Publications by authors named "Adrian Boyle"

73 Publications

Is 'sepsis' a failed paradigm?

Authors:
Adrian A Boyle

Emerg Med J 2021 Aug 6. Epub 2021 Aug 6.

Emergency Department, Addenbrooke's Hospital Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

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http://dx.doi.org/10.1136/emermed-2021-211627DOI Listing
August 2021

The Royal College of Emergency Medicine's curriculum in the UK.

Eur J Emerg Med 2021 08;28(4):249-251

Royal London Hospital, Barts Health NHS Trust, London, UK.

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http://dx.doi.org/10.1097/MEJ.0000000000000852DOI Listing
August 2021

The early course and treatment of posttraumatic stress disorder in very young children: diagnostic prevalence and predictors in hospital-attending children and a randomized controlled proof-of-concept trial of trauma-focused cognitive therapy, for 3- to 8-year-olds.

J Child Psychol Psychiatry 2021 Jun 14. Epub 2021 Jun 14.

Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK.

Background: The introduction of developmentally adapted criteria for posttraumatic stress disorder (PTSD) has improved the identification of ≤6-year-old children with clinical needs. Across two studies, we assess predictors of the development of PTSD in young children (PTSD-YC), including the adult-led acute stress disorder (ASD) diagnosis, and provide proof of principle for cognitive-focused therapy for this age range, with the aim of increasing treatment options for children diagnosed with PTSD-YC.

Method: Study 1 (N = 105) assessed ASD and PTSD-YC diagnosis in 3- to 8-year-old children within one month and at around three months following attendance at an emergency room. Study 2 (N = 37) was a preregistered (www.isrctn.com/ISRCTN35018680) randomized controlled early-phase trial comparing CBT-3M, a cognitive-focused intervention, to treatment-as-usual (TAU) delivered within the UK NHS to 3- to 8-year-olds diagnosed with PTSD-YC.

Results: In Study 1, the ASD diagnosis failed to identify any young children. In contrast, prevalence of acute PTSD-YC (minus the duration requirement) was 8.6% in the first month post-trauma and 10.1% at 3 months. Length of hospital stay, but no other demographic or trauma-related characteristics, predicted development of later PTSD-YC. Early (within one month) diagnosis of acute PTSD-YC had a positive predictive value of 50% for later PTSD-YC. In Study 2, most children lost their PTSD-YC diagnosis following completion of CBT-3M (84.6%) relative to TAU (6.7%) and CBT-3M was acceptable to recipient families. Effect sizes were also in favor of CBT-3M for secondary outcome measures.

Conclusions: The ASD diagnosis is not fit for purpose in this age-group. There was a strong and encouraging signal of putative efficacy for young children treated using a cognitive-focused treatment for PTSD, and a larger trial of CBT-3M is now warranted.
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http://dx.doi.org/10.1111/jcpp.13460DOI Listing
June 2021

Identifying and responding to domestic violence and abuse in healthcare settings.

BMJ 2021 05 7;373:n1047. Epub 2021 May 7.

Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK.

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http://dx.doi.org/10.1136/bmj.n1047DOI Listing
May 2021

Can artificial intelligence and machine learning help reduce the harms of emergency department crowding?

Eur J Emerg Med 2021 04;28(2):95-96

Emergency Department, Cambridge University Hospitals Foundation Trust, Cambridge, UK.

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http://dx.doi.org/10.1097/MEJ.0000000000000781DOI Listing
April 2021

Effect of tranexamic acid on intracranial haemorrhage and infarction in patients with traumatic brain injury: a pre-planned substudy in a sample of CRASH-3 trial patients.

Emerg Med J 2021 Apr 1;38(4):270-278. Epub 2020 Dec 1.

Clinical Trials Unit, London School of Hygiene & Tropical Medicine Faculty of Epidemiology and Population Health, London, UK.

Background: Early tranexamic acid (TXA) treatment reduces head injury deaths after traumatic brain injury (TBI). We used brain scans that were acquired as part of the routine clinical practice during the CRASH-3 trial (before unblinding) to examine the mechanism of action of TXA in TBI. Specifically, we explored the potential effects of TXA on intracranial haemorrhage and infarction.

Methods: This is a prospective substudy nested within the CRASH-3 trial, a randomised placebo-controlled trial of TXA (loading dose 1 g over 10 min, then 1 g infusion over 8 hours) in patients with isolated head injury. CRASH-3 trial patients were recruited between July 2012 and January 2019. Participants in the current substudy were a subset of trial patients enrolled at 10 hospitals in the UK and 4 in Malaysia, who had at least one CT head scan performed as part of the routine clinical practice within 28 days of randomisation. The primary outcome was the volume of intraparenchymal haemorrhage (ie, contusion) measured on a CT scan done after randomisation. Secondary outcomes were progressive intracranial haemorrhage (post-randomisation CT shows >25% of volume seen on pre-randomisation CT), new intracranial haemorrhage (any haemorrhage seen on post-randomisation CT but not on pre-randomisation CT), cerebral infarction (any infarction seen on any type of brain scan done post-randomisation, excluding infarction seen pre-randomisation) and intracranial haemorrhage volume (intraparenchymal + intraventricular + subdural + epidural) in those who underwent neurosurgical haemorrhage evacuation. We planned to conduct sensitivity analyses excluding patients who were severely injured at baseline. Dichotomous outcomes were analysed using relative risks (RR) or hazard ratios (HR), and continuous outcomes using a linear mixed model.

Results: 1767 patients were included in this substudy. One-third of the patients had a baseline GCS (Glasgow Coma Score) of 3 (n=579) and 24% had unilateral or bilateral unreactive pupils. 46% of patients were scanned pre-randomisation and post-randomisation (n=812/1767), 19% were scanned only pre-randomisation (n=341/1767) and 35% were scanned only post-randomisation (n=614/1767). In all patients, there was no evidence that TXA prevents intraparenchymal haemorrhage expansion (estimate=1.09, 95% CI 0.81 to 1.45) or intracranial haemorrhage expansion in patients who underwent neurosurgical haemorrhage evacuation (n=363) (estimate=0.79, 95% CI 0.57 to 1.11). In patients scanned pre-randomisation and post-randomisation (n=812), there was no evidence that TXA reduces progressive haemorrhage (adjusted RR=0.91, 95% CI 0.74 to 1.13) and new haemorrhage (adjusted RR=0.85, 95% CI 0.72 to 1.01). When patients with unreactive pupils at baseline were excluded, there was evidence that TXA prevents new haemorrhage (adjusted RR=0.80, 95% CI 0.66 to 0.98). In patients scanned post-randomisation (n=1431), there was no evidence of an increase in infarction with TXA (adjusted HR=1.28, 95% CI 0.93 to 1.76). A larger proportion of patients without (vs with) a post-randomisation scan died from head injury (38% vs 19%: RR=1.97, 95% CI 1.66 to 2.34, p<0.0001).

Conclusion: TXA may prevent new haemorrhage in patients with reactive pupils at baseline. This is consistent with the results of the CRASH-3 trial which found that TXA reduced head injury death in patients with at least one reactive pupil at baseline. However, the large number of patients without post-randomisation scans and the possibility that the availability of scan data depends on whether a patient received TXA, challenges the validity of inferences made using routinely collected scan data. This study highlights the limitations of using routinely collected scan data to examine the effects of TBI treatments.

Trial Registration Number: ISRCTN15088122.
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http://dx.doi.org/10.1136/emermed-2020-210424DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982942PMC
April 2021

Combined Point-of-Care Nucleic Acid and Antibody Testing for SARS-CoV-2 following Emergence of D614G Spike Variant.

Cell Rep Med 2020 Sep 1;1(6):100099. Epub 2020 Sep 1.

Department of Infectious Diseases, Cambridge University NHS Hospitals Foundation Trust, Cambridge, UK.

Rapid COVID-19 diagnosis in the hospital is essential, although this is complicated by 30%-50% of nose/throat swabs being negative by SARS-CoV-2 nucleic acid amplification testing (NAAT). Furthermore, the D614G spike mutant dominates the pandemic and it is unclear how serological tests designed to detect anti-spike antibodies perform against this variant. We assess the diagnostic accuracy of combined rapid antibody point of care (POC) and nucleic acid assays for suspected COVID-19 disease due to either wild-type or the D614G spike mutant SARS-CoV-2. The overall detection rate for COVID-19 is 79.2% (95% CI 57.8-92.9) by rapid NAAT alone. The combined point of care antibody test and rapid NAAT is not affected by D614G and results in very high sensitivity for COVID-19 diagnosis with very high specificity.
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http://dx.doi.org/10.1016/j.xcrm.2020.100099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7462534PMC
September 2020

The Attend Study: A Retrospective Observational Study of Emergency Department Attendances During the Early Stages of the COVID-19 Pandemic.

Cureus 2020 Jul 21;12(7):e9328. Epub 2020 Jul 21.

Emergency Medicine, Addenbrookes Hospital, Cambridge University Hospitals Foundation Trust, Cambridge, GBR.

Introduction: The coronavirus disease-19 (COVID-19) pandemic was associated with a large reduction in the number of attendances at emergency departments (EDs) in March 2020 in the United Kingdom (UK). We sought to identify which patient groups attended EDs least.

Methods: Single-centre before and after study. We used routine administrative data from March 2020 and compared this to a composite control of March 2019 and February 2020.  Results: Mean daily attendance fell by 30% from 342 patients per day in the composite control months to 242 patients per day in March 2020. Reductions in attendance were seen in almost all patient groups but were greatest in patients with injuries, those referred by another clinician, those arriving at the weekend, and in patients who received no investigations. Multivariate analysis revealed that the proportion of patients who were admitted to hospital fell, despite the patients being sicker, older, needing more investigations, and more likely to arrive by ambulance.

Discussion: The reduction in ED attendances seen in the early phases of the UK pandemic occurred in all patient groups, but was greatest in the lower acuity patients. Reasons for this are complex and likely to be multifactorial.
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http://dx.doi.org/10.7759/cureus.9328DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7444852PMC
July 2020

COVID-19: resetting ED care.

Emerg Med J 2020 Aug 14;37(8):458-459. Epub 2020 Jul 14.

Emergency Department, Guys & St Thomas' NHS Foundation Trust, London, UK.

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http://dx.doi.org/10.1136/emermed-2020-210282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7418608PMC
August 2020

COVID-19: resetting ED care.

Emerg Med J 2020 Aug 14;37(8):458-459. Epub 2020 Jul 14.

Emergency Department, Guys & St Thomas' NHS Foundation Trust, London, UK.

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http://dx.doi.org/10.1136/emermed-2020-210282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7418608PMC
August 2020

Updated framework on quality and safety in emergency medicine.

Emerg Med J 2020 Jul 13;37(7):437-442. Epub 2020 May 13.

Emergency Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia.

Objectives: Quality and safety of emergency care is critical. Patients rely on emergency medicine (EM) for accessible, timely and high-quality care in addition to providing a 'safety-net' function. Demand is increasing, creating resource challenges in all settings. Where EM is well established, this is recognised through the implementation of quality standards and staff training for patient safety. In settings where EM is developing, immense system and patient pressures exist, thereby necessitating the availability of tiered standards appropriate to the local context.

Methods: The original quality framework arose from expert consensus at the International Federation of Emergency Medicine (IFEM) Symposium for Quality and Safety in Emergency Care (UK, 2011). The IFEM Quality and Safety Special Interest Group members have subsequently refined it to achieve a consensus in 2018.

Results: Patients should expect EDs to provide effective acute care. To do this, trained emergency personnel should make patient-centred, timely and expert decisions to provide care, supported by systems, processes, diagnostics, appropriate equipment and facilities. Enablers to high-quality care include appropriate staff, access to care (including financial), coordinated emergency care through the whole patient journey and monitoring of outcomes. Crowding directly impacts on patient quality of care, morbidity and mortality. Quality indicators should be pragmatic, measurable and prioritised as components of an improvement strategy which should be developed, tailored and implemented in each setting.

Conclusion: EDs globally have a remit to deliver the best care possible. IFEM has defined and updated an international consensus framework for quality and safety.
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http://dx.doi.org/10.1136/emermed-2019-209290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413575PMC
July 2020

Prevalence and predictive value of ICD-11 post-traumatic stress disorder and Complex PTSD diagnoses in children and adolescents exposed to a single-event trauma.

J Child Psychol Psychiatry 2021 03 28;62(3):270-276. Epub 2020 Apr 28.

MRC: Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK.

Background: The 11th edition of the International Classification of Diseases (ICD-11) made a number of significant changes to the diagnostic criteria for post-traumatic stress disorder (PTSD). We sought to determine the prevalence and 3-month predictive values of the new ICD-11 PTSD criteria relative to ICD-10 PTSD, in children and adolescents following a single traumatic event. ICD-11 also introduced a diagnosis of Complex PTSD (CPTSD), proposed to typically result from prolonged, chronic exposure to traumatic experiences, although the CPTSD diagnostic criteria do not require a repeated experience of trauma. We therefore explored whether children and adolescents demonstrate ICD-11 CPTSD features following exposure to a single-incident trauma.

Method: Data were analysed from a prospective cohort study of youth aged 8-17 years who had attended an emergency department following a single trauma. Assessments of PTSD, CPTSD, depressive and anxiety symptoms were performed at two to four weeks (n = 226) and nine weeks (n = 208) post-trauma, allowing us to calculate and compare the prevalence and predictive value of ICD-10 and ICD-11 PTSD criteria, along with CPTSD. Predictive abilities of different diagnostic thresholds were undertaken using positive/negative predictive values, sensitivity/specificity statistics and logistic regressions.

Results: At Week 9, 15 participants (7%) were identified as experiencing ICD-11 PTSD, compared to 23 (11%) experiencing ICD-10 PTSD. There was no significant difference in comorbidity rates between ICD-10 and ICD-11 PTSD diagnoses. Ninety per cent of participants with ICD-11 PTSD also met criteria for at least one CPTSD feature. Five participants met full CPTSD criteria.

Conclusions: Reduced prevalence of PTSD associated with the use of ICD-11 criteria is likely to reduce identification of PTSD relative to using ICD-10 criteria but not relative to DSM-4 and DSM-5 criteria. Diagnosis of CPTSD is likely to be infrequent following single-incident trauma.
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http://dx.doi.org/10.1111/jcpp.13240DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7984249PMC
March 2021

Unintentional Drug-related Deaths in Cambridgeshire: A Retrospective Observational Study.

Cureus 2020 Jan 23;12(1):e6750. Epub 2020 Jan 23.

Public Health Directorate, Cambridgeshire County Council, Cambridge, GBR.

Background:  Drug-related deaths are a growing public health problem in the United Kingdom, overtaking road fatalities and homicides in terms of annual deaths. In this study, we investigated the causes and circumstances of unintentional drug-related deaths occurring in the county of Cambridgeshire, with the objective of identifying the prevalence of physical, mental, and social health problems within this cohort.

Methods:  We collected data on the demographics and mental and physical health of, and drugs contributing to, 30 consecutive unintentional drug-related deaths recorded by the Cambridgeshire and Peterborough County Council Coroners in 2017. A retrospective observational study was used, and data were collected by manual extraction from coroners' files.

Results:  Social isolation was identified as a recurring theme amongst the decedents, although homelessness was found in very few cases. Pharmacologically, multiple drug toxicity and opioid toxicity were highly prevalent, whilst prescription opioids were implicated in more cases than heroin. Chronic pain was also highly prevalent amongst the decedents, and a history of mental illness was found to occur in the majority of cases.

Discussion:  Our findings show that reports from the coronial system provide a rich narrative to understand the causes of drug-related deaths. We have identified that individuals who die from drug-related deaths frequently have multiple adverse physical, mental, and social problems. This implies that any attempt to reduce drug-related deaths requires a multi-faceted and multi-disciplinary approach.
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http://dx.doi.org/10.7759/cureus.6750DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7039352PMC
January 2020

Intimate Partner Violence Documentation and Awareness in an Urban Emergency Department.

Cureus 2019 Dec 28;11(12):e6493. Epub 2019 Dec 28.

Emergency Medicine, Addenbrookes Hospital Cambridge University, Cambridge, GBR.

Background Domestic violence rates in smaller cities have been reported to be some of the highest in Canada. It is highly likely that the staff at emergency departments (ED) will come in contact with victims of intimate partner violence in their daily practice. The purpose of this study is to better understand current practices for detecting intimate partner violence, staff awareness and knowledge regarding intimate partner violence, and barriers to questioning about intimate partner violence in the ED. Methods A standardized retrospective chart review captured domestic violence documentation rates in patients presenting to the ED, and a cross-sectional online survey was distributed to the ED staff. Results We found documentation about intimate partner violence in 4.64% of all included patient charts. No documentation was noted in the domestic violence field. Significantly, 16.4% of the ED staff reported never questioning female patients about intimate partner violence; 83.6% enquired when they thought it appropriate, and none asked routinely. None of the staff used a structured screening tool, and 81.8% of the ED staff had not received any formal training. Partner presence was the most common barrier to asking about intimate partner violence, followed by a lack of access to domestic violence management information, and a lack of knowledge regarding intimate partner violence. Conclusions Our findings suggest that the current documentation tools are not being properly utilized. Low rates of intimate partner violence documentation in high-risk patients and lack of education indicate that there is a need to improve current practices. In order to improve identification of this important problem, appropriate training and education about intimate partner/domestic violence are required to increase staff comfort as well as knowledge about available community resources for the victims.
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http://dx.doi.org/10.7759/cureus.6493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6984185PMC
December 2019

Is seniority of emergency physician associated with the weekend mortality effect? An exploratory analysis of electronic health records in the UK.

Emerg Med J 2019 Dec 30;36(12):708-715. Epub 2019 Oct 30.

Healthcare Operations, University of Cambridge Judge Business School, Cambridge, UK.

Objective: Admission to hospital over a weekend is associated with increased mortality, but the underlying causes of the weekend effect are poorly understood. We explore to what extent differences in emergency department (ED) admission and discharge processes, severity of illness and the seniority of the treating physician explain the weekend effect.

Methods: We analysed linked ED attendances to hospital admissions to Cambridge University Hospital over a 7-year period from 1 January 2007 to 31 December 2013, with 30-day in-hospital death as the primary outcome and discharge as a competing risk. The primary exposure was day of the week of arrival. Subdistribution hazards models controlled for multiple confounders, including physician seniority, calendar year, mode of arrival, triage category, referral from general practice, sex, arrival time, prior attendances and admissions, diagnosis group and age.

Results: 229 401 patients made 424 845 ED attendances, of which 158 396 (37.3%) were admitted to the hospital. The case-mix of admitted patients was more ill at weekends: 2530 (6.4%) admitted at a weekend required immediate resuscitation compared with 6450 (5.4%) admitted on a weekday (p<0.0001). Senior doctors admitted 24.8% of patients on weekdays and 24.0% at weekends, but junior doctors admitted 61.7% of patients on weekdays and 44.2% at weekends. 3947 (3.3%) patients admitted on a weekday and 1454 (3.7%) patients admitted at a weekend died within 30 days. In the adjusted subdistribution hazards model, the HR of in-hospital death was 1.11 (95% CI 1.04 to 1.18) for weekend arrivals. After controlling for confounders, the in-hospital mortality of patients admitted by junior doctors was greater at the weekend (adjusted HR (aHR) 1.15, 95% CI 1.06 to 1.24). In-hospital mortality for patients admitted by senior doctors was not statistically different at the weekend (aHR 1.08, 95% CI 0.98 to 1.19).

Conclusions: Our findings suggest that the weekend effect was driven by a higher proportion of admitted patients requiring immediate resuscitation at the weekend. Junior doctors admitted a lower proportion of relatively healthy patients at the weekend compared with the weekday, thus diluting the risk pool of weekday admissions and contributing to the weekend effect. Senior doctors' admitting behaviour did not change at the weekend, and the corresponding weekend effect was reduced.
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http://dx.doi.org/10.1136/emermed-2018-208114DOI Listing
December 2019

A core role for cognitive processes in the acute onset and maintenance of post-traumatic stress in children and adolescents.

J Child Psychol Psychiatry 2019 08 25;60(8):875-884. Epub 2019 Mar 25.

Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK.

Background: Post-traumatic stress disorder (PTSD) is a common reaction to trauma in children and adolescents. While a significant minority of trauma-exposed youth go on to have persistent PTSD, many youths who initially have a severe traumatic stress response undergo natural recovery. The present study investigated the role of cognitive processes in shaping the early reactions of child and adolescents to traumatic stressors, and the transition to persistent clinically significant post-traumatic stress symptoms (PTSS).

Methods: A prospective longitudinal study of youth aged 8-17 years who had attended a hospital emergency department following single trauma was undertaken, with assessments performed at 2-4 weeks (N = 226) and 2 months (N = 208) post-trauma. Acute stress disorder and PTSD were assessed using a structured interview, while PTSS, depression severity and peritraumatic and post-traumatic cognitive processes were assessed using self-report questionnaires. On the basis of their PTSS scores at each assessment, participants were categorised as being on a resilient, recovery or persistent trajectory.

Results: PTSS decreased between the two assessments. Cognitive processes at the 2- to 4-week assessment accounted for the most variance in PTSS at both the initial and follow-up assessment. The onset of post-traumatic stress was associated particularly with peritraumatic subjective threat, data-driven processing and pain. Its maintenance was associated with greater peritraumatic dissociation and panic, and post-traumatic persistent dissociation, trauma memory quality, rumination and negative appraisals. Efforts to deliberately process the trauma were more common in youth who experienced the onset of clinically significant PTSS. Regression modelling indicated that the predictive effect of baseline negative appraisals remained when also accounting for baseline PTSS and depression.

Conclusions: Cognitive processes play an important role in the onset and maintenance of PTSS in children and adolescents exposed to trauma. Trauma-related appraisals play a particular role when considering whether youth make the transition from clinically significant acute PTSS to persistent PTSS.
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http://dx.doi.org/10.1111/jcpp.13054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6711766PMC
August 2019

Quality: more than just timeliness.

Authors:
Adrian A Boyle

Emerg Med J 2019 Jun 15;36(6):325. Epub 2019 Mar 15.

Emergency Department, Addenbrooke's Hospital Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.

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http://dx.doi.org/10.1136/emermed-2019-208419DOI Listing
June 2019

Validation of the short form of the International Crowding Measure in Emergency Departments: an international study.

Eur J Emerg Med 2019 Dec;26(6):405-411

Beaumont Hospital.

Objective: There is little consensus on the best way to measure emergency department (ED) crowding. We have previously developed a consensus-based measure, the International Crowding Measure in Emergency Departments. We aimed to externally validate a short form of the International Crowding Measure in Emergency Department (sICMED) against emergency physician's perceptions of crowding and danger.

Methods: We performed an observational validation study in seven EDs in five different countries. We recorded sICMED observations and the most senior available emergency physician's perceptions of crowding and danger at the same time. We performed a times series regression model.

Results: A total of 397 measurements were analysed. The sICMED showed moderate positive correlations with emergency physician's perceptions of crowding, r = 0.4110, P < 0.05) and safety (r = 0.4566, P < 0.05). There was considerable variation in the performance of the sICMED between different EDs. The sICMED was only slightly better than measuring occupancy or ED boarding time.

Conclusion: The sICMED has moderate face validity at predicting clinician's concerns about crowding and safety, but the strength of this validity varies between different EDs and different countries.
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http://dx.doi.org/10.1097/MEJ.0000000000000579DOI Listing
December 2019

Clinical audits can work if they are followed up correctly.

Br J Hosp Med (Lond) 2018 Nov;79(11):656

Consultant in Emergency Medicine King's College Hospital London.

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http://dx.doi.org/10.12968/hmed.2018.79.11.656DOI Listing
November 2018

Can emergency physicians accurately interpret computed tomography scans performed for suspected nontraumatic subarachnoid haemorrhage: a cross-sectional study.

Eur J Emerg Med 2018 12;25(6):447-448

Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.

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http://dx.doi.org/10.1097/MEJ.0000000000000560DOI Listing
December 2018

What should we do about crowding in emergency departments?

Br J Hosp Med (Lond) 2018 Sep;79(9):500-503

Chair, Quality in Emergency Care Committee, Royal College of Emergency Medicine, London.

Our emergency departments have never been under so much pressure. Crowding in these departments is both a cause and symptom of this pressure. Crowding kills patients and harms staff. It is the most important problem affecting emergency departments in the UK. The causes are described and include factors relating to input, throughput and output. Interventions aimed at these causes may confer benefit, but the most important problem remains unsolved. This is exit block caused by lack of beds, and flow through those beds, exacerbated by downgrading of capacity in unscheduled care in the evenings, weekends and during holiday periods.
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http://dx.doi.org/10.12968/hmed.2018.79.9.500DOI Listing
September 2018

Clinical audit does not work, is quality improvement any better?

Br J Hosp Med (Lond) 2018 Sep;79(9):508-510

Consultant Emergency Physician, Department of Emergency Medicine, King's College Hospital, London.

This article reviews the history of clinical audit and appraises its effectiveness. It discusses why audit can be ineffective in improving care and makes proposals to remove these barriers. The article describes how quality improvement and improvement science may offer a better alternative to traditional audit. It describes how the Royal College of Emergency Medicine is the first specialty society to attempt a national quality improvement programme.
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http://dx.doi.org/10.12968/hmed.2018.79.9.508DOI Listing
September 2018

Neurocognitive testing in the emergency department: A potential assessment tool for mild traumatic brain injury.

Emerg Med Australas 2019 06 3;31(3):355-361. Epub 2018 Sep 3.

University Division of Anaesthesia, University of Cambridge, Cambridge, UK.

Objective: Despite mild traumatic brain injury (mTBI) accounting for 80% of head injury diagnoses, recognition of individuals at risk of cognitive dysfunction remains a challenge in the acute setting. The objective of this study was to evaluate the feasibility and potential role for computerised cognitive testing as part of a complete ED head injury assessment.

Methods: mTBI patients (n = 36) who incurred a head injury within 24 h of presentation to the ED were compared to trauma controls (n = 20) and healthy controls (n = 20) on tests assessing reaction time, speed and attention, episodic memory, working memory and executive functioning. Testing occurred during their visit to the ED at a mean of 12 h post-injury for mTBI and 9.4 h for trauma controls. These tasks were part of the Cambridge Neuropsychological Test Automated Battery iPad application. Healthy controls were tested in both a quiet environment and the ED to investigate the potential effects of noise and distraction on neurocognitive function.

Results: Reaction time was significantly slower in the mTBI group compared to trauma patients (P = 0.015) and healthy controls (P = 0.011), and deficits were also seen in working memory compared to healthy controls (P ≤ 0.001) and in executive functioning (P = 0.021 and P < 0.001) compared to trauma and healthy controls. Performances in the control group did not differ between testing environments.

Conclusion: Computerised neurocognitive testing in the ED is feasible and can be utilised to detect deficits in cognitive performance in the mTBI population as part of a routine head injury assessment.
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http://dx.doi.org/10.1111/1742-6723.13163DOI Listing
June 2019

Changing epidemiology of assault victims in an emergency department participating in information sharing with police: a time series analysis.

Emerg Med J 2018 Oct 25;35(10):608-613. Epub 2018 Jun 25.

Emergency Department, Addenbrooke's Hospital, Cambridge University Hospitals Foundation Trust, Cambridge, UK.

Introduction: Violent injury places a large burden on the NHS. We had implemented information sharing in our ED in 2007 and aimed to see which patient groups were most affected by information sharing, as this would provide clues as to how this complex intervention works.

Methods: Retrospective time series study of all the assault victims presenting for ED care between 2005 and 2014 at a single ED in England.

Results: 10 328 patients presented during the study period. There was a 37% decrease in the number of patients presenting after assault, consistent with national trends. The proportions of people arriving by ambulance, and the proportion of men did not change during the study period. There were no important changes in the age of our assault patients in this study. Greater, disproportionate, decreases in rates of violence were seen in patients who presented at the weekend up (incidence rate ratio (IRR)=0.57, 95% CI 0.50 to 0.64) versus weekdays (IRR=0.72; 95% CI 0.62 to 0.83) There were also disproportionately greater decreases over the study period in patients who were discharged with no hospital follow-up (IRR=0.51, 95% CI 0.45 to 0.56) versus those leading to either an inpatient admission (IRR=1.05, 95% CI 0.84 to 1.31) or outpatient follow-up (IRR=1.23, 95% CI 0.93 to 1.64).

Conclusions: The epidemiology of violent injury at our institution has changed over the last 10 years and is most marked in a reduction of visits at the weekend, and in those who leave without follow up.
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http://dx.doi.org/10.1136/emermed-2017-207087DOI Listing
October 2018

Draft Genome Sequence of a Highly Heterozygous Yeast Strain from the Metschnikowia pulcherrima Subclade, UCD127.

Genome Announc 2018 Jun 21;6(25). Epub 2018 Jun 21.

School of Biomedical and Biomolecular Sciences, Conway Institute, University College Dublin, Dublin, Ireland

strain UCD127 was isolated from soil in Ireland and sequenced. It is a highly heterozygous diploid strain with 385,000 single nucleotide polymorphisms (SNPs). Its ribosomal DNA has the highest similarity to that of , but its and loci and mitochondrial genome show affinity to those of , whose genome is significantly larger.
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http://dx.doi.org/10.1128/genomeA.00550-18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6013633PMC
June 2018

This emergency department crisis was predictable-and partly preventable.

BMJ 2018 01 8;360:k64. Epub 2018 Jan 8.

Royal College of Emergency Medicine, UK.

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http://dx.doi.org/10.1136/bmj.k64DOI Listing
January 2018

Has the Licensing Act 2003 affected violence rates in England and Wales? A systematic review of hospital and police studies.

Eur J Emerg Med 2018 Oct;25(5):304-311

Emergency Department, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.

Violence has been declining in the UK for two decades, with most assaults being alcohol related. The Licensing Act 2003 (England and Wales) aimed to reduce alcohol-related crime, giving local authorities control over premises licensing. We performed a systematic review of original research with the primary outcome of change in violence rates since the Act's implementation, including hospital-defined and police-defined measures of violence. Our secondary outcome was temporal distribution of violence. Fifteen studies were included, which were of overall poor quality. Seven found reduced violence rates after the Act's implementation, three found increased rates and five found no significant change. A subset of nine studies analysed temporal distribution, eight finding displacement of incidents later. This is the most complete analysis to date of the effect of this Act on violence, finding a lack of reliable evidence to answer the research question, but little to suggest that the Act has markedly impacted already-declining violence rates.
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http://dx.doi.org/10.1097/MEJ.0000000000000522DOI Listing
October 2018

Should we scrap the target of a maximum four hour wait in emergency departments?

BMJ 2017 10 25;359:j4857. Epub 2017 Oct 25.

Emergency Department, Plymouth Hospitals NHS Trust, Plymouth, UK.

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October 2017

Are rising admission thresholds good medicine?

Emerg Med J 2017 12 12;34(12):771-772. Epub 2017 Oct 12.

Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA.

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December 2017
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