Emergency Medicine Journal最新文献

Background: A significant challenge to achieving global 2030 elimination goals for blood-borne viruses (BBVs) is identifying undiagnosed individuals and relinking those who are no longer in care. To address this, the UK government has implemented opt-out BBV testing in emergency departments (EDs) to increase access to BBV testing in high prevalence areas. All adult ED patients having a routine blood test are automatically tested for HIV, hepatitis B and C, unless they opt out. This study aimed to identify barriers and facilitators to the implementation of ED opt-out BBV testing and provide recommendations for future rollouts.

Method: Semi-structured interviews with 23 staff members across five ED sites in very high HIV prevalence areas were analysed thematically, informed by Normalisation Process Theory.

Results: While there was some variation in staff knowledge and understanding of the programme, overall acceptance of the opt-out testing approach was found to be high. Training had a positive impact on staff understanding of the purpose of the intervention and the correct process, including the opt-out model. High workloads and competing priorities in EDs were significant barriers to testing. However, some specific systems and processes that facilitated the uptake of testing included automation and BBV champions. Giving the programme time to embed into practice and ensuring feedback loops and flexibility to 'tweak' the process was also essential to sustaining the programme.

Conclusion: To embed opt-out testing into emergency care, sites should implement automated test ordering, staff training, clear communication and dedicated champions, which can help to support earlier diagnosis, reduce inequalities and improve patient outcomes.

Background: Physician-based prehospital teams provide advanced critical care services in the UK (eg, prehospital anaesthesia). The last review of such teams in 2009, which included England, Wales and Northern Ireland, reported only one physician-based prehospital team available 24/7. Helicopter Emergency Medical Services (HEMS) across the UK offer paid physician-based teams, while other organisations may provide physician-based teams on a voluntary ad hoc basis. The primary aim of this study was to determine if access to a physician-based HEMS team has changed in the past 12 years.

Methods: An online survey was distributed to all UK HEMS organisations in January 2024. The primary outcome measure was the number of physician-based teams operated by HEMS in 2024 and the operational hours of such teams. Secondary outcomes included interventions offered by HEMS teams and any additional medical teams offered (eg, paramedic only).

Results: All 21 HEMS responded. The number of potentially available physician-based HEMS teams has increased from 11 in England, Wales and Northern Ireland in 2009 to 28 in 2024, with two services in Scotland (total=30). HEMS providing consistent 24/7 physician-based prehospital teams increased from one (5.9%) in 2009 to 11 (52.4%) in 2024. The East of England has the highest 24/7 availability, with Northern Ireland, South West England and Northern England the least. Within physician-based teams, variation remains in advanced interventions available-for example, 19 services (90.4%) offer blood transfusion while only one (4.7%) offers resuscitative balloon occlusion of the aorta. Only one service is completely government funded; the others are funded by charity alone or a combination of charity and government sources.

Conclusion: Both geographical and temporal variations in access to a physician-based HEMS remain across the UK, although there has been improvement since 2009. However, within this provision, variation exists in terms of interventions provided such as the provision of blood products.

Background: Scaphoid fractures comprise approximately 50-70% of carpal bone fractures but can be difficult to detect on initial plain film radiographs. A delayed diagnosis can lead to a high rate of non-union, avascular necrosis and Complex Regional Pain Syndrome. Current literature supports cone beam CT (CBCT) (within 10-14 days) as an effective method for diagnosing scaphoid fractures. We implemented an early outpatient CBCT pathway, prior to specialist review, with the aim to increase the proportion of patients with suspected scaphoid fracture undergoing CBCT within 7 days.

Methods: We designed an ambulatory pathway for suspected scaphoid fractures in the Emergency Department (ED) in which outpatient CBCT was requested by emergency medicine clinicians. A retrospective audit of current management of these patients was performed between 1 August 2022 and 31 October 2022 (prepathway period). A list of patients who underwent CBCT performed for the indication 'suspected scaphoid or carpal bone fracture' in the hospital was obtained and screened. Implementation of the pathway took place in February 2023 and was reviewed by continuous audit monitoring from 1 March 2023 to 31 May 2023 (postpathway period).

Results: Prepathway implementation, 54 patients underwent CBCT. Following implementation of our pathway, the number of CBCTs performed in the hospital for this clinical indication increased to 111 (postpathway). The proportion of patients undergoing CBCT within 7 days increased from 11.1% (6/54) to 91.8% (102/111) (p<0.000). There was a 71.9% reduction in fracture clinic attendances (50/54 (92.6%) prepathway and 23/111 (22.5%) post pathway (p<0.000).

Conclusion: We successfully implemented an ambulatory pathway for suspected scaphoid fractures in the ED that significantly increased the proportion of patients with suspected scaphoid fractures undergoing early (<7 days) CBCT and definitive care.

Background: When delivering nasal high flow (NHF) therapy in a medical ward, a high dependency unit or an intensive care unit, automated oxygen titration increases time spent within a target oxygen saturation (SpO₂) range compared with standard, manually titrated oxygen. This study explores whether this improvement is also seen when titrating oxygen with NHF in an emergency department (ED).

Method: This open-label, parallel groups, randomised controlled trial compared automated to manual oxygen titration using NHF therapy in hypoxaemic adult patients in the Wellington Regional Hospital ED between October 2022 and December 2023. Participants with a prescribed target SpO₂ range who demonstrated a minimum oxygen requirement were eligible for inclusion. A rank-based comparison was used for the primary outcome, the proportion of time spent within the target SpO₂ range of 92%-96%, or 88%-92% if at risk of hypercapnia, among participants achieving ≥30 min of therapy. An interaction term was applied to assess whether the proportion of time spent within target SpO₂ range depended on the prescribed target range itself (SpO₂ 92%-96% or 88%-92%).

Results: 83 participants were screened, 52 were randomised and 49 had data for the primary endpoint. Median (IQR) proportion of time spent within the target SpO₂ range with automated oxygen (n=25) was 96.4% (92.5% to 99.4%) compared with 89.9% (69.8% to 97.2%) with manually adjusted oxygen (n=24); difference (95% CI) 8.0% (1.7% to 16.9%), p=0.01. There was no evidence that the proportion of time spent within target SpO₂ range depended on the selected target SpO₂ range, P-interaction 0.60.

Conclusion: Automatically titrated oxygen therapy significantly increased time spent within a target SpO₂ range, compared with manual oxygen titration in adult patients receiving NHF therapy in the ED.

Background: Emergency departments (EDs) offer a valuable opportunity to intervene to support people to quit smoking. We sought to determine the effectiveness of smoking cessation interventions delivered in the ED setting on rates of abstinence at the longest follow-up.

Methods: We undertook a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines considering only randomised controlled trials (RCTs), based in the ED, where the goal of the intervention was smoking cessation and follow-up was at least 3 months. We systematically searched electronically published literature and trial registries from inception to May 2025. We pooled data using a Mantel-Haenszel random-effects model for behavioural interventions without pharmacotherapy, and using a fixed-effects model for interventions incorporating nicotine replacement therapy (NRT), with results reported as risk ratios (RR) and 95% CIs. The primary outcome was smoking cessation using the strictest available measure, biochemically validated where possible. Risk of bias was assessed using the Cochrane risk of bias tool. Certainty of overall evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation).

Results: Nineteen RCTs met inclusion criteria, of which 17 were deemed suitable for incorporating into meta-analyses. Participants randomised to receive a smoking cessation intervention involving NRT in the ED were significantly more likely to achieve abstinence (RR 1.55, 95% CI 1.27 to 1.89, p<0.0001, 6 RCTs, n=3528, I²=46%). Trials involving behavioural support alone delivered in the ED had an RR of quitting compared with controls of 1.18 (95% CI 0.85 to 1.64, p=0.32, 11 RCTs, N=4711, I²=37%). Of the 17 studies included in the meta-analyses, 14 were at high risk of bias, 1 at low risk and 2 where the risk was unclear. One study incorporated e-cigarettes and was not incorporated in the meta-analysis but demonstrated evidence of effectiveness.

Conclusion: There is moderate certainty evidence that smoking cessation interventions incorporating pharmacotherapy delivered in the ED are effective in supporting smoking cessation.

Introduction: Feedback is a vital yet underused tool for improving clinical outcomes in prehospital emergency care. This study aimed to develop and pilot a novel, theoretically grounded feedback mechanism for helicopter emergency medical service (HEMS) clinicians involved in out-of-hospital cardiac arrest (OHCA) in the East of England, UK.

Methods: Semistructured interviews were conducted in September 2022 with HEMS clinicians from Essex & Herts Air Ambulance, and the feedback process was co-designed with the Essex Cardiothoracic Centre (Essex, UK). Using the COM-B model (Capability, Opportunity, Motivation-Behaviour), we conducted qualitative interviews with prehospitalists (seven paramedics, three prehospital doctors) to explore gaps in existing feedback processes and identify their information needs, then iteratively co-developed a structured feedback proforma with stakeholders.

Results: Three themes emerged, specifically about weaknesses in current feedback and preferences for an improved system: (1) dissatisfaction with current ad hoc, 'punitive' approaches; (2) the educational and emotional importance of timely, targeted feedback; and (3) a strong preference for standardised, confidentiality-compliant delivery methods. The resulting feedback proforma included working diagnoses, key investigations completed, optimisation opportunities and patient outcomes (if already available), to be delivered within 24-48 hours of hospital admission.

Conclusions: Our study underscores the importance of stakeholder-driven development in shaping an effective prehospital feedback mechanism for OHCA aligned to clinicians' needs. By exploring feedback preferences and mapping insights onto the COM-B model, we highlight how knowledge, context and motivation can all steer behavioural change. Further research is needed in diverse emergency medical service contexts to test its impact on clinical practice and patient outcomes.

Objective: To evaluate whether intra-arrest diastolic blood pressure (DBP) and coronary perfusion pressure (CPP) are associated with improved return of spontaneous circulation (ROSC) in cardiac arrest.

Methods: A systematic search (PROSPERO registration: CRD420251042344) was conducted in English on EMBASE, MEDLINE, CINAHL and the Cochrane Library from inception to 1 May 2025. Grey literature sources (trial registries, conference abstracts, Google Scholar) were searched. Key resuscitation experts were contacted to identify unpublished or ongoing studies. The search strategy was peer-reviewed using the Peer Review of Electronic Search Strategies checklist. Eligible studies included randomised controlled trials (RCTs) contributing cohort data, observational studies and case series (≥10 patients) monitoring intra-arrest DBP or CPP in adult patients with cardiac arrest managed in prehospital or emergency department settings. Study selection involved two reviewers independently screening titles and abstracts, and full-text articles. Risk of bias was assessed using the Risk of Bias 2 and Risk of Bias in Non-randomised Studies of Interventions tools. This research received no funding.

Results: 15 studies (n=970 patients) across seven countries were included: 3 RCT-based prospective cohort studies and 12 observational studies. Meta-analysis was not performed due to heterogeneity in study designs. Aziz et al identified a DBP threshold of 35 mm Hg associated with ROSC (p<0.001), reporting a 5% increase in ROSC odds for every 1 mm Hg rise in DBP. This finding was supported by other observational studies reporting significantly higher maximum DBP values in patients with ROSC (34-56.5 mm Hg) compared with those without ROSC. Interventional studies aimed at augmenting DBP or CPP-including resuscitative endovascular balloon occlusion of the aorta-generally reported increases in ROSC, though studies were underpowered and at high risk of bias.

Conclusions: This review demonstrates an association between intra-arrest DBP and CPP and ROSC. DBP may provide a feasible clinical target, but definitive thresholds and their impact on survival to hospital discharge remain undefined.

Prospero registration number: CRD420251042344.

Background: Cardiac arrest, a critical emergency with high fatality rates, needs accurate early predictors of resuscitation outcomes. End-tidal carbon dioxide (ETCO₂) monitoring, reflecting tissue perfusion and metabolic activity, is highlighted in guidelines for predicting return of spontaneous circulation (ROSC). This systematic review and meta-analysis evaluates the prognostic accuracy of ETCO₂ at various time points and cut-offs to enhance clinical decision-making during cardiac arrest.

Methods: A systematic search of MEDLINE, Embase and the Cochrane Library identified relevant prognostic accuracy studies. Inclusion criteria were original articles reporting prognostic accuracy of ETCO₂ for ROSC prediction in adult cardiac arrest patients. Sensitivity, specificity and 95% CIs were calculated for ETCO₂ measurements at initial, 10 and 20 min using 2×2 contingency tables. A multiple thresholds model was used for meta-analysis, and the Median of Medians method analysed median ETCO2 values.

Results: Fourteen studies with 3186 cardiac arrest patients were included. The optimal ETCO₂cut-off was 19.8 mm Hg at initial (sensitivity 0.75 (95% CI 0.60 to 0.85), specificity 0.53 (95% CI 0.40 to 0.65)), 15.7 mm Hg at 10 min (sensitivity 0.91 (95% CI 0.72 to 0.97), specificity 0.68 (95% CI 0.56 to 0.78)) and 8.5 mm Hg at 20 min (sensitivity 0.95 (95% CI 0.53 to 0.99), specificity 0.78 (95% CI 0.39 to 0.95)). The highest area under the curve (AUC) was 0.88 (95% CI 0.31 to 0.98) at 20 min, followed by 0.82 (95% CI 0.61 to 0.91) at 10 min and 0.67 (95% CI 0.57 to 0.75) initially.

Conclusions: While initial ETCO₂ demonstrates limited prognostic accuracy for ROSC with a pooled AUC of only 0.67, ETCO₂ measurements taken at 10 and 20 min provide a negative predictive value exceeding 0.95 when using a cut-off of 10 mm Hg. However, to meet the stringent criteria for termination of resuscitation (TOR) decisions, a lower cut-off, such as 5 mm Hg, or the incorporation of additional prognostic indicators would be necessary. Serial ETCO₂ monitoring could also be considered as a potential adjunct in current TOR guidelines. Significant variability between studies necessitates cautious interpretation of these results.

Prospero registration number: CRD42024527811.

Introduction: Patients with traumatic out-of-hospital cardiac arrest (OHCA) continue to demonstrate poor outcomes. Although some prehospital studies suggest transfusion is associated with better outcomes, the association of blood transfusion at the emergency department (ED) with sustained return of spontaneous circulation (ROSC) in patients in traumatic OHCA remains unclear.

Methods: This multicentre retrospective study included adult patients with blunt traumatic OHCA who were brought to the National Taiwan University Hospital and affiliated institutions from January 2016 to August 2023. Patients under 18 years old and those who suffered from penetrating injury, burn, hanging or other non-blunt injury were excluded. Blood transfusion was defined as any blood product administration during the ED stay. The outcomes were sustained and any ROSC. The variables analysed included demographics and resuscitation factors. Multivariable logistic regression was conducted, reporting results as adjusted ORs (aORs) with 95% CI.

Results: This study included 442 patients, of whom 64 (14.5%) achieved sustained ROSC, whereas 378 (85.5%) did not. A total of 164 (37.1%) patients received blood transfusions. Among them, 2.4% patients survived to be discharged. Blood transfusion was found to be independently associated with sustained ROSC (aOR 4.58, 95% CI 2.45 to 8.58, p<0.001) whereas thoracostomy was associated with a significantly decreased likelihood of sustained ROSC (aOR 0.26, 95% CI 0.13 to 0.51, p<0.001). Factors independently associated with an increased likelihood of any ROSC included blood transfusion, witnessed arrest, arrest en route, while thoracostomy was associated with decreased likelihood of any ROSC.

Conclusions: Blood transfusion in the ED is associated with increased likelihood of sustained ROSC for patients with blunt traumatic OHCA, potentially serving as a bridge to definitive treatment. However, subsequent cost-effectiveness analysis should be considered for better resource allocation.