Major research gaps exist for how emergencies are managed in the UK

A scoping review of the emergency planning literature has found major gaps in the knowledge base. The project was managed by Andrew Lee from ScHARR Public Health and involved Steve Goodacre and Kirsty Challen from EMRiS, along with collaborators from Manchester and the Health Protection Agency. The report is available at:

http://www.netscc.ac.uk/hsdr/projdetails.php?ref=09-1005-03

Each year there are thought to be about 11 major incidents which often require a coordinated multi-agency responses including from the NHS. Interest in this topic has grown considerably in the aftermath of the 7/7 London bombings and the UK today is seen as a world leader in emergency planning, response and recovery.

The study involved examining more than 1,600 publications and interviewing 17 experts in the field of emergencies and disasters. It found that there was a limited knowledge-base from the UK and a considerable proportion of the literature was from North America. Much of the literature was not robust and there were concerns that findings from North American studies could not be easily extrapolated to the UK setting.

Many of the gaps in the literature were operational in nature rather than technical. For example, there was a lack of knowledge as to how individuals and organisations deal with risk and behave in emergencies, as well as how emergency managers make decisions in emergency situations.

The report concluded that there is a need to build a UK knowledge base, as well as find ways to use the evidence base and to learn from emergencies and disasters. Information from this study will enable research to be directed and developed to ensure that the emergency planning field continues to improve. In turn this will help emergency responders deal with emergencies better, and help strengthen and prepare local communities against disasters.

Findings are also published in the following articles:

Challen K, Lee ACK, Booth A, Gardois P, Woods HB, Goodacre SW. Where is the evidence for emergency planning: a scoping review. BMC Public Health 2012, 12:542. Available from: http://www.biomedcentral.com/1471-2458/12/542

Lee ACK, Phillips W, Challen K, Goodacre SW. Emergency Management in Health: Key Issues and Challenges in the UK. BMC Public Health 2012, 12:884. Available from: http://www.biomedcentral.com/1471-2458/12/884/abstract

 Mackway-Jones K, Carley S. An international expert delphi study to determine research needs in major incident management. Prehospital Disaster Medicine 2012 Aug; 27(4): 351-8. http://journals.cambridge.org/download.php?file=%2FPDM%2FPDM27_04%2FS1049023X12000982a.pdf&code=8e98c1e865ed473600828a47df480146

This project was funded by the National Institute for Health Research Health Services & Delivery Research Programme (NIHR HS&DR) (project number 09/1005/03). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR Programme, NIHR, NHS or the Department of Health.

CEM Scientific conference-posters and presentations

Copies of the EMRiS posters and presentations from the CEM annual scientific conference are now available via the EMRiS web site.

If you wish to contact any of the authors their contact details can be found here


EMRiS posters and presentations

EMRisS contact details

NHS 111 - a mixed start but potential for the future

The report of ScHARR's NHS 111 evaluation is now available

Press release

Project web page and full report

EMRiS at the CEM Annual Scientific Conference

The College of Emergency Medicine Annual Scientific Conference is being held in Sheffield on 7th November.
The contributions from members of EMRiS are shown below. Following the conference copies of the posters and presentation will be available to download from the EMRiS website. They will also be available via this blog.

Lightening Poster Session 1 The Edge Foyer 08:45

Kirsty Challen

• Pandemic Influenza Triage in the Emergency Department
• Predicting critical illness and death in the ED: not the same thing

Lightening Poster Session 2 High Tor 2 10:15

Robin Chatters

• Prospective Study to Explore the Link Between the use of First Aid and Patient Outcomes Following Emergency Medical Events

Jack Whitely

• Patient expectations of minor injury care

Rod Little prize abstract session High Tor 2 11:00

Kirsty Challen

• Scoping emergency planning: literature and stakeholders

Track 2 High Tor 4 13:30

Alastair Pickering

• Academic Emergency Medicine: The training years

Four top-scoring abstracts session High Tor 2 14:00

Colin O'Keeffe

• Confidence and experience of training junior doctors: Assessing the
  impact of the Emergency Department

Suzanne Mason

• Evaluating well-being in junior doctors: impact of emergency medicine

Lightening oral Session 2 High Tor 2 15:00

Steve Goodacre

• Systematic review and meta-analysis of the diagnostic and prognostic accuracy of CT coronary angiography in suspected acute coronary syndrome.
• Systematic review and meta-analysis of the diagnostic and prognostic accuracy of exercise ECG in suspected acute coronary syndrome.

Posters

Steve Goodacre

• Cost-effectiveness of presentation and delayed troponin testing for acute myocardial infarction 
• Systematic review and meta-analysis of alternative early biomarkers for myocardial infarction

MSc in Advanced Emergency Care- February intake

Following the popularity of the ScHARR's new MSc in Advanced Emergency Care we can confirm that will be having a second intake of part time students in February in time for semester two.
This is in keeping with our aims to make the course as flexible as possible,  enabling busy clinicians to combine studying with work and family life.

The MSc web pages will be updated soon with details of the semester two admission process.

MSc in Advanced Emergency Care

University of Sheffield postgraduate applications page

Thomas Locker

Patient deaths go up 20 per cent every ten miles travelled

Jon Nicholl's article has recently been published in the Mail on Sunday

"Patient deaths go up 20 per cent every ten miles travelled... so bigger isn't better for most families"

What have medical ward rounds got to do with the ED?

Yesterday the RCP and RCN published a joint statement on the conduct of medical wards rounds. This document details best practice guidance for the conduct of multidisciplinary medical ward rounds. What has this got to do with emergency medicine?
 Access to inpatient beds is well recognised as a key contributor to emergency department crowding. The recently revised College ofEmergency Medicine guideline on crowding states that “The main reason for crowding in almost all EDs is lack of hospital capacity”. Unfortunately today’s publication fails to mention the significant impact that the timing of medical wards rounds has upon the flow of patients through an emergency department.

The RCP/RCN report acknowledges that “Consultant-led ward rounds should be conducted in the morning to facilitate timely completion of tasks during the working day.” However it should also be recognised that the early morning review of patients is vital so that appropriate patients may be discharged and beds made available in time for the predictable rise in the requirement for inpatient beds that occurs from late morning until the evening.

It will be interesting to see if renewed focus upon consultant ward rounds can alleviate the problems of ED crowding in the UK as we approach the most demanding time of year. 

Ward rounds in medicine: Principles for best practice

Thomas Locker

Could the RATPAC trial have been stopped earlier with a different design?

The RATPAC trial [1] showed that using a point of care panel of troponin, CK-MB and myoglobin at presentation and 90 minutes could increase the proportion of patients successfully discharged after emergency department assessment for non-specific chest pain. The trial originally planned to recruit 3130 participants. After a lot of hard work and an extension to the planned time, the trial stopped with 2243 patients recruited after an interim analysis showed that further recruitment was unlikely to add worthwhile new information.

A reanalysis of the RATPAC trial data, published in the October issue of Annals of Emergency Medicine [2], suggests that the trial could have been stopped a year earlier, after 722 patients had been recruited, if a group sequential design had been used. This is a type of adaptive design which allows a trial to be stopped prematurely because of efficacy, futility or safety, according to the results of pre-planned interim analyses.

The reanalysis and an accompanying editorial [3] suggest that adaptive designs could be used more widely in emergency medicine to allow early recognition of an effective intervention or early termination of a futile trial. There are potential drawbacks to an adaptive design, however. Early termination of the RATPAC trial would have left it with less power to detect differences in secondary outcomes, such as adverse events and health care costs. This could be a problem as the RATPAC economic analysis [4] showed that, despite reducing admissions, use of the point of care panel may have been associated with increased health care costs.

Steve Goodacre

1. Goodacre SW, Bradburn M, Cross E, Collinson PO, Gray A, Hall AS on behalf of the RATPAC research team. The RATPAC Trial(Randomised Assessment of Treatment using Panel Assay of Cardiac markers): Arandomised controlled trial of point-of-care cardiac markers in the emergencydepartment. Heart 2011;97:190-196.
   
2.  Sutton L, Julious S, Goodacre S. Impact ofAdaptive Analysis on Unnecessary Patient Recruitment: Re-Analysis of the RATPACTrial. Ann Emerg Med 2012;60:442-448.
    
3.  Durkalski V. Adaptive designs: A true panaceafor the common clinical trial? Ann Emerg Med 2012;60:449-450.
    
4.  Fitzgerald P, Goodacre SW, Cross E, Dixon S. Cost-effectiveness of point-of-care biomarker assessment for suspectedmyocardial infarction: The RATPAC Trial (Randomised Assessment of Treatmentusing Panel Assay of Cardiac markers). Acad Emerg Med 2011;18:488-495. 

ScHARR's MSc in Advanced Emergency Care starts today

The MSc in Advanced Emergency Care started this week at ScHARR.  ScHARR has an international reputation for its research in the field of emergency and pre-hospital care. The MSc will complement this by providing training in emergency care research , management and on a range of clinical topics.

Eleven new modules have been developed for this course. Most are delivered entirely by distance learning, enabling busy clinicians to work and study at the same time.

The modules are lead by both ScHARR academic staff and clinicians with expertise in a range of disciplines. In addition ScHARR has worked with Irwin-Mitchell, one the UK's leading law firms, to jointly develop the medico-legal and forensic medicine module.

Further development of the course will be happening in the coming months and details will posted here and on the ScHARR website.

Thomas Locker

Is it time to drop the 10 hour troponin from NICE chest pain guidance?

NICE chest pain guidance is due for review in 2013. When the guidance was developed there was insufficient evidence relating to high-sensitivity troponin to make recommendations, but since then the evidence has increased. We therefore undertook an economic analysis to determine the cost-effectiveness of different troponin testing strategies for patients with suspected myocardial infarction. The results, published in the October issue of Heart, suggest that the NICE recommendation that troponin should be measured 10 hours after symptom onset does not promote cost-effective care. In most of the scenarios we studied the additional costs incurred by 10 hour troponin testing did not represent value for money for the quality-adjusted years of life gained, compared to high sensitivity troponin testing at presentation. Amendment of NICE guidance to recommend presentation or 3 hour troponin testing instead of 10 hour testing could substantially reduce chest pain admissions, with an associated reduction in pressure on acute beds and consequent cost savings.

Steve Goodacre

Thokala P, Goodacre SW, Collinson PO, Stevens JW, Mills NL, Newby DE, MorrisF, Kendall J, Stevenson MD. Cost-effectiveness of presentation and delayed troponin testing for acute myocardial infarction. Heart 2012;98:1498-1503 doi:10.1136/heartjnl-2012-302188

CT scans and cancer risk in children

The use of CT scanning in the assessment of minor head injury has increased substantially in recent years. Concerns have been raised that this will increase the risk of radiated induced cancer. A study published in the Lancet of 178,604 children and young adults who received a CT scan shows that in the 10 years after the first scan for patients younger than 10 years, one excess case of leukaemia and one excess case of brain tumour per 10 000 head CT scans is estimated to occur.

Should this influence our decision to use CT in children with minor head injury? Our analysis undertaken suggests that it should, but that clinical decision rules probably provide an appropriate balancing of risks and benefits. We modelled the benefits of CT scanning in minor head injury, in terms of detected and treating serious bleeding, and the risks, in terms of lifetime cancer risk using similar estimates to the Lancet study. The results showed that the best outcomes (measured as quality-adjusted life years) were achieved using CT selectively based on a decision rule. Indiscriminate use of CT scanning worsened outcomes by increasing the cancer risk, while failure to use CT worsened outcomes relating to head injury.

Determining the appropriate balance between sensitivity and specificity for a decision rule is tricky and could do with more detailed study, but our analysis in adults suggested that currently available rules with 98-99% sensitivity and 40-50% specificity have probably got the balance right. It isn’t worth sacrificing specificity below 40% to achieve 100% sensitivity and it isn’t worth sacrificing sensitivity below 95% to improve specificity. It would obviously be great if we could improve both sensitivity and specificity, but diagnostic decision-making usually involves a trade-off between them.

Pearce et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet, published online 7/6/12

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60815-0/abstract 

Pandor et al. Diagnostic management strategies for adults and children with minor head injury: a systematic review and an economic evaluation.

http://www.hta.ac.uk/1765 

BMA industrial action

The BMA have announced that a day of industrial action will take place on the 21^st June in response to changes in the NHS pension scheme. It has been announced that emergency and urgent care will not be affected, but is this genuinely the case? On the day of the industrial action, assuming routine elective cases are not admitted to inpatient beds, it is possible that access to such beds for patients requiring admission from the emergency department might actually improve. There may be a positive effect upon flow through the ED with reduced crowding and decreased lengths of stay in the ED for admitted patients. However, it is likely that there will be delays in the care patients already in hospital will receive. This could affect non-urgent radiological investigations or may simply mean no routine ward rounds to determine that a patient is fit to be discharged from hospital. This may result in increased bed occupancy in the days following the industrial action and this in turn may then result in delays in admission from the ED. The lost productivity in elective work will need to be regained at some point although this is likely to be spread over a longer period of time and the effect upon ED performance may not be noticeable.

It will be interesting to see exactly what the effect on ED performance is.

BMA website