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1st December 2023
An opt-out testing programme for bloodborne viruses in emergency departments in England is to be expanded after the success of schemes in extremely high prevalence areas of HIV, the Department of Health and Social Care has announced.
Almost 4,000 people have been identified as having HIV and hepatitis B and C through the opt-out testing programme that was launched in April 2022 at 34 emergency departments in areas with the highest prevalence of HIV.
The new testing programmes will be launched in 46 further emergency departments across 32 high-prevalence areas of England.
Backed by £20 million in funding from the National Institute for Health and Care Research, the expanded initiative is expected to save, and improve the quality of, thousands of lives, particularly from groups less likely to come forward for routine testing.
It is part of the Government’s ambition to reduce new HIV transmissions in England by 80% in 2025 and end new transmissions of HIV by 2030, all while getting people into the right care.
Richard Angell, chief executive of the Terrence Higgins Trust, referred to the announcement as a ‘testing turbo boost that’s needed if we are to end new HIV cases by 2030’.
‘It’s hugely significant that an additional two million HIV tests will be carried out in A&Es over the next year thanks to a temporary but wholesale expansion of opt-out HIV testing to 46 additional hospitals,’ he said.
‘The evidence is crystal clear: testing everyone having a blood test in emergency departments for HIV works. It helps diagnose people who wouldn’t have been reached via any other testing route and who have often been missed before.
‘It also saves the NHS millions, relieves pressure on the health service and helps to address inequalities with those diagnosed in A&E more likely to be of black ethnicity, women and older people.’
Also commenting on the announcement, health and social care secretary, Victoria Atkins, said: ‘As well as promoting prevention for all, the more people we can diagnose, the more chance we have of ending new transmissions of the virus and the stigma wrongly attached to it.
‘This programme, which improves people’s health and wellbeing, saves lives and money.’
The existing bloodborne virus opt-out testing programme provides joined-up care so previously undiagnosed patients, or those disengaged from their care, gain access to medication and a treatment and care pathway.
During the first 18 months of the programme, 33 emergency departments conducted 1,401,866 tests for HIV, 960,328 for hepatitis C and 730,137 for hepatitis B.
It identified 934 people unknowingly living with HIV or disengaged with their care. A further 2,206 people were identified as having hepatitis B and 388 were disengaged from hepatitis B care. And 867 people were found to be living with hepatitis C and 186 were identified as being disengaged from care.
Professor Kevin Fenton, the Government’s chief advisor on HIV and chair of the HIV Action Plan Implementation Steering Group, said: ‘We know HIV is most commonly unknowingly spread by people who don’t know their status. Knowledge is power in preventing HIV transmission and accessing life-saving care.’
He added: ‘The opt-out testing programme will boost our progress to identify the estimated 4,500 people who could be living with undiagnosed HIV and help us ensure we meet our 2030 ambition, with the possibility to save thousands of lives in the process.’
3rd October 2023
Two of the four internationally recommended sepsis screening tools used by emergency medical services (EMS) are inadequate for recognising the condition, according to a new study presented at the European Society of Emergency Medicine (EUSEM)‘s recent congress.
The study also highlighted that both EMS and emergency physicians should be more vigilant in documenting a suspicion of sepsis so that further clinical patient assessment and evaluation can take place. This could help the condition to be diagnosed and treated earlier, which could help to save lives and maintain patients‘ quality of life.
Researchers from the Charité – Universitätsmedizin Berlin and the universities of Magdeburg and Jena in Germany, aimed to assess which of four screening tools recommended in the Surviving Sepsis Campaign guidelines was best for emergency medical services (EMS) to predict the condition.
They found only the National Early Warning Score (NEWS-2) screening tool to have a reasonably accurate prediction rate for sepsis. A second tool – the quick Sequential Organ Failure Assessment (qSOFA) – had a high level of accuracy in predicting patients who did not have it.
However, the two other standard screening tools, Systemic Inflammatory Response Syndrome (SIRS) and the Modified Early Warning Score (MEWS), performed poorly in both sensitivity and specificity of sepsis detection.
Dr Wolfgang Bauer, senior physician at the Charité, said: ‘In emergency care, there are good and long-established standards for the detection and treatment of heart attacks and stroke that have improved patients’ chances of survival. Unfortunately, a lot less attention is paid to sepsis and standards to improve early sepsis recognition and survival.
‘Our study found there was a similar incidence for sepsis (1.6%) as for heart attacks (2.6%) and stroke (2.7%) in cases seen by emergency medical services. However, in terms of both percentages and absolute numbers, more patients died from sepsis than from heart attacks or stroke.
‘Out of all cases with sepsis, 31.4% died within 30 days after being seen by emergency services, versus 13.4% and 11.8% respectively for heart attacks and stroke. These findings emphasise the need for better sepsis awareness and more frequent use of effective screening tools.‘
The retrospective cohort study linked data on 221,429 emergency care cases, with follow-up between 2016 and 2017 from 10 health insurance companies, with information from documentation by paramedics and emergency doctors. In doing so, it was possible to calculate the ability of the four tools to predict a sepsis diagnosis.
Only the NEWS-2 had a reasonably accurate prediction rate for sepsis, with it able to correctly predict 72.2% of all cases (sensitivity) and correctly identify 81.4% of negative, non-septic cases (specificity).
In contrast, the qSOFA had a much lower sensitivity (24.1%) but a high specificity (96.6%) for identifying those without sepsis.
For SIRS, the corresponding sensitivity and specificity were 30.4% and 93.8%, respectively, and for MEWS they were 46.8% and 88.4%.
In total, 24.3% of cases were predicted to have sepsis by at least one of the screening tools, and only 0.9% of cases were predicted to have the conditon by all four tools.
The predictions were confirmed or rejected during subsequent hospital investigations after contact with EMS.
Silke Piedmont, a health scientist for the Department of Emergency Medicine, Campus Benjamin Franklin at the Charité, and first author on the abstract said: ‘We found that paramedics never documented a suspicion of sepsis, and emergency services physicians rarely did so, only documenting a suspicion in 0.1% of cases. The screening tools recommended in the Surviving Sepsis Campaign guidelines differed greatly in terms of which and how many patients were identified as possibly having sepsis.’
Emphasising the need for better awareness and more frequent use of screening tools, Ms Piedmont added: ‘No screening tool provides ideal performance. NEWS-2 best supports EMS in identifying most patients with sepsis. EMS patients that are NEWS-2 positive should be flagged up as potentially having sepsis and referred for special attention and assessment by emergency doctors who are expert in sepsis. If EMS insist on using the qSOFA, they should be aware that a positive qSOFA makes sepsis likely, but also that a negative qSOFA cannot rule out sepsis conclusively.
‘A rule of thumb for EMS staff could be that NEWS-2 negative patients are the most likely not to have sepsis, and qSOFA positive patients are the most likely to have sepsis – and also that qSOFA misses many patients with sepsis.‘
The researchers hope their findings will help to inform new guidelines on the condition, which are being drawn up in some countries to give more specific recommendations for its screening. In particular, Ms Piedmont said: ‘Future sepsis guidelines should be more precise and omit recommendations for MEWS and SIRS for EMS since they were inferior in all the measures for accuracy.’
These findings could also apply to other countries, the researchers suggest, especially as previous studies performed in Canada and the UK support aspects of their results.
‘Ours is the first study comparing all four screening tools and showing the predictive usefulness of applying the screening tools to all adult patients independently of any presumptions or preliminary diagnoses by EMS,‘ said Mrs Piedmont.
2nd October 2023
Tailoring opioid prescriptions for patients discharged from an emergency department (ED) with acute pain can support recovery and help to avoid the risk of drug misuse, according to a study presented at the European Society of Emergency Medicine (EUSEM)‘s recent congress.
The study found half of patients discharged from an ED with acute pain required five tablets or fewer of morphine 5 mg or an equivalent opioid painkiller to help manage their pain and recover from their injury or condition at home.
By tailoring the number of opioid painkillers prescribed for each patient, ED clinicians can ensure the right balance between sufficient pain relief and avoiding the over-prescribing of these drugs, which can lead to dependence and abuse in some cases.
Professor Raoul Daoust, from the University of Montreal, Canada, who presented the research, said: ‘Opioids such as morphine can be very beneficial for patients suffering acute pain, for example when they have injured their neck or broken a bone. However, patients are often prescribed too many opioid tablets and that means unused tablets are available for misuse. On the other hand, since the opioid crisis, the tendency in the USA is to not prescribe opioids at all, leaving some patient in agonising pain.
‘With this research I wanted to provide a tailored approach to prescribing opioids so that patients have enough to manage their pain but almost no unused tablets available for misuse.‘
Some 2,240 adult patients were recruited for the study, all of whom were treated at one of six hospital EDs in Canada for a condition that causes acute pain. They were each discharged with an opioid prescription and were asked to complete a pain medication diary for the following two weeks.
While half of patients took five 5 mg morphine tablets or fewer, the researchers noted that the number of tablets each patient required during the two-week period varied greatly according to the patient’s painful condition. For example, patients suffering from renal colic or abdominal pain needed only eight tablets and patient with broken bones needed 24 tablets.
Professor Daoust added: ‘Our findings make it possible to adapt the quantity of opioids we prescribe according to patient need. We could ask the pharmacist to also provide opioids in small portions, such as five tablets initially, because for half of patients that would be enough to last them for two weeks.’
Also commenting on the results, Professor Youri Yordanov from the St Antoine Hospital emergency department in Paris, France, who is chair of the EUSEM 2023 abstract committee but was not involved in the research, added: ‘It’s estimated that millions of people around the world are struggling with opioid addiction and more than 100,000 people die of opioid overdose every year. These drugs play an important role in emergency medicine, but we need to ensure they are prescribed wisely.
‘This study shows how opioid prescriptions could be adapted to specific acute pain conditions, and how they could be dispensed in relatively small numbers at the pharmacy to lower the chance of misuse. This research could provide a safer way to prescribe opioids that could be applied in emergency departments anywhere in the world.‘
Although widely prescribed in an emergency setting, a recent study has found that using opioids for patients with acute low back or neck pain offers no significant pain relief advantage compared to placebo.
27th September 2023
The diagnostic ability of the artificial intelligence system ChatGPT is similar to that of emergency department clinicians when examining some complex diagnostic cases, according to the findings of a new study presented at the European Society of Emergency Medicine (EUSEM)‘s recent congress.
Simultaneously published in the Annals of Emergency Medicine, the study used data from 30 undiagnosed patients who were ultimately given a single proven diagnosis.
The research team retrospectively investigated the ability of ChatGPT to generate accurate differential diagnoses based on the physician notes recorded at the initial emergency department presentation. The patient data was fed into two versions of ChatGPT: the free 3.5 version and the 4.0 subscriber version.
Clinicians correctly included the diagnosis in the top five differential diagnosis for 83% of cases. For ChatGPT v3.5 this was 77% and for v4.0 was 87%. Furthermore, the correct diagnosis was included within clinician‘s top five likely diagnoses in 87% of the cases, which compared favourably to the 97% for ChatGPT version 3.5 and 87% for version 4.0.
When laboratory results were included in the assessment, clinicians chose the correct leading diagnosis in 53% of the cases, which was of comparable accuracy to ChatGPT v3.5 at 60% and v4.0 at 53%.
Commenting on these diagnostic results, lead author, Dr Hidde ten Berg said: ‘We found that ChatGPT performed well in generating a list of likely diagnoses and suggesting the most likely option. We also found a lot of overlap with the doctors’ lists of likely diagnoses. Simply put, this indicates that ChatGPT was able suggest medical diagnoses much like a human doctor would.
‘For example, we included a case of a patient presenting with joint pain that was alleviated with painkillers, but redness, joint pain and swelling always recurred. In the previous days, the patient had a fever and sore throat. A few times there was a discolouration of the fingertips. Based on the physical exam and additional tests, the doctors thought the most likely diagnosis was probably rheumatic fever, but ChatGPT was correct with its most likely diagnosis of vasculitis.’
Professor Youri Yordanov from the St Antoine Hospital emergency department in Paris, France, who is chair of the EUSEM 2023 abstract committee but was not involved in the research, added: ‘We are a long way from using ChatGPT in the clinic, but it’s vital that we explore new technology and consider how it could be used to help doctors and their patients.
’People who need to go to the emergency department want to be seen as quickly as possible and to have their problem correctly diagnosed and treated. I look forward to more research in this area and hope that it might ultimately support the work of busy health professionals.
ChatGPT is an artificial intelligence system that is being increasingly explored in healthcare, although its value is currently varied. For example, it has shown some promise for relatively straightforward questions in cardiology but performed less well in more complex vignettes.
30th May 2023
Burnout, retirement and a reliance on locum staff are among a host of concerns raised in a new report from the Royal College of Emergency Medicine (RCEM), which urges the UK Government to take action to support and maintain the emergency medicine (EM) workforce.
The report, entitled ‘Emergency Medicine Workforce in England’, published on 28 May, reveals the extent of the capacity and staffing issues experienced by emergency departments, which is having a negative impact on staff morale and retention, as well as on patient care.
For example, there should be one whole-time equivalent consultant for every 4,000 annual attendances, but the report states that this ratio currently stands at 1:7052. What’s more, some 45% of the total EM workforce is made up by trainee doctors, posing a potential threat to service provision, especially out of hours.
Another particularly pressing issue, the RCEM notes, is the ageing pool of consultants employed within emergency departments. Some 29% of its consultant members are now aged over 50. Many are doing fewer hours during this stage of their careers, and ‘with a third of the workforce approaching retirement age at the same time, we may witness a mass exodus of experienced senior clinicians’, the report states.
These issues have resulted in an overreliance on locum staff, which takes a significant percentage of the wage bill.
Highlighting that the system is stretched beyond capacity and requires the next generation of EM doctors to bolster it, the RCEM’s president Dr Adrian Boyle said: ‘You have to keep the topping up the team, and that is why we are urgently calling on the Government to commit to ensuring there will be at least 120 extra training places for EM doctors every year for at least six years.’
This recommendation from the report, which would see more than 700 new trainee EM doctors being trained between 2024 and 2030, aims to help achieve safe staffing levels, ease pressure on existing staff and support capacity and resilience in emergency departments.
Dr Boyle concluded: ‘We are still waiting for the long-promised NHS workforce plan. And it is becoming increasingly important that this is published as soon as possible to avoid the crisis in the NHS worsening; and that it contains specific numbers, details and costings. Nothing less would be a disservice to our members, their colleagues, to patients and the public.’
Staffing shortages are being seen across the UK and Europe, with a mass-exodus of hospital and healthcare staff being widely reported. In the UK, the much-anticipated NHS workforce plan has indeed been delayed once again as rumours circulate around its prohibitively high cost.
25th May 2023
The use of short-stay wards located in an emergency department (ED) and managed by emergency care clinicians, benefits patients by reducing their length of stay (LOS) and 28-day mortality risk, according to the findings of a retrospective study by Korean researchers.
Published in BMC Emergency Medicine, the researchers hypothesised that ED clinician care within the ESSW was more likely to reduce patient’s LOS in the department and without affecting overall clinical care. They retrospectively analysed adult patients who visited the ED at a tertiary academic hospital in Seoul.
The patients were divided into three groups: those admitted to the ESSW and treated within the ED (ESSW-EM); those admitted but treated by other departments (ESSW-Other) and those who were admitted to general wards (GW). The researchers had a single, co-primary outcome which was ED length of stay and 28-day mortality.
A total of 29,596 patients were included in the analysis, with 31.3% categorised as ESSW-EM and 59.8% as GW.
When comparing ED LOS, the researchers found that the shortest time was for those in the ESSW-EM group (mean 7.1 hours). The mean ED LOS was 8.0 hours and 10.2 hours in the ESSW-Other and GW groups respectively (p < 0.001 for both comparisons). In addition, 28-day hospital mortality was 1.9% for the ESSW-EM group and 4.1% for the GW group (p < 0.001).
Using multivariable logistic regression analyses, being in the ESSW-EM group was independently associated with a lower hospital mortality compared with both the ESSW-Other group (adjusted p = 0.030) and the GW group (adjusted p < 0.001).
With patients’ LOS being a potential surrogate marker for overcrowding, the authors suggested that admission to an ESSW, under the care of emergency care clinicians, is a potentially effective strategy to alleviate emergency department overcrowding and improve patient outcomes.
Emergency department boarding, or overcrowding, is known to increase both hospital LOS and mortality. Consequently, in an effort the alleviate overcrowding, many Westernised countries have introduced a waiting time target, to reduce the time spend by patients in the department. This target has often been set at four hours and there is some evidence that it does reduce mortality rates. Nevertheless, a systematic review in 2010 concluded that the introduction of such targets, has not resulted in a consistent improvement in care.
An alternative proposed solution to reduce ED overcrowding and the associated mortality risks, is to have short-stay units within the ED. These emergency department short-stay wards (ESSW) are specific areas within the department designed to provide short-term care for a selected group of patients and hopefully to alleviate overcrowding.
While a potentially promising approach, a systematic review in 2015 noted insufficient evidence to make any firm conclusions on either the effectiveness or safety of short-stay units compared with inpatient care. Nevertheless, other work has shown that use of an ESSW is associated with a low rate of subsequent ICU admission. In contrast, an ESSW designed to manage patients with cardiac problems, actually increased patient’s hospital LOS.
Despite the limitations of the evidence, no previous studies have explored the potential benefit of using emergency care clinical staff within the ESSW.
4th May 2023
Nausea and vomiting were responsible for 1.6 million US emergency department (ED) visits in 2007. Antiemetic drugs such as ondansetron and metoclopramide are effective. Despite this, there is a lack of evidence to support the efficacy of one drug over any other. There is some evidence that inhaled isopropyl alcohol (IPA) appears effective for post-operative nausea and vomiting (PONV). For example, 70% inhaled IPA is more effective than promethazine in PONV. How well inhaled IPA compares to other anti-emetics is currently unknown.
The present meta-analysis searched for trials using IPA to treat adult ED patients with nausea and vomiting. The primary outcome was set as a change in nausea severity, measured by a validated scale.
Inhaled isopropyl alcohol and nausea reduction
Only two trials with a total of 195 patients met the inclusion criteria. The pooled decrease in nausea severity was 2.18 on a 0-10 scale, favouring inhaled IPA over placebo. A further trial comparing inhaled IPA and oral ondansetron did not meet the inclusion criteria but was useful for a secondary analysis. This analysis found a similar decrease in nausea (2.16).
There were no differences between inhaled IPA and placebo for the number of vomiting episodes.
The authors report that the available evidence suggests that inhaled IPA significantly reduces self-reported nausea in patients presenting to the ED with the condition. However, they note that only 275 participants have evaluated the intervention, adding the need for larger trials of the intervention.
Low back pain (LBP) is responsible for nearly 5% of all emergency department visits. Opioids and NSAIDs are useful emergency department (ED) treatments for acute LBP. Moreover, skeletal muscle relaxants, including diazepam (DP) and methocarbamol (MC) can serve as viable alternatives. Despite this, there is insufficient evidence to identify whether any one class of medication has a net advantage.
This lack of evidence led to researchers to undertake the current study. This double-blind RCT set out to compare intravenous DP with MC in acute non-traumatic musculoskeletal LBP. Both groups of patients also received morphine. Pain assessment was performed using a simple numeric rating scale, NRS, ranging from 0 (no pain) to 10 (worst possible pain). The primary outcome was the difference in pain relief post-intervention after 60 minutes.
Diazepam and post-intervention pain relief
There were 101 patients with 51 who received diazepam. Pain scores were lower with both treatments in comparison to baseline levels (p < 0.001). After 60 minutes, pain score reductions were slightly greater with DP (p = 0.048). The length of stay in the ED was similar between the two groups (MC = 5.9 hours vs DP = 4.8 hours, p=0.365). However, patients receiving diazepam were more likely to report drowsiness (4% vs 15% , p = 0.001).
These findings led the authors to concluded that DP and MC gave rise to similar pain relief after 60 minutes. Nevertheless, DP use may be associated with more drowsiness.
Upper gastrointestinal (GI) bleeding mortality is 5-10% largely due to peptic ulcers and portal hypertensive gastropathy. A common scoring system to evaluate patients with upper GI bleeding is the Glasgow-Blatchford Score (GBS). In fact, the European Society of Gastrointestinal Endoscopy suggests that a GBS score of <1 prior to endoscopy, indicates a low risk of re-bleeding. Both GBS and a modified version appear to be moderately accurate for decision-making in those with an upper GI bleed. CANUKA has a similar performance to the GBS and more accurately identifies those with a low risk for adverse outcomes. Nevertheless, currently, there is a lack of comparative data on these three systems.
Recently, researchers sought to compare the effectiveness of each system for identifying patients at low risk of death or the need for a subsequent intervention. Using a retrospective approach, the team considered emergency department patients with an upper GI bleed. They explored the need for blood transfusion, endoscopic haemostasis or re-bleeding within seven days. The scoring system sensitivity, specificity, positive and negative predictive values were used as outcome measures. Cut-off thresholds for low risk of the GBS, the modified version (mGBS) and CANUKA were set at <1, 0 and <2 respectively.
GBS and CANUKA identification of low-risk upper GI bleeding patients
There were 386 patients with a median age of 60 years (65.3% male) with sufficient data to calculate the three scores.
Using the threshold levels for GBS, mGBS and CANUKA, 24.9%, 18.2% and 18.9% of patients respectively, were at low risk. Furthermore, with these cut-off levels, only 2.2%, 4.6% and 0% respectively, required a further intervention. Sensitivity values with these cut-offs were broadly similar (98.2% to 100% for CANUKA). The negative predictive values ranged from 97.8% (GBS) to 100% for CANUKA. In addition, no deaths occurred for patients identified as being at low risk.
These findings led the authors to conclude that a Glasgow-Blatchford score of <1 and a CANUKA score of <2 appears to be safe for identifying patients at low risk of death or the need for an intervention following an upper GI bleed.
Raised cardiac troponin in acute dyspnoea could be a useful prognostic marker in those without an acute myocardial infarction (MI).
Acute dyspnoea is a common complaint within an emergency department (ED). Dyspnoea is also a common symptom of an acute myocardial infarction (MI), affecting nearly two-thirds of patients. This consequently necessitates prompt patient assessment.
High-sensitivity cardiac troponin T (CTT) can quickly assess patients with chest pain to rule out an MI. Nevertheless, elevated cardiac troponin T levels can also occur in those experiencing chest pain without an MI.
In the current study, researchers set out to determine role of CTT in ED patients presenting with acute dyspnoea not due to an acute MI. Adult patients with acute dyspnoea were included and CTT levels measured together with their clinical history. CTT levels were divided into three levels: <15, 15-100 and >100 µg/l. An analysis provided the three-month relative risk of mortality with adjustment to models for a patient’s clinical history.
Cardiac troponin and three-month mortality risk
A sample of 1001 patients had usable data. With CTT levels < 15 set as the reference point, a CTT level between 15 and 100 gave rise to a more than three-fold higher mortality risk (Hazard ratio, HR = 3.68 (95% CI 1.72-7.84). The mortality risk was even higher with levels above 100 µg/l (HR = 10.523, 95% CI 4.46-24.80).
Patients with higher cardiac troponin levels were generally older, had a higher number of co-morbidities and more severe symptoms. The researchers felt that the data highlighted the value of CTT as an important risk factor in acute dyspnoea without a cardiac cause.
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