This website is intended for healthcare professionals only.
Take a look at a selection of our recent media coverage:
30th December 2024
Research suggests that children or young people who attend emergency departments for care because of violence are at greater risk of experiencing this again. Dr Sarah Bekaert PhD describes schemes that are putting extra support in place to try to change future outcomes.
Is there a navigator scheme for young people in your local hospital?
These are a valuable resource and growing in number. Navigators provide support to young people who attend the hospital as a result of violence. Connecting with young people at a moment of injury or crisis, where they me be more open to intervention, the navigator works with the young person to potentially stop violence escalation. A navigator offers immediate assistance, at this reachable moment, and a pathway of support beyond the hospital.
Navigators are non-medical or nursing staff, often with youth work training, co-located with the staff in the emergency department (ED). They reach out to the young person in crisis, listen, and potentially link them into ongoing support in the community.
Young people appreciate the normality of this interaction in a fast-paced, alien environment; trust is developed, and therefore they are more likely to continue with this support beyond the hospital setting.
In one example, the Thames Valley Hospital Navigator Scheme, implemented in five emergency departments by five voluntary community sector organisations, 70% of young people referred engage with the service. In this service, referrals are made for young people who have either directly experienced violence, or the possible root causes of violence such as substance abuse or mental health crisis.
While a specific incident may bring young people to the ED, the cause may be a combination of wider issues requiring wider support such as housing, substance misuse or counselling. The navigator begins to work with the young person on these wider or ongoing challenges, starting in the hospital and continuing into the community.
The Thames Valley Hospital Navigator Scheme also brings people with lived experience such as previous drug use or mental health challenges – into the navigator role. This adds value as the young people can see how it is possible to change the pathway.
Through flexible contact and support, offered over time by navigators, positive relationships are developed with the young people.
Not having set parameters around the type of support offered is a strength of the service. They may, for example, accompany young people to community-based services, or advocate for the young person with housing or the GP. Sometimes a formal referral can be made, such as to mental health services or mentorship programmes. The navigator journeys alongside the young person to a point of stability and thriving beyond.
Evaluation of the Thames Valley scheme has shown that most benefitted from a short-term intervention, with 52% achieving a successful outcome within three months. A further 24% received signposting – a brief intervention where the young person was linked straight into appropriate services – and 24% required support beyond three months.
In the hospital, navigators provide invaluable support to the ED team. Navigators can step in to reassure and calm patients, freeing up nursing and medical staff time. More specifically, the support has been shown to respond to a gap in services for young adults – the transition years between child and adult services. For example, in the Thames Valley scheme, 35% of young people referred into the scheme were aged between 18 and 25 years, representing the largest age group supported by the service.
The service also responds to another current societal need, offering rapid response to young people experiencing mental health challenges. While 37% were referred for violence, a significant 27% were referred for mental health support.
Such services also have the potential to contribute to reduced ED reattendance. For example, in the Thames Valley scheme, 77% of young people who accepted navigator support did not re-attend the emergency department within a six-month follow-up period – early signs of an effective demand reduction approach.
There is potential cost saving by reducing ED reattendance, and wider socio-economic savings for society. The cost-benefit saving of hospital navigator schemes has been estimated to be £4.90 per £1 spent with the financial benefits across several public agencies, including acute health.
Consequences of violence have implications for the individual, community and society – these include anxiety, depression, drug and alcohol use, and the likelihood of reactive perpetration. Considering the wider societal impact of an initiative aimed at reducing and preventing violence related injury, the cost benefit of such early intervention schemes has been estimated at £82 for every £1 spent.
In the Crime Survey for England and Wales figures, 1.1 million violent offences were recorded for the year ending December 2022. These occurrences of violence often result in hospital care. A Youth Endowment Fund report states that in 2021, for young people there was a 12% increase in violence against the person – offences such as harassment, common assault, actual or grievous bodily harm.
In 2019, the UK Home Office commissioned 18 Violence Reduction Units to develop effective ways of tackling violent crime and its causes. One approach adopted has been to provide support to vulnerable young people in specific settings, such as healthcare, as an early intervention approach. Many have implemented a navigator scheme within local Trust EDs.
There is a growing recognition in the UK of the benefits of schemes able to reach young people at a moment of crisis and/or injury such as hospital navigator schemes. The model is also being effectively implemented in other settings such as schools and custody. A focus on young people is an opportunity for early intervention and support to interrupt the cycle of violence and promote positive pathways into adulthood.
Dr Sarah Bekaert PhD is a senior lecturer in child health at Oxford Brookes University, registered nurse (RN) Child and research manager for the Thames Valley Violence Reduction Unit.
This article was originally published by our sister publication Nursing in Practice.
25th July 2024
A project aiming to improve the care of older people in emergency departments (EDs) in the UK has found ‘room for improvement’ nationally, the Royal College of Emergency Medicine (RCEM) has announced.
The ‘Care of Older People’ RCEM National Quality Improvement Programme – now in its second of three years – has compared the performance of 118 participating EDs against a set of RCEM standards of care for patients aged 75 and older.
Published in its Year 1 interim report, the results show a need for ‘room for improvement across the board, in all standards’, and highlight ‘the first areas where change should be taking place‘.
As such, the report includes recommendations for the second and third years of the project to enhance the experience and outcomes for older people receiving ED care and help to achieve the required standards.
Dr Adrian Boyle, President of RCEM said the project ‘provides a valuable opportunity to gain the first insights into the level of care being given to older and frail patients on a national level‘ and thanked the participating emergency departments for their collaboration.
A total of 9,155 Type 1 ED attendances for older patients meeting inclusion criteria for the National Quality Improvement Programme were included, with a Type 1 ED being defined as one that provides a 24-hour, consultant-led service with full resuscitation facilities.
The report captured a ‘baseline’ level of care of older people presenting with a Version 2 National Early Warning Score (NEWS2) of 4 or under from May 2023 to October 2023. It then measured the percentage of participating EDs that carried out a range of assessments including tests for delirium and risk of falls.
In relation to RCEM’s Standard 1, that all people aged 75 years and older in ED should be screened for delirium using the 4AT tool, assessed for falls risk, and screened for frailty, the results showed that 21.5% of patients (n=1997) were screened for delirium using any tool, and only 68.3% of these were screened using the 4AT tool.
As such, only 14.98% of patient care met the standard, while 31.7% failed to meet the standard because of the screening tool used.
A total of 43.79% of patients received the falls risk assessment and 53.06% of patients were screened using a recognised frailty scoring system.
Standard 2 requires that action is taken based on the findings of screening processes. This includes a delirium management plan, post-fall assessment, falls mitigation and comprehensive geriatric assessment (CGA) being initiated where appropriate.
The report revealed that of the patients found to have delirium (n=467), 28.76% had a complete delirium management plan initiated.
When it came to falls, 37.25% of patients presenting after a fall had a dedicated post-fall assessment, and 32.58% of patients identified as being at risk of falls had a full falls mitigation plan put in place.
On average, 35.5% of patients had a CGA initiated if indicated from their frailty score. The control limits showed that the process is relatively stable but unlikely to reach beyond 50% compliance unless there is a change in the system.
Standard 3 requires that patients should have their basic care needs met whilst in the ED via a safety round. The report found that 55.8% of all patients had an ED length of stay of more than six hours, and of these, 31.5% had a full safety round initiated.
Comprehensive training for all relevant ED staff was the most common recommendation outlined in the report, with education encompassing the identification of delirium, falls and frailty in patients, the tools that should be used to assess and screen patients and the next steps that should be taken being included.
Standardising care was also highlighted as a priority, with recommendations around developing clinical pathways, departmental policies and documentation protocols, as well as including alerts, prompts and mandatory fields on patient records to ensure screening is undertaken and appropriate next steps are widely understood and actioned.
The RCEM also noted organisational audit recommendations, including that all participating EDs should perform an organisational scorecard two to three times a year to review performance and make targeted plans for improvement.
It also flagged that pharmacists should be engaged in EDs to screen for polypharmacy and support prescribing for older people, and that concise discharge summaries should be available to give to patients.
Commenting on the report, project leader Dr Anu Mitra, consultant emergency physician at Imperial College Healthcare NHS Trust, said: ‘Older people constitute a cohort of emergency department patients which is growing in size, complexity and care needs and reflects a continuing demographic trend in all four nations.
‘As a specialty whose workload reflects issues in the wider health and social care landscape, emergency medicine must accordingly meet the challenges of caring for older people at the front door.
‘This national QIP has set a broad range of standards which cover both individual care and system design, to improve experience and outcomes for older people from the moment they enter the emergency department, using recognised quality improvement methodology and sharing of best practice.’
The RCEM said it plans to share this report widely with stakeholders within the immediate departments, and added: ‘As we embed this in our routine practice, we seek to get the support that EDs require to help them in their QI activities… If all teams share their thoughts and feedback, we would have a wealth of learning to share with each other and improve future programmes.’
10th July 2024
Emergency medicine has gained official recognition as a medical specialty in Spain, the Spanish Society of Emergency Medicine (SEMES) has announced.
The Council of Ministers of the Government of Spain gave the green light to a Royal Decree establishing emergency medicine as a recognised speciality on 2 July 2024.
This will standardise the training of emergency doctors, with the first resident internal physician positions planned for 2025, and aims to support and retain young people who aspire to specialise in this field.
This will avoid ‘the terrible drain of talent that, for some time, has been weakening our National Health System’, SEMES said.
Commenting at the time of the announcement, SEMES president Dr Tato Vázquez Lima said: ‘Today is a day of great relevance for the health of our country, and a day of satisfaction and joy for all emergency physicians who, finally, see our efforts, vocation and dedication recognised.
‘With the creation of the specialty of emergency medicine, the Government of Spain makes it possible for all Spanish patients to be treated by specialists with regulated, homogeneous and recognised training, just as the citizens of our country deserve, regardless of where they reside.’
Dr Vázquez Lima also thanked the Government officials, medical associations, societies and scientists involved in the announcement for their ‘joint effort and generosity for the common good to reach the consensus that has allowed the approval of the specialty of emergency medicine in Spain’.
The recognition brings Spain in line with the majority of European Union countries and follows a similar move from the Government of the Netherlands in October 2023 after 25 years of lobbying by the Dutch Society for Emergency Medicine.
In a statement, the European Society for Emergency Medicine said: ‘We extend our congratulations to our colleagues in Spain and SEMES for achieving this remarkable milestone after years of campaigning and advocating the imperative need to recognise this specialty.’
3rd November 2023
Emergency medicine will be legally recognised as a medical specialty in the Netherlands after the outgoing health and care minister Ernst Kuipers gave the green light.
This marks the ratification of the decision by the College of Medical Specialists (CGS) in March 2023 to recognise emergency medicine as a medical specialty, which the Dutch Society for Emergency Medicine (NVSHA) has been pursuing for 25 years.
To reach its decision, the CGS tested the 10 criteria for recognition and held an extensive consultation. This confirmed that generalism is an increasingly important element in medicine and the CGS concluded that there is ‘sufficient demarcation’ compared to existing specialisms and ‘a social need’ for emergency medicine.
In a letter to the House of Representatives on 26 October 2023, Mr Kuipers said that he would ‘take into account the current situation on which the CGS’s decision to recognise the emergency doctor as a medical specialist is based. Namely the current situation in the emergency department, such as the open format whereby patients can be seen directly (without the intervention of the emergency physician) by the specialist relevant to them, depending on their care needs, the generalist profile of the emergency physician and the current three-year training period for emergency physicians.’
The NVSHA had informed Mr Kuipers that it endorsed the generalist profile and is committed to a ‘team performance’ with ‘various specialists at the bedside’.
It is thought that the recognition, which will come into force on 1 January 2023, will protect emergency doctor job titles, broaden training opportunities and facilitate applications for subsidies for scientific research and guideline development. Such research could centre on how best to staff emergency departments.
The NVSHA hopes that the recognition will in turn help to retain employees and improve workforce pressures.
Chairman of the Federation of Medical Specialists Piet-Hein Buiting said: ‘The emergency physician has an important role in acute care and I would like to congratulate [the NVSHA] on this legal recognition from the minister.’
In a statement, the European Society for Emergency Medicine said: ‘EUSEM warmly congratulates the NVSHA on this remarkable achievement, which will undoubtedly bring tremendous benefits to the entire healthcare system and emergency medicine doctors in the Netherlands.
‘As a society whose aim is to achieve the recognition of emergency medicine as a specialty across Europe we feel honoured to have the NVSHA as a member and thank NVSHA for their work. We look forward to continued collaborative work to make emergency medicine in Europe the best it can be.’
26th October 2023
The quality of patients’ access to urgent and emergency care in England ‘depends too much’ on where they live, the House of Commons Public Accounts Committee (PAC) has said in a scathing new report into urgent and emergency care access.
Entitled ‘Access to urgent and emergency care‘, the report said staff ‘have been let down by a system which has seen performance fall far below the standard the NHS says patients should expect to receive’.
It highlights that NHS’s own target for A&E waits had not been met since 2015, and its target for ambulance handovers had been missed each year since it began reporting against this metric in 2017. Regional variation was found to be particularly prevalent, it said.
Proportions of the most serious A&E patients waiting less than four hours in March 2023 ranged from 53.3% in the Midlands to 62.1% in the South East.
Ambulance services covering large rural areas, like the South West and East of England, are especially challenged, with Category 1 response times in 2021/22 varying from 6 minutes and 51 seconds in London to 10 minutes and 20 seconds in the South West.
The PAC said that evidence suggested the Department of Health and Social Care had ‘not sufficiently held NHS England to account’ for meeting targets and improving urgent and emergency care.
What’s more, differences in the capability of individual trusts, including around management, clinical leadership, and technology, were also highlighted. The PAC said these must be addressed to reduce variations in patients’ access to and experience of services.
Commenting on the report, Dr Adrian Boyle, president of the Royal College of Emergency Medicine, said: ’This is another report that lays out the damning reality of emergency care. Our members and their patients are being let down.’
And he described the Committee’s finding that performance varies from region to region as ‘disheartening but not surprising’.
He added: ’We must be able to better understand what is happening at a local level. At the moment we do not know how well or how poorly individual hospitals are doing because the official data is published by each trust, which may encompass several sites.
’RCEM is campaigning for NHS England to publish transparent performance figures for individual A&Es, so increased resources and support can be provided to the sites that are struggling the most. Improving equality of care and resulting in significant benefit to patients and staff.’
The PAC report also highlighted that not enough is being done to tackle delayed discharges, which has a serious knock-on impact throughout the whole urgent and emergency care system, with beds unable to be released for new patients and thus exacerbating A&E waiting time issues.
The number of patients staying in hospital when they no longer need to stood at an average of 13,623 in Q4 of 2022/23, up from 12,118 in the same period one year before.
To this end, Dr Boyle said: ’We are on the cusp of what looks likely to be another devastating winter. Having adequate capacity for our patients is vital. This will reduce dangerous levels of bed occupancy and improve flow through our hospitals and go some way to easing the pressure on the system.
“We know that since the pledge [to] increase bed numbers by 5,000 was made in January, we have not made nearly enough progress on this fundamental solution. The priority must now be on significantly increasing bed numbers before the cold weather, and the inevitable winter pressures hit.’
The PAC also called into question the ‘assumptions underpinning’ NHS England’s plan to retain 130,000 staff over the next 15 years, as set out in its recent workforce plan, particularly given the staff turnover rate in the health service was 9% in 2022/23.
And despite having ‘more money and staff than ever before’, the NHS has made ‘poor use of it’ to improve urgent access for patients with urgent and emergency services ‘deteriorating’ in spite of greater spend, it concluded.
It also flagged a 23% fall in NHS productivity following the Covid-19 pandemic, even though it had been improving pre-pandemic.
It has now called on NHS England to set out its understanding of the causes for the fall in productivity and how it will address them.
Similarly, it urged NHS England to establish the causes for variation in performance, and how it might bring the ‘worst-performing organisations’ closer in line to the standards achieved by the best.
Committee chair and Labour MP Dame Meg Hillier said: ‘Excluding demand-led spending such as welfare payments, health takes up approximately 40% of day-to-day budgeted spending by Whitehall departments. It is vital this is delivering benefits for patients. The Government and health system need to be alert to the serious doubts our report lays out around the workforce crisis, both the approach to tackling it now and the additional costs funding it in the future.’
Responding to the inquiry report, NHS England’s national clinical director for urgent and emergency care, Professor Julian Redhead, said: ‘While this report includes data which is more than two years old and coincided with a once in a generation pandemic, it is right to note the NHS has been under increasing pressure with staff experiencing record A&E attendances, hospitals fuller than at any point in their history and with thousands of beds taken up each day, in part, due to pressures in social care.
‘It is testament to the hard work of staff and results of our NHS winter plan – rolling out 800 new ambulances, 10,000 virtual ward beds and work towards 5,000 extra core beds – that waiting times for ambulances, 999 calls and in A&E have improved across the country during this financial year.
‘This progress has come as the NHS has committed to delivering £12bn of annualised savings by 2024/25 – all while dealing with more than a 100,000 staff posts being vacant.’
A version of this story was originally published by our sister publication Healthcare Leader.
13th April 2022
A high proportion of cancer diagnoses occur through emergency care presentations and which are associated with a greater 12-month mortality compared to non-emergency care detected cancers. This was the main finding of a study by an international team of researchers.
There is some evidence to show that many patients with cancer are first diagnosed through an emergency presentation and which is associated with inferior clinical and patient-reported outcomes. Furthermore, one US study found that among patients with stage IV colon cancer, 34.6% presented as emergencies.
The reasons for the high level of emergency care cancer diagnoses are complex and related to several different and interacting factors. For example, patients might experience no or only minimal symptoms prior to life-threatening complications requiring urgent medical or surgical attention.
Secondly, patient-related factors e.g., knowledge, beliefs and attitudes, may also lead to ‘first presentation’ as an emergency diagnosis and thirdly, there could by any number of different and practical barriers that have prevented prior care.
For the present study, which formed part of the International Cancer Benchmarking Partnership, the researchers aimed to identify predictors and the consequences of cancer diagnoses made through an emergency presentation across 8 different cancer sites: stomach, colon, rectal, liver, pancreatic, lung and ovarian.
For the purposes of the study, they defined an emergency presentation as one in which a cancer diagnosis was made within 30 days after an emergency hospital admission Countries for which data was collected included England, Norway, Denmark and several provinces such as Victoria (Australia) and Ontario (Canada).
Cancer diagnoses and emergency visits
A total of 857,068 patients with at least one of the 8 cancers mentioned above were included in the analysis. Across the different areas, the percentage of cancer diagnoses made through an emergency presentation ranged from 24% to 42.5%.
The most commonly diagnosed cancer was pancreatic cancer, with an average of 46.1% but which ranged from 34.1% to 60.4%. The least commonly diagnosed cancer was rectal cancer, with an average of 12.1% and ranging from 9.1% to 19.8%.
Among factors associated with an emergency presentation cancer diagnosis were older age (85 years and older) and stomach and among stomach and colon cancer diagnoses, there was a J-shaped distribution by age, whereby patients aged 15 to 64, had the highest percentage of emergency presentation diagnoses.
The cancer stage adjusted odds ratios for 12-month mortality, compared with non-emergency presentations, were greater than 3.2 in all of the different areas studied, e.g. for Norway the odds ratio was 3.31 (95% CI 3.39 – 3.53).
Commenting on their findings, the authors suggested that the high level of emergency presentation diagnoses for pancreatic cancer probably reflected the low predictive value for symptoms such as abdominal or back pain. In contrast, rectal cancers were likely diagnosed less frequently due to the much clearer symptoms such as rectal bleeding.
The concluded that emergency presentations were frequent and associated with worse prognostic implications.
Citation
Mcphail S et al. Risk factors and prognostic implications of diagnosis of cancer within 30 days after an emergency hospital admission (emergency presentation): an International Cancer Benchmarking Partnership (ICBP) population-based study Lancet Oncol 2022
1st February 2022
Relevant vital sign cut off values used for the risk stratification and hence prognosis for patients attending an emergency department do not exist for some signs which has important implications for their use and interpretation. This was the conclusion of a large study by a team from the Emergency Department, Maxima Medical Centre, Veldhoven, The Netherlands.
An emergency department encounters a large number of sick patients who require quick evaluation to detect those who have serious medical problems and which might require hospital admission.
This has led to the introduction of various triage tools such as the modified early warning score (MEWS) which serves as a rapid, simple triage method to identify medical patients in need of hospital admission and those at increased risk of in-hospital death.
Other tools commonly used such as the quick sequential organ failure assessment (qSOFA) rely on the use of vital sign measurements and specify a cut-off for each vital sign to discriminate between a better or worse prognosis.
However, the use of disease severity assessment tools may not be appropriate, particularly for elderly patients as revealed in one study of sepsis, which concluded that ‘prognostic and discriminative performance of the five most commonly used disease severity scores was poor and less useful for risk stratification of older ED sepsis patients.’
For the present study, the Dutch team looked to assess the association between vital signs and relevant clinical outcomes such as mortality and admission to an intensive care unit. In addition, they wanted to determine whether a single cut-off or threshold existed for each vital sign and the extent to which these were influenced by advancing age.
They undertook an observational study at three EDs in the Netherlands and examined consecutive adult patients (18 years and older) where one or more of the following vital signs were measured: respiratory rate (RR), peripheral oxygen saturation (SpO2), systolic (SBP) and diastolic (DBP) blood pressure, mean arterial blood pressure (MAP), heart rate (HR) and temperature.
Patients were stratified by age into three categories; 18 – 65, 66 – 80 and > 80 years and the primary outcome was whether there was a vital sign category that could be used as a cut-off to predict the outcome of in-hospital mortality or ICU admission.
Findings
A total of 101,416 patients with a mean age of 59.6 years (49.6% female) were included in their analysis. In many cases the vital sign values were outside of the usual range. For example, 23.4%, 79.1% and 14.2% of the total cohort had a RR, SBP and SP02 respectively, outside of the normal range. This proportion was also higher in older patients as seen for example with SBP for which 83.3% of patients aged > 80 had a reading outside of the normal range compared to 76.3% of those aged 18 to 65 years.
Among the cohort, a total of 2374 (2.3%) patients died. The adjusted odds ratios (aOR) for predicted mortality increased gradually with worsening values of SBP and SpO2 although there was no clear cut-off point for SBP, DBP, Sp02 and HR and mortality. In addition, for all vital signs, older adults had a larger increase in absolute mortality. For ICU admission, SBP had a relevant cut-off at 70mmHg and for MAP there was a threshold of < 60 mmHg.
In summarising their findings, the authors noted how in-hospital mortality increased gradually with decreasing SBP and SpO2 and there was no evidence of a specific cut-off for either vital sign. For DPB, MAP and HR, there was a quasi-U-shaped association with in-hospital mortality and while there was a single cut-off for MAP, RR and temperature, the authors argued that using a single cut-off value would ignore further increase of risk with more extreme values for these vital signs.
They concluded that the use of a single cut-off for each vital sign in acute care deserves scrutiny and that age-adjusted numerical scores would improve risk stratification since older patients have a larger increase in mortality with changing vital signs even after adjustment for confounds.
Citation
Candel BGJ et al. The association between vital signs and clinical outcomes in emergency department patients of different age categories Emerg Med J 2022
10th January 2022
The subsequent stroke risk among those who experience a transient ischaemic attack (TIA) is higher in patients seen at an emergency department compared to those seen at a rapid-access TIA clinic according to a meta-analysis by a team from the Neurology Department, Neuroscience Institute, Geisinger Health System, Pennsylvania, US.
After a TIA, the ischaemic stroke risk can range from 2.4% within 2 days to 4.7% within 90 days although the authors of this study hint that this risk may have reduced in the last two decades. Although patients with a suspected stroke might normally visit a hospital, the availability of 24-hour TIA clinics with immediate initiation of preventive treatment, have the potential to greatly reduce length of hospital stay.
Despite the presence of TIA clinics there is currently little is known about the outcomes for those experiencing a TIA who have been treated in different care settings. For the present study, the US team performed a meta-analysis to estimate and compare the risk of a subsequent ischaemic stroke in those with a TIA or minor ischaemic stroke (mIS) who received their care at either a rapid access TIA clinic, an inpatient unit, emergency departments (EDs) or other settings.
The researchers focused on the subsequent stroke risk after 4 defined time periods; 2, 7, 30 and 90 days. Their literature search covered medline, Embase, CINAHL and clinical trial databases for studies that provided information on the occurrence of an ischaemic stroke after a TIA or mIS and included both retrospective and prospective studies.
The primary outcome of the study was the proportion of early ischaemic strokes after the index TIA or mIS among patients receiving care in the four different settings and they focused their comparison on a TIA clinic vs inpatient facilities.
Findings
A total of 71 studies were included in the final analysis with 226,683 patients, 5636 from a TIA clinic, 130,136 inpatients, 3605 emergency department patient and 87,303 from a unspecified centre. The mean age of patients ranged from 65.7 to 78.3 years and proportion of male patients from 38.4% to 52.4%.
The stroke risk after a TIA or mIS at a TIA clinic was 0.3% within 2 days, 1% within 7 days, 1.3% after 30 days and 2.1% after 90 days. The highest risk was for patients treated at unspecified settings and which ranged from 2.2 % within 2 days to 6% within 90 days.
When comparing the stroke risk between a TIA clinic or inpatient facility, there was no significant difference in any of the 4 time intervals. However, the risks were significantly higher among those receiving emergency department care compared to a TIA clinic within 2, 7 and 90 days.
The authors concluded that the risk of subsequent stroke among patients who were evaluated in a TIA clinic was not higher than among those hospitalised adding that patients treated in an emergency department without further follow-up had a higher risk of subsequent stroke.
Citation
Shahjouei S et al. Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack: A Systematic Review and Meta-analysis JAMA Netw Open 2022
8th November 2021
Levels of three amino acids, glycine, phenylalanine and valine measured upon admission to an ED in patients admitted with dyspnoea are strongly predictive of 90-day mortality. This was the conclusion of a study by a team from the Department of Clinical Sciences, Lund University, Malmo, Sweden. Dyspnoea is a common presentation in an ED with one study of over 3,000 patients, finding that 5.2% of ED presentations, 11.4% of ward admissions and 19.9% of intensive care unit admissions were due to dyspnoea. There are a number of underlying conditions which can cause dyspnoea which presents as either an impaired ventilation or increased ventilatory demand, or some cases, both. Irrespective of the underlying cause, in patients with dyspnoea there is the release of stress hormones and metabolic changes, one of which is the induction of a catabolic state and insulin resistance.
Interestingly, some previous work has shown that the elevation of a combination of three amino acids could be used to successfully predict future diabetes. Based on these observations, the Lund University team hypothesised that the insulin resistance induced by stress in those with acute dyspnoea, would also alter levels of certain amino acids and that these alterations might be of valve in the assessment of dyspnoea severity and possibly even predictive of dyspnoea mortality.
In an effort to examine their hypothesis, the researchers retrospectively analysed patient data for those admitted to an ED with acute dyspnoea between 2013 and 2015. Plasma levels of nine amino acids were measured and Cox proportional hazard models used to explore the relationship between the level of these amino acids and the risk of 90-day mortality, which served as the primary endpoint for the study.
Findings
Data were analysed for a total of 663 patients with a mean age of 71.5 years (53.4% female), of whom 61% were admitted to a ward and 20.1% required intensive care treatment. Overall, 12% of patients died during the 90-day follow-up period. Only three amino acids of the original nine measured, demonstrated a significant association with 90-day mortality. These were glycine (hazard ratio, HR = 1.32, 95% CI 1.08 – 1.62, p < 0.001), phenylalanine (HR = 1.53) and valine (HR = 0.61).
Next, the researchers created an amino acid mortality risk score (AMRS) which was divided into quartiles and they found that in quartile 1, the 90-day mortality was 2.4% whereas it increased massively to 26.5% in quartile 4.
Commenting on these findings, the authors suggested that changes in the levels of these three amino acids, measured during presentation at the ED, were able to strongly predict 90-mortality in patients with acute dyspnoea, irrespective of the underlying cause. They concluded that a score using just these three amino acids could be used as a guide in risk assessment and to support decision-making to establish an appropriate level of care for patients presenting to an ED with acute dyspnoea.
Citation
Wiklund K et al. Amino acids predict prognosis in patients with acute dyspnea. BMC Emerg Med 2021
A substantial number of emergency care (EC) visits for young children represent non-urgent attendance (NUA). This is the conclusion of a retrospective analysis of hospital database by a team from the School of Health and Related Research, The University of Sheffield, Sheffield, UK.
Data for the UK show that in 2018-19, there were 24.8 million attendances at accident and emergency (A&E) departments, which represents a 4% increase on the previous year and a 21% increase since 2009-10. While much attention has focused on adult attendance at A&E, visits by children and young people has been less well studied despite the fact that children make more frequent visits to A&E. For example, in 2015/16 there were 425 A&E attendances for every 1000 children and young people an 345 A&E attendances for every 1000 adults aged 25 and over.
Research suggests that non-urgent attendance to EC can vary between 20 and 40% and there is evidence that younger age is one of several associated factors, though specific data on characterising NUA in children is limited. For the present study, the Sheffield team sought to define the proportion of NUA by children which were amenable to treatment or management elsewhere, how these non-urgent attendances varied by patient age as well as the impact on waiting times in the EC department. Patient characteristics such as as age, gender, date of attendance, disposal, type of treatment etc were extracted from a hospital database containing information for more than a tenth of England’s population over a 3-year period. The team defined a non-urgent attendance as one in which there was no treatment/investigations or referrals that required the facilities of an EC department.
Findings
A total of 1,068,598 EC attendances from children aged 0 – 15 years were identified and included in the analysis. Overall, the proportion of visits deemed NUA was 21.4% (208,788). Compared to visits for children less than 1 years of age, the odds ratio for a NUA was much more likely in children aged 1 – 4 years (odds ratio, OR = 0.82, 95% CI 0.80 – 0.83). However, NUA decreased with increasing age, for example, among children aged 10 – 14 years, the proportion of NUA was 14.6% (OR = 0.40) compared with 20.5% (OR = 0.61) for those aged 5 – 9 years. The odds of a patient presenting with a NUA was also significantly higher (OR = 1.19, 95% CI 1.18 – 1.20) for those attending out of hours compared to in hours (i.e., 8 am to 6 pm, Monday to Friday).
The researchers also found that for a NUA, the mean waiting, treatment and department times were all lower compared with urgent cases. Extrapolating their findings, the authors estimated up to 1 million non-urgent attendance visits across England in 2018-19 for ages 14 years and under.
They concluded that targeting groups such as those age under 5 years, particularly in providing accessible, timely care outside of usual community care opening hours would be of benefit.
Citation
Simpson RM et al. Non-urgent emergency department attendances in children: a retrospective observational analysis. Emerg J Med 2021
IMPORTANT LINKS
MORE FROM COGORA
© Cogora 2025
Cogora Limited. 1 Giltspur Street, London EC1A 9DD
Registered in the United Kingdom. Reg. No. 2147432
