Emergency Medicine Journal

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

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

Background and importance Emergency Department (ED) crowding is an increasing public health concern, with evidence of harms to patients, the public and healthcare systems. When the number of patients requiring emergency care exceeds the capacity of EDs, operational decisions must be made regarding the best place of care for patients. It is not known if there is an association between place of escalation area care (for example 'ramping' in an ambulance, or in an ED corridor) and patient outcomes. Objective(s) This study aimed to assess the association between the relative proportion of all escalation area care that a site provided in an ambulance (the Ambulance:Escalation Index) and all-cause 28-day mortality. Design A secondary analysis of a prospective cohort study. Adult patients of 16 years or older, attending EDs in England, Wales and Northern Ireland in March 2025. Intervention or exposure (if any) The Ambulance:Escalation Index, a site-level indicator of the proportion of all time in escalation area care provided in an ambulance. Outcome measures and analysis The profile of site-level ambulance use was presented descriptively. Multivariable survival analysis was used to assess the primary outcome, all-cause 28-day mortality. Main results Of 131 EDs using escalation area, 82 (62.6%) used ambulances as a place of escalation area care. There was a significant association between a site's increasing use of ambulances as escalation areas and mortality; for each 5% increase in the proportion of a site's total escalation area care delivered in ambulances, there was a 2.1% increase in the hazard of death by 28 days (HR 1.021, 95% CI 1.002-1.041, p=0.032). Conclusion Emergency Department crowding is associated with poor outcomes irrespective of where departments are forced to deliver care; however this study suggests that there is excess mortality where escalation area care is more often delivered in ambulances.

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.

BackgroundRecent trends in high-income countries indicate a shift in the causes of major trauma, with low-energy transfer mechanisms, particularly falls from less than two meters, becoming increasingly prevalent. This study aimed to compare the demographics, care processes, and outcomes of major trauma patients injured by low and high-energy transfer mechanisms. MethodsThis comparative cohort study utilized anonymized data from adult patients recorded in the Trauma Audit and Research Network in 2019. Patients were categorized into low-energy (falls less than 2 meters) and high-energy (other mechanisms) groups. The study focused on patients with an Injury Severity Score (ISS) greater than 15. Data from up to 179 English and Welsh hospitals were included. ResultsIn 2019, 53.6% (n=16,087) of major trauma patients were injured by low-energy falls. When compared to the high-energy cohort, these affected older patients (median age 80 vs. 47 years), with a higher prevalence of pre-existing comorbidities (90.4% vs. 56.2%) and traumatic brain injuries (74.0% vs. 49.8%). Low-energy fall patients were more likely to be initially treated in Trauma Units rather than Major Trauma Centres and received fewer interventions such as surgery and critical care admission. Low-energy falls patients had a higher in-hospital mortality rate (16.1% vs. 12.6%). ConclusionsThe increasing burden of major trauma from low-energy falls necessitates a re-evaluation of current trauma care systems and injury prevention strategies to better serve this distinct and growing patient population. Future research should focus on optimizing care pathways, defining patient orientated outcomes and improving outcomes for patients injured by low-energy falls.

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.

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.

BackgroundCOVID-19 is a global health emergency. Recent data indicate a 50% mortality rate across UK intensive care units. MethodsA single institution, two-centre retrospective analysis following implementation of a Decision Support tool and real-time data dashboard for early detection of patients requiring personalised enhanced care, focussing on respiratory rate, diastolic blood pressure, oxygenation indices, C-reactive protein, D-dimer and ferritin. Protocols differing from conventional practice included high-dose prophylactic anticoagulation for all COVID-19 positive patients and prescription of antioxidants. ResultsBy 22/04/2020, 923 patients tested COVID-19 positive. 569 patients (61.7%) were male. The majority presented with advanced disease: interquartile ranges were C-reactive protein 44.9-179mg/L, D-dimer 1070-3802ng/mL, and ferritin 261-1208{micro}g/L. Completed case fatality rates were 25.1% [95% CI 20.0, 30.0] in females, 40.5% [95% CI 35.9, 45.0] in males. 139 patients were admitted to intensive care where current death rates are 16.2% [95% CI 3.8, 28.7] in females, 38.2% [95% CI 28.6, 47.8] in males with no trends for differences based on ethnicity. A real-time traffic lights dashboard enabled rapid assessment of patients using critical parameters to accelerate adjustments to management protocols. In total 513 (55.6%) of patients were flagged as high risk for thromboembolic disease, exceeding the numbers flagged for respiratory deteriorations (N=391, 42.4%), or cytokine storm (N=68, 7.4%). There was minimal evidence that age was associated with disease severity, but males had higher levels of all dashboard indices, particularly C-reactive protein and ferritin (p<0.0001) which displayed no relationship with age. ConclusionsSurvival rates are encouraging. Protocols employed (traffic light-driven personalised care, protocolised early therapeutic anticoagulation based on D-dimer >1,000ng/mL and/or CRP>200 mg/L, personalised ventilatory strategies and antioxidants) are recommended to other units. Males are at greater risk of severe disease, most likely as the obligate SARS-CoV-2 receptor is encoded by the X-chromosome, and require especially close, and early attention.

Background: Pain management post-rib fractures is often difficult. High pain levels can lead to altered respiratory mechanics and delayed complications such as poor mobility. Whilst as-needed Opioids are the mainstay of treatment, the potential negative side effects have led to research into alternatives such as kinesiotaping, single-shot chest wall regional anaesthesia, and incentive spirometry. Methods: A systematic review was undertaken using Medline (Ovid), Emcare, CINAHL, and the Cochrane Library. Article review and selection were undertaken by two independent reviewers using Covidence. Quality was assessed through the Mixed Methods Appraisal Tool (MMAT). Where appropriate, meta-analysis was undertaken using R studio with a REML random effects model. Forest plots were completed, and Higgins I2 and Chi2 were calculated. Results: Kinesiotaping demonstrates a reduced pain score than medication alone (SMD: -1.87, 95% CI [-2.65, -1.08]), as did single-shot chest wall regional anaesthesia (SMD: -0.79 [-1.15, -0.01]). The regional anaesthesia group had lower opioid consumption (SMD -0.84 [-2.18, 0.50]) and reduced length of hospital stay (SMD: -0.18 [-0.39, 0.03]) but no change in the risk of complications (RR: 0.92 [0.36, 2.36]). The incentive spirometry group had an increased risk of complications (RR: 3.35 [0.68, 16.44]); however, the causative effect could not be inferred due to significant confounding variables. Conclusions: Low-to-moderate certainty evidence suggests that kinesiotaping and single-shot chest wall regional anaesthesia may reduce pain in adult emergency department patients with rib fractures. However, evidence is insufficient to show a clear benefit for opioid reduction, length of stay, or complications. The current evidence does not support routine use of incentive spirometry in this setting, but the evidence is severely confounded by baseline injury severity in the current published studies.

BackgroundExtrication is the process of removing injured or potentially injured people from their vehicles. The origin of current extrication techniques and paradigms is largely unknown. An understanding of the historical evidence related to motor vehicle collisions (MVCs), injuries and deaths will provide context for accepted, contemporary, extrication practices. MethodsExtrication related search terms were developed and applied across of range of sources including Clinical and health care data, Trial registries, Grey literature, Academic and specific Transport related sources. Results7089 articles were identified, following review, 170 are included in this qualitative synthesis. Key themes / categories included: Extrication training and principles, Injures, Immobilisation, Care during entrapment, Clinical response type, Vehicle deformity intrusion entrapment, and Extrication. ConclusionThere is a paucity of published evidence to support the current approach to extrication of entrapped patients following an MVC. Focused studies identifying in detail the injures and their sequelae associated with entrapment, the biomechanics of current techniques and ensuring that the patient perspective is captured will enable the development of much needed evidence based multidisciplinary guidance.

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

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.

Background Emergency Department (ED) crowding is an international crisis primarily driven by exit block. Point of care (POC) cardiac biomarker testing and reduced sampling intervals have been proposed to mitigate crowding by improving throughput, but whole-ED operational impacts remain poorly understood, and evaluations often rely on vulnerable observational designs. This study aimed to assess whether introducing POC high-sensitivity troponin testing and reduced sampling intervals changed whole-ED flow metrics, and to test the robustness of interrupted time series (ITS) methodology in this setting. Methods A multi-centre controlled interrupted time series (CITS) across two large urban intervention EDs and one untreated control ED in Glasgow, UK. The intervention combined whole-blood POC high-sensitivity troponin testing with a reduction in sampling intervals from 3 to 2 hours. Outcomes included daily ED admissions, mean occupancy, maximum occupancy, and mean length of stay. Analyses used a window of 120 days either side of each implementation date. Effects were evaluated using segmented ITS models, with and without controls, with permutation tests against 147 pre-intervention placebo dates. The minimum detectable effects of a similar study, applied to a national dataset, were simulated. Results Across 483,412 presentations to the intervention sites, the intervention produced no statistically significant change in any whole-ED flow metric against the untreated control at either site. Analysed alone, one intervention site appeared to show reductions in mean occupancy (-6.08, 95% CI -12.04 to -0.12) and maximum occupancy (-7.60, -14.47 to -0.73); the untreated control department produced reductions in the same direction at the same date, and both estimates attenuated to the null once the control was applied. Under a pre-specified 14-day transition specification the reductions in the untreated department reached statistical significance while those at the treated site did not. The study was limited by power due to the study window and limited control pool. Simulation demonstrated that a national dataset has the potential to provide operationally feasible and clinically important findings. Conclusion POC cardiac biomarker testing and reduced sampling intervals did not detectably improve whole-ED flow, though the design was underpowered. More importantly, uncontrolled ITS designs are highly vulnerable to confounding in complex healthcare systems; evaluations of operational interventions must utilise concurrent controls, and routinely report falsification tests.

BackgroundMajor trauma is a highly heterogeneous clinical condition, posing significant challenges for accurate diagnosis, timely transfer, and effective treatment. Identification of meaningful subgroups using Latent Class Analysis (LCA) can inform clinicians and policymakers, but this approach has seldom been applied to diverse trauma cohorts. We therefore aim to identify clinically meaningful subgroups of trauma patients and explore predictors of group membership. MethodologyWe merged data for n=4,403 patients from ambulance service electronic patient care reports with a national major trauma audit and applied LCA to identify subgroups. We then used multinomial regression to examine associations between class membership and prehospital physiological parameters. ResultsUsing LCA, we identified five distinct patient classes by integrating demographics, care pathways, and outcomes of ranging severity: (1) Severe Trauma - critical care, (2) Moderate limb trauma - surgical management, (3) Minor-moderate chest, limb and spinal trauma - non-operative, (4) Head trauma - conservative management and (5) Complex, chest and head trauma. The five-class solution showed the best separation based on fit statistics and clinical interpretation. Analysis of prehospital physiological data showed that the Glasgow Coma Score was significantly lower in (1) and (4) with means of 13.0 and 13.2 respectively. ConclusionsThis first application of LCA to major trauma patients demonstrates its potential for identifying distinct patient cohorts within a heterogeneous population. Recognising these trajectories enables targeted evaluation of prehospital and in-hospital factors associated with outcomes.

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 [&le;] 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.

BackgroundAcute heart failure is a common presentation to Emergency Departments (ED) the world over. Amongst the most common presenting signs and symptoms is dyspnoea due to acute pulmonary oedema, a life-threatening emergency that if left untreated or poorly managed. There is increasing evidence demonstrating improved outcomes following the use of vasodilators or non-invasive ventilation for these patients in the emergency setting. Consequently, the potential exists that initiating these therapies in the prehospital setting will similarly improve outcomes. MethodsA historical cohort study was conducted to assess the effect of a prehospital initiated treatment protocol of nitrates plus non-invasive ventilation (NIV) versus regular therapy for severe cardiogenic APO on all-cause in-hospital mortality at 7 days, 30 days, and in total. Secondary outcomes included changes in EMS respiratory and haemodynamic parameters; admission status; length of stay; and emergency endotracheal intubation. ResultsThe intervention led to an approximate 85% reduction in adjusted odds of mortality at 7 days compared to the regular therapy (AOR 0.15, 95% CI: 0.05 - 0.46, p = 0.001); approximate 80% reduction in odds of mortality at 30 days (AOR 0.19, 95% CI: 0.07 - 48, p < 0.0001); and Approximate 60% reduction in odds of total mortality (AOR 0.25, 95% CI: 0.12 - 0.56, p = 0.001). ConclusionThe results of this analysis provide strong evidence of the potential synergistic benefits that can be achieved with the early implementation of a simple treatment protocol of prehospital administered nitrates and initiation of NIV for cardiogenic APO.

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

ObjectivesTo examine the relationship between deprivation and Accident and Emergency department attendance. DesignRetrospective cohort study. SettingEngland, United Kingdom, from 21 March 2021 to March 2022 ParticipantsAll individuals in the 2021 Census, aged 0 to 95 with an Emergency Department attendance record within the Emergency Care Dataset (ECDS). Our full sample included 51,776,958 individuals and 11,498,520 A&E attendance records. Main outcome measuresThe primary outcome was any visit to an Accident and Emergency service in England between 21st March 2021 and 31st March 2022 as recorded in ECDS. ResultsAfter adjusting for age, sex and ethnicity, the odds of A&E attendance increased as the level of deprivation increased, with the odds for those in the most deprived decile being 1.69 (95% CI - 1.68 to 1.69) times greater than those in the least deprived decile. Adjusting for underlying health attenuated but did not fully explain the association between deprivation and A&E attendance, with the odds ratio of attendance for those in the most deprived decile reduced to 1.41 (95% CI - 1.40 to 1.41). This pattern was similar across age groups however the gradient of the slope was steeper for working age adults and the magnitude of the reduction in odds for the most deprived decile relative to the least deprived decile after adjusting for health was greatest in those aged 30 to 79. By acuity, those living in the most deprived decile had 2.26 times (95% CI = 2.23 to 2.28) higher odds of attending A&E for a condition classified as low acuity compared with those in the least deprived decile. Even after adjusting for health, those in the most deprived decile had 2.02 (95% CI = 1.99 to 2.02) times the odds of attending for a low acuity condition compared with those in the least deprived decile. This was true for all levels of acuity, except those classified as immediate care, where after adjustment for health, those in the most deprived decile had 0.83 (95% CI = 0.82 to 0.85) times the odds of attendance compared with those in the least deprived decile. ConclusionsPeople living in more deprived areas were more likely to access A&E services than those living in less deprived areas and these differences are not fully explained by differences in underlying health. The differences were larger for A&E attendance for less severe conditions. Differences in access to primary care services may explain part of these differences in A&E access. Knowing which groups are more likely to attend A&E services will give valuable insight for health services providers, and allow decision makers to better understand how populations can access care differently depending on a range of factors. Key messagesO_ST_ABSWhat is already known on this subjectC_ST_ABSO_LIPrevious work has found a clear link between deprivation and health. C_LIO_LISmall-scale or single-centre studies have found links between deprivation and Accident and Emergency attendance. C_LI What this study addsO_LIThis study of 51,776,958 people, and 11,498,520 people with at least one Accident and Emergency department attendance shows a clear deprivation effect, even after adjusting for underlying health. C_LIO_LIPeople living in more deprived areas were more likely to attend A&E, particularly for low conditions classed as low acuity. C_LIO_LIUnderlying health is less important a driver of attendance patterns for people under 30 and is more important a factor for people aged 30 to 65 years of age. C_LI

Objectives Emergency Department (ED) crowding is an international concern, predominantly caused by 'exit block', the lack of availability of inpatient beds for those requiring admission. The implementation of Flow Navigation Centre Plus (FNC+) services in Scotland aimed to reduce self-presentation to EDs and reduce crowding by providing remote clinical assessment for patients contacting urgent care by telephone and professional-to-professional advice on patient pathways, but their effectiveness is unknown. This study aimed to estimate the effect of board-wide implementation of FNC+ on ED attendances and long waits during the first year of FNC+ operation. Methods Controlled interrupted time series using weekly, publicly reported Public Health Scotland data. The intervention was implementation of the FNC+ in NHS Lanarkshire on 1 April 2024. Counts were summed across constituent sites and percentages derived from board totals. Co-primary outcomes were ED attendance volume and the proportions of attendances spending more than 4, 8 and 12 hours in the department. Segmented regression was fitted with contemporaneous control boards, seasonal terms, and accounted for autoregression. Results 118 pre-intervention and 52 post-intervention weeks were analysed across all 3 EDs in the implementing board. Attendances showed no detectable step change (+1.20%; 95%CIs -0.66 to +3.10) relative to the counterfactual. The estimated effect increased across follow-up, however, changing by +3.95% over 52 weeks (95% CI +0.36 to +7.67%). There was no significant step change in the proportion of attendances waiting more than 4 hours following the intervention (+1.74%; 95%CIs -0.71 to 4.20%). Some transition and structural sensitivity analyses demonstrated significant deteriorations in ED performance, and increased attendances, in the year following implementation, and none demonstrated improvements. Conclusions Board-wide implementation of a Flow Navigation Centre Plus was not associated with a step change in ED attendances or in long waits, but there is some evidence that attendances increased and long waits increased in the year following implementation. Their provision of supply-sensitive care is a possible mechanism. Additionally, given their action at the point of input, aiming to divert patients from ED attendance, it is unlikely that such services could relieve a constraint due to exit block, the availability of inpatient care for those requiring admission.