Pub Date : 2024-04-24DOI: 10.1136/emermed-2023-213461
Kevin H Chu, Anne-Maree Kelly, W. Kuan, Frances B Kinnear, G. Keijzers, D. Horner, Said Laribi, Alejandro Cardozo, M. Karamercan, S. Klim, Tissa Wijeratne, Sinan Kamona, Colin A Graham, Richard Body, Tom Roberts
OBJECTIVES Only a small proportion of patients presenting to an ED with headache have a serious cause. The SNNOOP10 criteria, which incorporates red and orange flags for serious causes, has been proposed but not well studied. This project aims to compare the proportion of patients with 10 commonly accepted red flag criteria (singly and in combination) between patients with and without a diagnosis of serious secondary headache in a large, multinational cohort of ED patients presenting with headache. METHODS Secondary analysis of data obtained in the HEAD and HEAD-Colombia studies. The outcome of interest was serious secondary headache. The predictive performance of 10 red flag criteria from the SNNOOP10 criteria list was estimated individually and in combination. RESULTS 5293 patients were included, of whom 6.1% (95% CI 5.5% to 6.8%) had a defined serious cause identified. New neurological deficit, history of neoplasm, older age (>50 years) and recent head trauma (2-7 days prior) were independent predictors of a serious secondary headache diagnosis. After adjusting for other predictors, sudden onset, onset during exertion, pregnancy and immune suppression were not associated with a serious headache diagnosis. The combined sensitivity of the red flag criteria overall was 96.5% (95% CI 93.2% to 98.3%) but specificity was low, 5.1% (95% CI 4.3% to 6.0%). Positive predictive value was 9.3% (95% CI 8.2% to 10.5%) with negative predictive value of 93.5% (95% CI 87.6% to 96.8%). CONCLUSION The sensitivity and specificity of the red flag criteria in this study were lower than previously reported. Regarding clinical practice, this suggests that red flag criteria may be useful to identify patients at higher risk of a serious secondary headache cause, but their low specificity could result in increased rates of CT scanning. TRIAL REGISTRATION NUMBER ANZCTR376695.
目的在急诊室就诊的头痛患者中，只有一小部分患者的头痛病因比较严重。SNNOOP10标准包含了严重原因的红色和橙色标志，该标准已被提出，但尚未得到充分研究。本项目旨在比较在一个大型跨国急诊室头痛患者队列中，诊断为严重继发性头痛和未诊断为严重继发性头痛的患者中，符合 10 项公认红旗标准（单独或合并）的患者比例。研究结果为严重继发性头痛。结果共纳入 5,293 例患者，其中 6.1%（95% CI 5.5% 至 6.8%）的患者有明确的严重病因。新的神经功能缺损、肿瘤病史、年龄较大（大于 50 岁）和近期头部外伤（2-7 天前）是严重继发性头痛诊断的独立预测因素。对其他预测因素进行调整后，突然发病、劳累时发病、怀孕和免疫抑制与严重头痛诊断无关。红旗标准的综合灵敏度为96.5%（95% CI为93.2%至98.3%），但特异性较低，仅为5.1%（95% CI为4.3%至6.0%）。阳性预测值为 9.3%（95% CI 8.2% 至 10.5%），阴性预测值为 93.5%（95% CI 87.6% 至 96.8%）。就临床实践而言，这表明红旗标准可能有助于识别继发性严重头痛风险较高的患者，但其特异性较低可能会导致 CT 扫描率增加。
{"title":"Predictive performance of the common red flags in emergency department headache patients: a HEAD and HEAD-Colombia study.","authors":"Kevin H Chu, Anne-Maree Kelly, W. Kuan, Frances B Kinnear, G. Keijzers, D. Horner, Said Laribi, Alejandro Cardozo, M. Karamercan, S. Klim, Tissa Wijeratne, Sinan Kamona, Colin A Graham, Richard Body, Tom Roberts","doi":"10.1136/emermed-2023-213461","DOIUrl":"https://doi.org/10.1136/emermed-2023-213461","url":null,"abstract":"OBJECTIVES\u0000Only a small proportion of patients presenting to an ED with headache have a serious cause. The SNNOOP10 criteria, which incorporates red and orange flags for serious causes, has been proposed but not well studied. This project aims to compare the proportion of patients with 10 commonly accepted red flag criteria (singly and in combination) between patients with and without a diagnosis of serious secondary headache in a large, multinational cohort of ED patients presenting with headache.\u0000\u0000\u0000METHODS\u0000Secondary analysis of data obtained in the HEAD and HEAD-Colombia studies. The outcome of interest was serious secondary headache. The predictive performance of 10 red flag criteria from the SNNOOP10 criteria list was estimated individually and in combination.\u0000\u0000\u0000RESULTS\u00005293 patients were included, of whom 6.1% (95% CI 5.5% to 6.8%) had a defined serious cause identified. New neurological deficit, history of neoplasm, older age (>50 years) and recent head trauma (2-7 days prior) were independent predictors of a serious secondary headache diagnosis. After adjusting for other predictors, sudden onset, onset during exertion, pregnancy and immune suppression were not associated with a serious headache diagnosis. The combined sensitivity of the red flag criteria overall was 96.5% (95% CI 93.2% to 98.3%) but specificity was low, 5.1% (95% CI 4.3% to 6.0%). Positive predictive value was 9.3% (95% CI 8.2% to 10.5%) with negative predictive value of 93.5% (95% CI 87.6% to 96.8%).\u0000\u0000\u0000CONCLUSION\u0000The sensitivity and specificity of the red flag criteria in this study were lower than previously reported. Regarding clinical practice, this suggests that red flag criteria may be useful to identify patients at higher risk of a serious secondary headache cause, but their low specificity could result in increased rates of CT scanning.\u0000\u0000\u0000TRIAL REGISTRATION NUMBER\u0000ANZCTR376695.","PeriodicalId":410922,"journal":{"name":"Emergency medicine journal : EMJ","volume":"6 2","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-04-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140660823","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-24DOI: 10.1136/emermed-2024-214007
Kei Ouchi, Adrian Haimovich, Jason K Bowman
{"title":"Prognostic awareness of seriously ill older adults in the emergency department.","authors":"Kei Ouchi, Adrian Haimovich, Jason K Bowman","doi":"10.1136/emermed-2024-214007","DOIUrl":"https://doi.org/10.1136/emermed-2024-214007","url":null,"abstract":"","PeriodicalId":410922,"journal":{"name":"Emergency medicine journal : EMJ","volume":"51 42","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-04-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140662139","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-22DOI: 10.1136/emermed-2023-213721
Gerry FitzGerald
{"title":"GP patients in the emergency department.","authors":"Gerry FitzGerald","doi":"10.1136/emermed-2023-213721","DOIUrl":"https://doi.org/10.1136/emermed-2023-213721","url":null,"abstract":"","PeriodicalId":410922,"journal":{"name":"Emergency medicine journal : EMJ","volume":"31 11","pages":"296-297"},"PeriodicalIF":0.0,"publicationDate":"2024-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140676336","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-22DOI: 10.1136/emermed-2023-213426
A. Cooper, Michelle Edwards, F. Davies, D. Price, Pippa Anderson, A. Carson-Stevens, Matthew Cooke, Jeremy Dale, Liam Donaldson, B. Evans, B. Harrington, Julie Hepburn, P. Hibbert, Thomas Hughes, Alison Porter, A. Siriwardena, Alan Watkins, H. Snooks, Adrian Edwards
Background Addressing increasing patient demand and improving ED patient flow is a key ambition for NHS England. Delivering general practitioner (GP) services in or alongside EDs (GP-ED) was advocated in 2017 for this reason, supported by £100 million (US$130 million) of capital funding. Current evidence shows no overall improvement in addressing demand and reducing waiting times, but considerable variation in how different service models operate, subject to local context. Methods We conducted mixed-methods analysis using inductive and deductive approaches for qualitative (observations, interviews) and quantitative data (time series analyses of attendances, reattendances, hospital admissions, length of stay) based on previous research using a purposive sample of 13 GP-ED service models (3 inside-integrated, 4 inside-parallel service, 3 outside-onsite and 3 with no GPs) in England and Wales. We used realist methodology to understand the relationship between contexts, mechanisms and outcomes to develop programme theories about how and why different GP-ED service models work. Results GP-ED service models are complex, with variation in scope and scale of the service, influenced by individual, departmental and external factors. Quantitative data were of variable quality: overall, no reduction in attendances and waiting times, a mixed picture for hospital admissions and length of hospital stay. Our programme theories describe how the GP-ED service models operate: inside the ED, integrated with patient flow and general ED demand, with a wider GP role than usual primary care; outside the ED, addressing primary care demand with an experienced streaming nurse facilitating the ‘right patients’ are streamed to the GP; or within the ED as a parallel service with most variability in the level of integration and GP role. Conclusion GP-ED services are complex . Our programme theories inform recommendations on how services could be modified in particular contexts to address local demand, or whether alternative healthcare services should be considered.
{"title":"Programme theories to describe how different general practitioner service models work in different contexts in or alongside emergency departments (GP-ED): realist evaluation","authors":"A. Cooper, Michelle Edwards, F. Davies, D. Price, Pippa Anderson, A. Carson-Stevens, Matthew Cooke, Jeremy Dale, Liam Donaldson, B. Evans, B. Harrington, Julie Hepburn, P. Hibbert, Thomas Hughes, Alison Porter, A. Siriwardena, Alan Watkins, H. Snooks, Adrian Edwards","doi":"10.1136/emermed-2023-213426","DOIUrl":"https://doi.org/10.1136/emermed-2023-213426","url":null,"abstract":"Background Addressing increasing patient demand and improving ED patient flow is a key ambition for NHS England. Delivering general practitioner (GP) services in or alongside EDs (GP-ED) was advocated in 2017 for this reason, supported by £100 million (US$130 million) of capital funding. Current evidence shows no overall improvement in addressing demand and reducing waiting times, but considerable variation in how different service models operate, subject to local context. Methods We conducted mixed-methods analysis using inductive and deductive approaches for qualitative (observations, interviews) and quantitative data (time series analyses of attendances, reattendances, hospital admissions, length of stay) based on previous research using a purposive sample of 13 GP-ED service models (3 inside-integrated, 4 inside-parallel service, 3 outside-onsite and 3 with no GPs) in England and Wales. We used realist methodology to understand the relationship between contexts, mechanisms and outcomes to develop programme theories about how and why different GP-ED service models work. Results GP-ED service models are complex, with variation in scope and scale of the service, influenced by individual, departmental and external factors. Quantitative data were of variable quality: overall, no reduction in attendances and waiting times, a mixed picture for hospital admissions and length of hospital stay. Our programme theories describe how the GP-ED service models operate: inside the ED, integrated with patient flow and general ED demand, with a wider GP role than usual primary care; outside the ED, addressing primary care demand with an experienced streaming nurse facilitating the ‘right patients’ are streamed to the GP; or within the ED as a parallel service with most variability in the level of integration and GP role. Conclusion GP-ED services are complex . Our programme theories inform recommendations on how services could be modified in particular contexts to address local demand, or whether alternative healthcare services should be considered.","PeriodicalId":410922,"journal":{"name":"Emergency medicine journal : EMJ","volume":"21 9","pages":"287 - 295"},"PeriodicalIF":0.0,"publicationDate":"2024-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140676519","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-22DOI: 10.1136/emermed-2024-214077
Ashleigh Trimble, Bethany Sampson, Charlotte Grace Underwood, Roshan Cherian, Fiona McDonald, Victoria Webster, John Shepherd, J. V. van Oppen
{"title":"Journal update monthly top five.","authors":"Ashleigh Trimble, Bethany Sampson, Charlotte Grace Underwood, Roshan Cherian, Fiona McDonald, Victoria Webster, John Shepherd, J. V. van Oppen","doi":"10.1136/emermed-2024-214077","DOIUrl":"https://doi.org/10.1136/emermed-2024-214077","url":null,"abstract":"","PeriodicalId":410922,"journal":{"name":"Emergency medicine journal : EMJ","volume":"75 3","pages":"333-334"},"PeriodicalIF":0.0,"publicationDate":"2024-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140676915","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-22DOI: 10.1136/emermed-2023-213638
Antoni Martín-Jiménez, Francisco Miralles-Aguiar, Daniel García-Gil
{"title":"Recurrent calf pain after sport activity.","authors":"Antoni Martín-Jiménez, Francisco Miralles-Aguiar, Daniel García-Gil","doi":"10.1136/emermed-2023-213638","DOIUrl":"https://doi.org/10.1136/emermed-2023-213638","url":null,"abstract":"","PeriodicalId":410922,"journal":{"name":"Emergency medicine journal : EMJ","volume":"5 2","pages":"295-340"},"PeriodicalIF":0.0,"publicationDate":"2024-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140674394","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-22DOI: 10.1136/emermed-2023-213643
James Murray, Edwin Almaraj Raja, Josip Plascevic, Mark Jacunski, Jamie G. Cooper
{"title":"Is arrival by ambulance a risk factor for myocardial infarction in emergency department patients with cardiac sounding chest pain?","authors":"James Murray, Edwin Almaraj Raja, Josip Plascevic, Mark Jacunski, Jamie G. Cooper","doi":"10.1136/emermed-2023-213643","DOIUrl":"https://doi.org/10.1136/emermed-2023-213643","url":null,"abstract":"","PeriodicalId":410922,"journal":{"name":"Emergency medicine journal : EMJ","volume":"33 10","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140673261","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-09-06DOI: 10.1136/emermed-2022-212420
E. Regen, K. Phelps, J. V. van Oppen, Peter Riley, Jagruti Lalseta, Graham Martin, S. Mason, S. Conroy
Background Little is known about how frailty impacts on older people’s experiences of emergency care, despite patient experience being essential to providing person-centred care. This qualitative study reports on the experiences of older people with frailty in the ED and their and their carers’ preferences for emergency care. Methods Older people (aged 75+ years) who were at least mildly frail and/or their carers, with current or recent experience of emergency care, were recruited from three EDs in England between January and June 2019. Data were collected via semi-structured in-depth interviews which explored participants’ views on their recent experience of emergency care and their priorities and preferred outcomes. Interviews were audio-recorded, transcribed verbatim and analysed following the principles of the Framework approach. Results Forty participants were interviewed: 24 patients and 16 carers who, between them, described ED attendances for 28 patients across the three sites. Often informed by previous negative experiences, there was a strong desire to avoid conveyance to EDs, and a sense of helplessness or acquiescence to attend. Although staff attitudes were on the whole seen as positive, the ED experience was dominated by negative experiences relating to very basic issues such as a lack of help with eating, drinking, toileting and discomfort from long waits on hard trolleys. Participants reported that communication and involvement in decision making could be improved, including involving next of kin, who were viewed as critical to supporting vulnerable older people during sometimes very protracted waits. Conclusion Frailty reflects a vulnerability and a need for support in basic activities of daily living, which EDs in this study, and perhaps more widely, are not set up to provide. Changes at the levels of clinical practice and service design are required to deliver even the most basic care for older people with frailty in the ED environment.
{"title":"Emergency care for older people living with frailty: patient and carer perspectives","authors":"E. Regen, K. Phelps, J. V. van Oppen, Peter Riley, Jagruti Lalseta, Graham Martin, S. Mason, S. Conroy","doi":"10.1136/emermed-2022-212420","DOIUrl":"https://doi.org/10.1136/emermed-2022-212420","url":null,"abstract":"Background Little is known about how frailty impacts on older people’s experiences of emergency care, despite patient experience being essential to providing person-centred care. This qualitative study reports on the experiences of older people with frailty in the ED and their and their carers’ preferences for emergency care. Methods Older people (aged 75+ years) who were at least mildly frail and/or their carers, with current or recent experience of emergency care, were recruited from three EDs in England between January and June 2019. Data were collected via semi-structured in-depth interviews which explored participants’ views on their recent experience of emergency care and their priorities and preferred outcomes. Interviews were audio-recorded, transcribed verbatim and analysed following the principles of the Framework approach. Results Forty participants were interviewed: 24 patients and 16 carers who, between them, described ED attendances for 28 patients across the three sites. Often informed by previous negative experiences, there was a strong desire to avoid conveyance to EDs, and a sense of helplessness or acquiescence to attend. Although staff attitudes were on the whole seen as positive, the ED experience was dominated by negative experiences relating to very basic issues such as a lack of help with eating, drinking, toileting and discomfort from long waits on hard trolleys. Participants reported that communication and involvement in decision making could be improved, including involving next of kin, who were viewed as critical to supporting vulnerable older people during sometimes very protracted waits. Conclusion Frailty reflects a vulnerability and a need for support in basic activities of daily living, which EDs in this study, and perhaps more widely, are not set up to provide. Changes at the levels of clinical practice and service design are required to deliver even the most basic care for older people with frailty in the ED environment.","PeriodicalId":410922,"journal":{"name":"Emergency medicine journal : EMJ","volume":"226 1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132486904","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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