Emergency medicine

Top 10 priorities

1. What is the best way to reduce the harms of emergency department crowding and exit block? We need a better measure of crowding that drives sensible improvements for the seriously ill and injured, adolescents and the frail elderly.
2. Is a traditional Emergency Department the best place to care for frail elderly patients? Would a dedicated service for these patients be better (involving either a geriatric Emergency Department, or geriatric liaison services within the Emergency Department), or given that this population is expanding should our current services be tailored towards this group?
3. How do we optimise care for mental health patients; including appropriate space to see patients, staff training, early recognition of symptoms, prioritisation compared to physical illness, and patient experience?
4. With regard to how Emergency Department staff development is managed, what initiatives can improve staff engagement, resilience, retention, satisfaction, individuality and responsibility?
5. How can we achieve excellence in delivering end of life care in the Emergency Department; from the recognition that a patient is dying, through symptomatic palliative treatment, potentially using a dedicated member of staff to work with palliative patients and their relatives, and handling associated bereavement issues?
6. The effects of implementing new techniques in assessing patients with chest pain (which include new ways of using high sensitivity troponin tests, and decision rules such as the MACS rule and the HEART score) in practice. Would patients like a say in what is an acceptable risk, and should these tools be used alongside shared decision making to provide safe and appropriate care, minimise unnecessary risk and inconvenience for patients?
7. What is the ideal staffing for current UK Emergency Medicine practice, including doctors, nurses, health care assistants, porters, radiographers, clerical and reception staff?
8. Do early undifferentiated (broad spectrum) antibiotics in suspected severe sepsis have a greater benefit and cause less harm to patients than delayed focussed antibiotics in the Emergency Department?
9. In adults who are fully alert (GCS 15) following trauma does cervical spine immobilisation (when compared to no cervical spine immobilisation) reduce the incidence of neurological deficit, and what is incidence of complications?
10. Which trauma patients should be transferred to a Major Trauma Centre rather than going to another hospital first?

The following questions were also discussed and put in order of priority at the workshop:

11. A prospective evaluation of a CT head scan rule out pathway (within 6hrs of headache onset) without recourse to lumbar puncture in Emergency Department patients with acute severe headache.
12. What is the optimal management strategy for patients taking anticoagulants who sustain head injuries?
13. The use of prophylactic anticoagulation for patients with lower limb injury and temporary immobilisation is a key issue for which international equipoise continues. These patients are a common presentation to emergency departments worldwide and a lack of definitive evidence has led to a state of variable practice with little understanding of the clinical or cost effectiveness of local regimens. Should we give VTE prophylaxis in these patients?
14. What information can be used to accurately predict which older, frail patients attended by an ambulance crew can be safely and effectively managed at home, without the need to take them to hospital?
15. Does a departmental simulation and team training program reduce medical error and improve quality of patient care?
16. In patients with sepsis does a liberal fluid resuscitation strategy versus early vasopressor use result in increased morbidity and mortality?
17. There have been many proposed interventions within the last decade designed to streamline diagnosis of suspected pulmonary embolism and avoid costly hospital admissions or problems related from overtesting. These interventions have not been assessed as a composite and the risk benefit profile of their introduction when compared to standard care is unclear.
18. Could more be done in the initial few hours in the Emergency Department to prevent secondary damage in patients with head injury (e.g. reducing intracranial pressure).
19. What is the impact of emergency medicine Consultant presence in the clinical area on patients, staff and performance of the Emergency Department (including quality and safety) - including an assessment of the benefit of 24 hour cover?
20. How can we improve work/life balance amongst Emergency Department staff to better retain our staff, including rota design and other working conditions.
21. Does rapid assessment and triage by a senior doctor improve time to admit or discharge? Is there an optimum time to do it? Is it appropriate for both minors and majors patients?
22. Use of biomarkers in adult patients with minor traumatic brain injury (mTBI) in particular protein S-100B, incorporation into NICE adult head injury guidance; There is evidence to suggest that the use of this biomarker may decrease rate of neuroimaging by up to 30%. It has a very high sensitivity (reported >97%) and therefore is a good 'rule out' option. Of particular benefit to patients with a minor head injury who are: anticoagulated (warfarin); intoxicated; or the elderly patient (with background dementia or cognitive decline).
23. In adults diagnosed with isolated sub-segmental pulmonary embolism is treatment with anti-coagulation required?
24. How may we best tackle the challenge of people who use the Emergency Department very frequently in the UK?
25. Which factors predict significant traumatic brain injury in head injury patients that present more than 24 hours after the injury?
26. In adult patients with small closed haemothorax secondary to trauma, does attempted drainage vs conservative management result in improved long term morbidity and mortality?
27. Does increased use of clinical 'support' staff (physician assistants, extended role Health Care Assistants) improve efficiency of doctors and nurses, improve flow and is it financially sound?
28. Does early high-dose fibrinogen supplementation with cryoprecipitate reduce mortality in adult trauma patients who have haemorrhagic shock and active bleeding?
29. In adult patients with presumed sepsis in the prehospital environment does the administration of prehospital antibiotics compared to no antibiotics decrease mortality?
30. How can viscoelastic studies guide transfusion in trauma and other haemorrhage states? Viscoelastic studies allow us to go one step further and effectively offer a bespoke transfusion to the bleeding patient. This allows the patient to receive the products they need, but also allows greater control over limited resources in the blood bank.

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For a full list of the 72 priority research questions identified by this PSP, please see the document below