Emergency Medicine

Refining the National Emergency Department Overcrowding Scale (NEDOCS) as an automated real-time ED crowding tool

Addressing priority 1: Royal College of Emergency Medicine funded project

Trainee-led evaluation of the need for Inter-shift Recovery among Emergency Department doctors in the United Kingdom (TIRED) Study

Addressing priority 4: Royal College of Emergency Medicine funded project

Optimising shared decision making for patients with chest pain

Addressing priority 6: Royal College of Emergency Medicine funded project

Cardiovascular risk prediction in the Emergency Department has previously been focused upon short term outcomes, however we collect data which could be used to inform long term outcomes. The efficient use of data and NHS-patient interactions will be key in preventative medicine strategies. A group of researchers, with the support of a Royal College of Emergency Medicine project grant, plans to investigate this by conducting a systematic review of the existing evidence for long term cardiovascular risk prediction in the acute care setting. There will be subsequent qualitative studies including patients, emergency physicians and general practitioners to ascertain the feasibility and barriers to implementation that this may face.

The anticipated outcome is a long term cardiovascular risk prediction strategy for acute care. The hope is that it can be used to enhanced shared decision making in patients presenting with chest pain, aligning with the James Lind Alliance priority six.

PROcalcitonin and NEWS evaluation for Timely identification of sepsis and Optimal use of antibiotics in the Emergency Department (PRONTO)

Addressing priority 8: NIHR research in progress

The optimal treatment for sepsis includes early recognition, prompt antibiotics and fluids into a vein (intravenous/IV). Currently, clinicians assess severity in patients in the Emergency Department with a scoring system based on simple to measure observations: the National Early Warning Score (NEWS). NEWS helps clinicians identify the sickest patients. It is not specific and tends to over-diagnose sepsis leading to over prescribing of antibiotics, thus promoting antimicrobial resistance. It is currently used in over 70% of English hospitals. Procalcitonin (PCT), a blood test not widely used in the NHS, helps to identify bacterial infection. The primary aim of this study is to compare PCT- supported assessment with standard care of suspected sepsis in adults presenting to the ED, and measure whether this approach reduces prescriptions of antibiotics without increasing mortality by decreasing uncertainty in the group who may not need IV antibiotics urgently within 1 hour, or not need antibiotics at all. The evaluation will be done via a randomised controlled trial in ten hospitals. If the study shows that PCT-supported assessment is superior to current practice, then it will lead to better outcomes in sepsis, improved care and a reduction in inappropriate antibiotics prescriptions.

Spinal Immobilisation Study (SIS)

Addressing priority 9: NIHR research in progress

This study aims to assess whether movement minimisation is no worse than triple spinal immobilisation for patients who have may have or are suspected of a spinal injury in the pre-hospital and emergency setting.

A national pre-hospital major trauma triage tool/process - the Major Trauma Triage Study (MATTS)

Addressing priority 10: NIHR research in progress

The term 'triage' means to sort patients in terms of priority. Paramedics currently use a 'triage tool' to help them to recognise whether a patient is seriously injured or not and therefore whether it might be beneficial to transport them to a major trauma centre rather than a non-specialist hospital which could be closer. The tool is a checklist of patient and injury features, for example the presence of low blood pressure. Unfortunately, research has suggested that current tools are not very accurate, as they may miss patients with serious injury and often direct patients with more minor injuries to the major trauma centre unnecessarily. This study aims to develop a new and more accurate tool that will help get the right patient to the right place at the right time.

Work investigating the sensitivity of a computed tomography (CT) performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage

Addressing priority 11: Royal College of Emergency Medicine funded project

There is a good evidence base that a CT within 6 hours is sensitive enough to rule-out subarachnoid haemorrhage without the need for a lumbar puncture. However, this has not been universally adopted in UK practice. This is emphasised by the fact that the Emergency Medicine PSP priority 11 directly highlighted this question. The Trainee Emergency Research Network is currently in the advanced stages of planning a prospective observational cohort study aimed at validating this question. The study will start in the summer of 2019, with results published in the summer of 2020.

Sepsis Trials In Critical Care (SepTIC)

Addressing priority 16: NIHR research in progress

We urgently need to know the best treatments for sepsis. This research looks to answer three important questions: 1) Is it better for patients if we use rapid microbiology tests (that take only a few hours to work out what the infection is) to allow antibiotics to be changed early? 2) Is it better for patients with sepsis to have less fluid than current standard care? 3) Does it help to give the sickest patients with sepsis and low white blood cell counts (a sign of a weakened immune system) a drug that stimulates the immune system? By answering three important research questions at the same time we will get answers more quickly and save money.

Early Vasopressors in Sepsis (EVIS)

Addressing priority 16: NIHR research in progress

The aim of this research study is to compare two treatments (fluid and blood pressure medication via a drip) for patients in hospital with sepsis, a life-threatening condition caused by the overreaction of the body's immune system to infection.

Stopping anticoagulation for isolated or incidental sub-segmental pulmonary embolism (STOPAPE)

Addressing priority 23: NIHR research in progress

Pulmonary embolism (PE) is a potentially serious condition, whereby blood clots cause a blockage of the blood supply to the lungs. PEs are often caused by blood clots in the legs and occasionally the arms (deep vein thrombosis (DVT)) breaking off and travelling to the lungs. The treatment of PE includes anticoagulant medication (blood thinners) that are taken over months. This study aims to find out more about smaller clots, where it is unclear whether anticoagulant treatment is required or whether they may be removed by the body's own mechanisms for dissolving clots without needing anticoagulants, which can cause side effects in some patients.

Implementation of the non-medical practitioner workforce into the urgent and emergency care system skill-mix in England: a mixed methods study of configurations and impact.

Addressing priority 27: NIHR research in progress

Demand for urgent and emergency care services is growing every year, especially urgent treatment centres (UTCs). People are going to Emergency Departments (ED) with more complicated issues and many patients are admitted to hospital. There are not always enough doctors for these departments, and staff are leaving or going off sick in high numbers. One solution is to employ 'non-medical practitioners'. These are qualified staff from other healthcare backgrounds who work at the same level as doctors. Some research shows that patient results are the same if they see a non-medical practitioner as if they see a doctor. We need to know what balance - known as 'skill-mix' - of nonmedical practitioners, doctors and nurses in a team and service achieves the best results. This study will explore the result of different skill-mix in ED/UTCs in England, to make recommendations about the best balance.

Sepsis - Accuracy, impact and cost-effectiveness of prehospital clinical early warning scores for adults with suspected sepsis

Addressing priority 29: NIHR research in progress

Sepsis is a life-threatening condition caused by the body having an abnormal response to infection that leads to heart, lung and kidney failure. People with sepsis need urgent treatment with antibiotics and intravenous fluids, and may need treatment in intensive care. However, some features of sepsis may be seen with uncomplicated infections or other illnesses, particularly in people with underlying diseases. This can make it difficult to correctly identify who has sepsis and needs urgent treatment, and who does not. Early warning scores can be used to identify patients with sepsis and prioritise their treatment in a busy emergency department. This research aims to determine how accurately existing and potential new early warning scores identify cases of sepsis that need urgent treatment. It also aims to determine the likely impact of paramedics using early warning scores to (a) alert the emergency department so they are seen immediately on arrival, or (b) provide treatment for sepsis in the ambulance.

Digital alerting to improve sepsis detection and patient outcomes in NHS Trusts

Addressing priority 29: NIHR research in progress

Previous research done by this team in a busy London hospital has already shown that the introduction of a digital sepsis alert is associated with more patients receiving antibiotics in the target of one hour after identification and fewer patients dying. The team wants to expand this work to include sites from other areas of the UK. Different hospitals have used different methods of creating a score and introduced the digital alerting systems in different ways, some of which include details on a patient's clinical history. They want to establish which method works best, and how. This research will assess whether different digital alerts, and the way in which they were introduced results in better outcomes for patients.

Predicting severe pneumonia in the Emergency Department (PERN)

Addressing a number of the priorities: Royal College of Emergency Medicine funded project

Community acquired pneumonia (CAP) is one of the commonest serious bacterial infections in children worldwide. It is an important cause of childhood illness and a frequent cause of emergency department visits and hospitalisation. There is currently no evidence-based, validated tool to help health professionals make decisions about how to manage childhood CAP. The objective of this study is to develop a clinical prediction rule to accurately identify children with CAP who are at risk for low, moderate, and severe disease. Under questions 31-72 identified by the PSP, there is a stated need for meaningful research around clinical decision making to target interventions and improve the diagnostic process. It will also help to decrease over-investigation of patients, which is a particularly important goal in paediatric emergency departments.