Breaking Evidence: the Rod Little Prize shortlisted abstracts 4-7

Author: Charlotte Kennedy / Codes: HAP29 & CC2O / Published: 28/08/2018

Academic Emergency Medicine (EM) is a small but rapidly growing field. There are now numerous large randomised control trials being run by Emergency Departments across the globe, we are trailblazers in areas such as staff wellbeing research and many senior EM academics are now house-hold names (well, amongst other EM folk anyway!). But what about the next generation of up-and-coming researchers? What are the topics that interest them? And what can we expect from them in the near future?

The Rod Little prize is awarded every year by the Royal College of Emergency Medicine to a United Kingdom (UK) based trainee for their research as presented at the Annual Scientific Conference. This year the conference was held in conjunction with EUSEM and here we present short summaries of the top-scoring abstracts nominated for the prize.

“A qualitative study of practitioner perspectives on medical record keeping in sudden onset disasters” by Anisa Jafar (ST4 OOPR, PhD Candidate and Research Associate at HCRI, Manchester)

Global health is an increasing concern to many EM clinicians. Indeed, some will go a step further by volunteering to work for humanitarian non-governmental organisations such as medecins sans frontieres. Yet learning lessons from disaster relief missions is difficult as in most cases medical record-keeping is notoriously poor. In order to change this, we need to understand what unique challenges these situations present to record-keeping and what the practical and cultural barriers to improving it are. This study aimed to tackle this through qualitative work with healthcare professionals who have worked in this area.

The author used an inductive approach taken from a base-line of grounded theory. Over a 2-month period they conducted 13 semi-structured interviews with healthcare workers in the areas of general surgery, anaesthesia, emergency medicine, paediatrics, physiotherapy and orthopaedic surgery. The participants were all experienced in working in disaster settings, had between them worked for over 15 different organisations and represented 9 different nationalities. Thematic analysis of the interviews found several key themes emerging, to include: the need to incentivise medical documentation; the fact that both paper and electronic record keeping have limitations and an ideal approach would encompass both; and the acceptance that creating systems directly tailored to the disaster environment would be more likely to succeed than trying to adapt civilian solutions to the problem.

The results of this work will be fed back to the WHO emergency medical team secretariat and other key global organisations delivering emergency response in order that when documentation is redeveloped to meet new WHO minimum reporting standards, repeating past mistakes can be avoided and the standard of documentation and data capture can move forward.

Anisa’s take home message

“To use a qualitative lens on this perennial problem has captured and condensed essential ideas into digestible, practical information for practitioners and policy-makers to use when planning how to document the care provided in some of the most challenging of circumstances.”

Contact Anisa about this work: anisa.jafar@manchester.ac.uk or on twitter @EMergeMedGlobal

“What do patients want from us? A systematic review and meta-synthesis of qualitative studies aimed at identifying key determinants of patient experience in Emergency Department care” by Blair Graham et al. (PhD Emergency Medicine Trainee, Plymouth)

We all want our patient’s to have a good experience whilst in our Emergency Departments. But do we know what our patients really want or what influences their experience? These are the questions behind the meta-synthesis by these authors.

To identify what determinants influence a patient’s experience in the Emergency Department, the authors conducted a systematic review of all qualitative studies in this area. Pubmed, CINAHL, EMBASE and BNI were searched, identifying 876 results, of which 33 were extracted for full review. Using the Critical Appraisal Skills Programme (CASP) checklist, papers were then quality appraised and only those meeting all criteria were included in the meta-synthesis. In total 15 studies met the criteria, most of which used semi-structured interview techniques. The authors identified major themes from these and organised them into categories of personal, technical, cultural or physical determinants of experience. These results have been used to create a framework from which patient experience can be measured and optimised in the future. The work represents the first phase in developing a patient experience measure for adults over the age of 65, which should help us make targeted improvements to the way we care for older people in the ED. Watch this space…

Our take home message about Blair’s work

To truly measure quality we need to look beyond just targets and approach the question in a patient-centred way. The first step in being able to do this is to understand what affects patient’s experience whilst in the Emergency Department. We hope to see more work from this group in the future on how patient experience can be directly measured and constructive feedback collected effectively in our departments.

“What are the CT scan findings and outcomes for patients taking warfarin with mild head injury? A quantitative analysis of AHEAD data” by Rachel Evans et al. (CT2 doctor, Sheffield Teaching Hospitals)

Head injury is a common presentation to the ED and a frequent cause of CT scan requests. In the UK, NICE recommends that all patients with a head injury who are on warfarin have a CT scan to rule out intracranial injury. However, people have started to question whether this is always necessary. Is that 82 year old man with the innocuous injury 22 hours ago likely to have an intracranial injury and if so, are we likely to intervene? The AHEAD study was a large, multicentre observational study that examined the rate of adverse outcomes in head injured patients taking warfarin. This study looked at the imaging findings for these patients and the outcomes of those who had abnormal neuroimaging.

The AHEAD study recruited 3,534 patients from across 33 different Emergency Departments in England and Scotland. Despite national guidance that all head injured patients on warfarin should receive a CT scan, only 1,897 (53.7%) of those recruited underwent neuroimaging. Of the study patients with a GCS of 14 or 15, 153 patients had an intracranial abnormality likely to be attributable to their injury, of which the most common abnormality was subdural haematoma (37%), followed by mixed types of haemorrhage (21%), subarachnoid haemorrhage (16%) and intracerebral haemorrhage (14%). Of the patients with a demonstrated intracranial injury, 9 went on to have neurosurgery and only 1 patient died. The bottom line is that the risk of intracranial injury in anticoagulated patients with a Glasgow Coma Scale of 14 or above after blunt head injury is low. More work needs to be done to model the potential costs, benefits and harms associated with CT scanning in these low risk patients and we hope to see a decision model in due course.

Rachel’s take home message

“Patients with head injuries on warfarin who are GCS 15 and do not have other reasons for a CT scan (eg mechanism, loss of consciousness) are highly unlikely to suffer any serious sequalae. They may not need a CT scan. Current guidelines promote a generic “one-size-fits-all” approach to highly individual, varied patients. Talk to your patient and make a sensible decision together.”

Contact Rachel about this work: r.j.evans@sheffield.ac.uk or on twitter @RJEvans1234.

Assessing the impact of introducing S100B biomarker into the UK head injury guidelines. By Nicholas Moore et al ST3 Emergency Medicine in North East London

Most of the head injuries that we see in our EDs on a day-to-day basis are mild, yet we still conduct neuroimaging in a large cohort of these patients. In the UK, NICE has defined a set of criteria which guide clinicians on the need for neuroimaging based on features from the history and examination. But other countries have gone one step further than this in their decision algorithms and in 2013 the Scandinavian Neurotrauma Committee introduced the use of the blood biomarker S100B into their guidelines. The authors of this paper wanted to determine what effect introducing S100B in the UK might have on neuroimaging rates were we to consider adopting it.

The study was run over a 28 day period and captured data on all patients aged 18-65 attending with a head injury to the ED of a large teaching hospital in England. Cases were reviewed retrospectively as to whether the patient underwent neuroimaging and whether they would have qualified for S100B measurement under the Scandinavian guidelines (GCS14-15, presenting within 6 hours of injury, with no high risk features except vomiting or syncope). In total 238 patients were identified as having attended with a head injury, of which 212 had a GCS of 14-15 on assessment. 114 (48%) of these patients underwent neuroimaging, with no abnormalities found on any of the CT scans. Of those that had a CT, 96 would have potentially qualified for S100B measurement. Previous studies conducted on S100B allowed the authors to estimate that 32% of patients qualifying for measurement would have had values low enough to avoid further investigation, which would translate to a reduction in neuroimaging in this study of approximately 25%. Scaling this up to the UK population as a whole, it has the potential to avoid over 75,000 CT scans per year. However, the use of S100B in the UK needs further validation in our population before it is adopted into clinical decision rules and we hope to see more along these lines from the authors in due course.

Nicholas’ take home message about this work:

The S100B biomarker has convincing potential to reduce CT scans, admissions and perhaps presentations to emergency departments in patients with mild head injuries in the UK. A validation study is warranted.

Contact Nicholas about this work:

The above work highlights how diverse and exciting research in Emergency Medicine can be. We hope it also shows that research can be done in different ways, accessed through different channels and undertaken at different stages of a clinical career. We congratulate all the authors on their shortlisting and wish them the very best of luck in their continuing work. Let’s hope we see more from them in the near future!

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