6% for triaged calls). In addition, callers in the non-triaged call cohort attended ED later than the triaged call cohort (median 10 vs 8 hours, p<0.001 by log rank test). The time-to-attend ED aHR for non-triaged calls vs triaged calls was 0.32 (95%CI 0.30-0.34). ConclusionThe time-to-event analysis found that callers to NHS 111 who do not wait to be triaged, are slower to attend ED with a non-avoidable cause than those who are triaged, and are more likely to attend ED with an avoidable cause than triaged callers. This suggests that, for patients with a serious health problem that would be considered non-avoidable at ED, triaging by NHS 111 supports those patients to seek appropriate help more quickly. In turn, patients with such health conditions who end the call before triage may delay seeking appropriate levels of healthcare.

BackgroundTriage is a key principle in the effective management of major incidents. However, there is an increasing body of evidence demonstrating that existing paediatric methods are associated with high rates of under-triage and are not fit for purpose. The aim of this study was to derive a novel paediatric triage tool using machine learning (ML) techniques. MethodsThe United Kingdom Trauma Audit Research Network (TARN) database was interrogated for all paediatric patients aged under 16 years for the ten-year period 2008-2017. Patients were categorised as Priority One if they received one or more life-saving interventions from a previously defined list. Six ML algorithms were investigated for identifying patients as Priority One. Subsequently, the best performing model was chosen for further development using a risk score approach and clinically relevant modifications in order to derive a novel triage tool (LASSO M2). Using patients with complete pre-hospital physiological data, a comparative analysis was then performed comparing this to existing pre-hospital paediatric major incident triage tools. Performance was evaluated using sensitivity, specificity, under-triage (1-sensitivity) and over-triage (1-positive predictive value). ResultsComplete physiological data were available for 4962 patients. The LASSO M2 model demonstrated the best performance at identifying paediatric patients in need of life-saving intervention, sensitivity 88.8% (95% CI 85.5, 91.5) and was associated with the lowest rate of under-triage, 11.2% (8.5, 14.5). In contrast, the Paediatric Triage Tape and JumpSTART both had poor sensitivity when identifying those requiring life-saving intervention (36.1% (31.8, 40.7) and 44.7% (40.2, 49.4)) respectively. ConclusionThe ML derived triage tool (LASSO M2) outperforms existing methods of paediatric major incident triage at identifying patients in need of life-saving intervention. Prior to its recommendation for clinical use, further work is required to externally validate its performance and undertake a feasibility assessment in a clinical context. What is known about this topicChildren are frequently involved in all types of major incidents. A key principle in their management is triage, the process of prioritising patients on the basis of their clinical acuity. Unlike in the adult population, there are currently only a limited number of paediatric triage tools for use in a major incident, with a paucity of evidence supporting their use. A recent comparative analysis demonstrated that the adult triage tool, the MPTT-24, outperformed all existing pre-hospital paediatric triage tools at determining the Priority One paediatric patient. What this study addsWe have applied machine learning algorithms to derive a novel triage tool, the LASSO M2. This triage tool demonstrated an absolute increase in sensitivity of 52{middle dot}7% over the existing UK method of pre-hospital paediatric major incident triage, the Paediatric Triage Tape. This study has demonstrated that utilising additional parameters out with patient physiology, can lead to a marked improvement in triage tool performance.

BackgroundPrevious studies have indicated that crowding within the Emergency Department (ED) is associated with longer lengths of stay in the ED and higher mortality. Boarding, the time patients spend waiting for an inpatient bed after ED assessment, represents a clinically unproductive delay, and occupies scarce ED resources. We aimed to explore the impact of medical patients boarding not only on their outcomes but also indirectly on other patients in the ED and in and awaiting ambulances. MethodsA retrospective cohort study using routine data for 3 EDs in England from June 2021 to May 2024 was performed. Direct outcomes of medical patient boarding time were investigated: inpatient length of stay, 30-day readmission rate and mortality. Indirect outcomes of medical patient boarding levels consisted of time in ED for non-admitted patients, ambulance handover times, and ambulance response times. Regression analysis was used to model each relationship while controlling for other potentially confounding variables. ResultsIn all, data on 223,856 ambulance responses, 117,800 ambulance handovers, 367,985 non-admitted ED patients, and 46,976 medical admissions were studied. Medical patients, covering two-thirds of ED admissions, constituted 82% of total ED boarding time. Regression analysis showed that for a typical 25-bed ED, each additional five medical boarders was associated with an extra 12 and 39 minutes for Category 2 and 3 ambulance response times (p<0.001) and an extra 20 minutes for ambulance handover times (p<0.001). For admitted medical patients, each additional 4 hours of boarding time was associated with an extra 13 hours inpatient length of stay (p<0.001) and a 6% increase in odds of 30-day mortality (p<0.01). ConclusionBoarding of medical patients in the ED is associated with direct harm for those patients, and indirect harms for other patients in the ED and awaiting ambulances. What is already known on this topicA prolonged length of stay in the Emergency Department is known to increase mortality for those patients. What this study addsMedical admissions make up 85% of boarding time in the ED waiting for an inpatient bed. This delay affects them directly with increased mortality, readmission and length of stay. It affects other patients with delayed ambulance offload and ambulance response times for other patients. How this study might affect research, practice or policyThe boarding delay for medical patients in the ED results in a longer inpatient length of stay and therefore fewer beds available for future patients. Stopping this practice would free up much needed hospital capacity, improve ambulance response times, and reduce mortality.

Background Emergency departments (EDs) in high-income countries face rising demand, workforce shortages and crowding. We investigated whether prehospital point-of-care blood gas analysis (BGA), used by emergency physicians, is associated with higher ambulatory treatment rates and improved patient selection for hospital admission. Methods We retrospectively analysed routinely collected data from a pilot implementation of a mobile blood gas analyser in physician-staffed emergency medical services (EMS) in Jena, Germany (July 2023 to May 2024). Adult emergency patients receiving prehospital BGA were compared with propensity score-matched EMS controls without BGA. Primary outcomes were the proportion treated on scene and, among transported patients, the hospital admission rate. Secondary outcomes were 30-day safety among ambulatory patients and associations between BGA parameters and disposition. We used standardised mean differences to assess balance and receiver operating characteristic analysis for lactate thresholds. Results Of 109 patients receiving prehospital BGA, 98 met inclusion criteria after excluding 9 patients with missing NACA scores, 1 on-scene death and 1 invalid age record; these were matched to 390 controls (total n = 488). Baseline demographics, severity and vital signs were well balanced. Ambulatory treatment was markedly higher in the BGA cohort compared with matched controls (27.6% vs 8.7%; OR 3.98, 95% CI 2.26 to 7.01; p<0.001). No ambulatory BGA patient required ED re-attendance or repeat EMS contact within 30 days. Among transported patients, 58% in the BGA cohort were admitted to hospital, compared with an overall regional ED conversion rate of approximately 30%. Lactate [&ge;]2.6 mmol/L was the most influential parameter for disposition decisions, with elevated lactate and acid-base disturbances strongly associated with transport and admission. Conclusion Prehospital BGA was associated with fourfold higher ambulatory treatment rates (27.6%) and a twofold higher ED conversion rate among the patients who were transported (58%), indicating improved risk stratification and resource allocation. These findings suggest that integrating objective biochemical data into prehospital assessment may enhance treat-and-refer decision-making and support more efficient use of limited emergency care capacity.

The RESHAP-ED1 trial is a pragmatic, multicentre, two-arm, parallel randomised controlled trial which aims to test the effectiveness of primary-contact physiotherapy for musculoskeletal pain when compared to the traditional doctor/nurse pathway, on patient flow (i.e. length of stay) in the emergency department. The objective of this trial is to compare two approaches to physiotherapy involvement in the assessment and management of patients who present to emergency departments with simple musculoskeletal problems that are both standard of care in Australian emergency departments. The primary health services outcome is emergency department length of stay defined as the period between when a patient presents at an emergency department, and when that person is recorded as having physically departed the emergency department. The primary outcome will be analysed using a generalised linear mixed effects model with a fixed effect of intervention (primary-contact physiotherapy vs control) and a random effect for hospital. The statistical analysis plan pre-specifies the method of analysis for primary, secondary and safety outcomes and key variables collected in the trial. Secondary, and subgroup group analyses have been pre-specified as well.

BackgroundOlder adults constitute a considerable number of attendances at emergency departments (EDs). Whilst many require hospital admission, a greater focus now is on admission avoidance with older adults being subsequently discharged from EDs. Little is known, however, about the experiences out of hours (OOH) when specialist older person support services are unavailable. AimTo explore senior health care professionals experiences of discharging older people during out of hours from EDs. MethodA qualitative study involving individual semi-structured interviews was used to explore the experiences of healthcare professionals. Fourteen participants in total responded from a wide geographical spread. Data analysis was undertaken using Braun and Clarkes (2022) six-step framework for Thematic Analysis. ResultsOne overarching theme was identified focusing on risks and safety for the older person whilst being discharged OOH from the ED. Three sub-themes included "Should they stay, or should they go?", "Bright lights and noise", and "New ways of working", which included risks in discharging an older person OOH from the ED, risks in delaying discharge, and recommendations for future practice. Significant differences were reported between office hours and OOH discharge of older adults from the ED. Diversity in practice assessments, and resources available was also evident across EDs. Significant adverse consequences were identified for older adults having to stay for prolonged periods in the ED. ConclusionsThere have been many welcome developments in healthcare services for older people who attend and are subsequently discharged from the ED. However, further innovative practice and collaboration with senior decision makers is needed to meet the healthcare needs of a rapidly ageing population. Safe, equitable and effective discharge practice 24/7 should be a norm for all older people in every ED regardless of location. Gaps in care identified must be addressed taking cognisance of the relevant recommendations for future practice.

BackgroundCovid-19 virus activity appears to have affected some parts of the United Kingdom more than others. Dumfries and Galloway (D&G) has seen fewer hospitalised cases than predicted. We wondered whether this might be related at least in part to population density. MethodsWe compared Covid-19 hospitalisation rates/100,000 population in D&G with those of the other 10 mainland Scottish health boards. We chose two time points: 19th April which was the peak of the pandemic in Scotland and 15th May, seven and a half weeks after lockdown. We used chi square and odds ratios with 95% confidence intervals to test for differences in hospitalisation rates and Pearsons correlation coefficient to examine the relation between hospitalisation rates and population density. Population density for each health board was provided by National Records of Scotland. ResultsHospitalisation in D&G was 13.4/100,000 on 19th April, falling to 1.3/100,000 by 15th May. Corresponding hospitalisation rates in Greater Glasgow & Clyde (GGC) were 50.1/100,000 and 38.9/100,000. Compared to GGC, hospitalisation rates in D&G were 3 times lower at peak (OR 0.27, 95% CI 0.17, 0.42) and 30 times lower by 15th May (OR 0.03, 95% CI 0.01, 0.14). Hospitalisation rates for the other health boards lay in between values recorded for D&G and GGC and fell in 10 of the 11 boards between these two dates. There was a positive association between hospitalisation rate and population density (r=0.756, p=0.007 on 19th April and r=0.840, p<0.001 for 15th May). ConclusionWe have confirmed there are large differences in Covid-19 hospitalisation rates across the 11 mainland Scottish health boards, that are in part related to population density. These data support a regional rather than one nation approach to easing Covid-19 restrictions.

ObjectiveExpanding staff levels is a strategy for hospitals to increase surge capacity. This study aimed to evaluate whether emergency healthcare workers (HCWs) are willing to work (WTW) during a crises or disaster and which working conditions would influence their decision. MethodsHCWs of emergency departments (ED) and intensive care units (ICU) of five Dutch hospitals were surveyed about elevens disaster scenarios. For each scenario, HCWs were asked about their WTW and which conditions would influence their decision. Knowledge and perceived risk and danger was assessed per scenario. Results306/630 HCWs completed the survey. An influenza epidemic, SARS-CoV-2 pandemic and natural disaster were associated with highest WTW rates (69.0%, 63.7% and 53.3% respectively). WTW was lowest in nuclear incident (4.6%) and dirty bomb (3.3%) scenarios. WTW was higher in physicians than in nurses. Male ED HCWS, single HCWs and childless HCWs were more often WTW. Personal protective equipment (PPE) and safety of HCWs family were the most important working conditions. Perceived knowledge scored lowest in dirty bomb, biological and nuclear incident scenarios. These scenarios rated highest with regards to perceived danger. ConclusionsWTW depended on disaster type, profession and working department. Provision of PPE and safety of HCWs family were found to be predominant working conditions.

ObjectivesEmergency department clinicians can use triage tools to predict adverse outcome and support management decisions for children presenting with suspected COVID-19. We aimed to estimate the accuracy of triage tools for predicting severe illness in children presenting to the emergency department (ED) with suspected COVID-19 infection. MethodsWe undertook a mixed prospective and retrospective observational cohort study in 44 EDs across the United Kingdom (UK). We collected data from children attending with suspected COVID-19 between 26 March 2020 and 28 May 2020, and used presenting data to determine the results of assessment using the WHO algorithm, swine flu hospital pathway for children (SFHPC), Paediatric Observation Priority Score (POPS) and Childrens Observation and Severity Tool (COAST). We recorded 30-day outcome data (death or receipt of respiratory, cardiovascular or renal support) to determine prognostic accuracy for adverse outcome. ResultsWe collected data from 1530 children, including 26 (1.7%) with an adverse outcome. C-statistics were 0.80 (95% confidence interval 0.73-0.87) for the WHO algorithm, 0.80 (0.71-0.90) for POPS, 0.76 (0.67-0.85) for COAST, and 0.71 (0.59-0.82) for SFHPC. Using pre-specified thresholds, the WHO algorithm had the highest sensitivity (0.85) and lowest specificity (0.75), but POPS and COAST could optimise sensitivity (0.96 and 0.92 respectively) at the expense of specificity (0.25 and 0.38 respectively) by using a threshold of any score above zero instead of the pre-specified threshold. ConclusionExisting triage tools have good but not excellent prediction for adverse outcome in children with suspected COVID-19. POPS and COAST could achieve an appropriate balance of sensitivity and specificity for supporting decisions to discharge home by considering any score above zero to be positive. RegistrationISRCTN registry, ISRCTN28342533, http://www.isrctn.com/ISRCTN28342533