RCEM Research Grants and Awards

Streaming and redirection of adult minor acuity patients attending the Emergency Department (STREAM-ED)

Date of award: 2022
Lead applicant: Professor Jonathan Benger
Summary of project:
STREAM-ED was originally planned as an evaluation of the local implementation of a digital tool (EDST) that streams and redirects patients on arrival at the Emergency Department. This tool was due to be implemented within an ICB area (BNSSG) in January 2022, however due to some local challenges this study has re-framed its approach to encompass the consideration of a wider range of patient experience of different types of streaming and redirection on arrival at the ED. This includes the addition of NHS Hospital Trusts from the Surrey Heartlands Integrated Care System (who are already using the EDST).

After successfully gaining approval for this amendment to the research plan from the HRA to include the addition of new Trusts in February, other minor amendments are currently being devised in order to make it easier for clinical staff to support recruitment remotely. Recruitment to the study is planned for summer this year.

The DAShED (Diagnosis of Acute Aortic Syndrome in the ED) study: An observational cohort study of people attending the ED with symptoms consistent of Acute Aortic syndrome (AAS)

Date of award: 2022
Lead applicant: Dr Rachel McLatchie
Summary of project:
Acute aortic syndrome (AAS) is a life-threatening emergency condition affecting the upper aorta affecting ~4000 people in the UK a year with an ED misdiagnosis rate as high as 38%. Previous research has identified several strategies combining clinical probability scoring with blood tests (D-Dimer) to rule out the condition but when applied to a large population (ED) with relatively low numbers of actual cases, these result in a high rate of computed tomographic angiography (CTA) scanning. Current guidelines reflect the uncertainty of existing evidence.

This study aims to ultimately assess which of the four aforementioned clinical decision tools is most effective, assess external validity, and assess clinical impact. Phase 1 (DAShED) involved prospective data collection on all characteristics of four different risk scores, in addition to evaluation of patient characteristics, potential CT aorta rates with different strategies, and enrolment rates at participating sites. This will inform Phase 2, which will involve full interventional external validation study of the decision aid(s) selected in Phase 1 (including biomarker collection); the main objective being to select the score subject to assessment of clinical impact (intervention step-wedge trial) in Phase 3. The study is currently ongoing and results should be available towards the end of 2023.

Publications/presentations: DAShED – Emerge Research

The impact of body-worn cameras in the emergency department: An uncontrolled mixed methods before-and-after study

Date of award: 2020
Lead applicant: Dr Nicholas Tilbury
Summary of project:
Violence and aggression towards emergency staff is widespread, with approximately one third of healthcare workers experiencing it during their careers. It significantly affects staff physical and psychological well-being, recruitment and retention and impacts the quality of patient care. One solution that has seen benefit in other environments is the use of body-worn cameras; these are being trialled in the Royal Derby Hospital Emergency Department, and both their impact and patient and staff perception of their use is being studied.

This study aimed to evaluate the impact of the use of these devices in the Royal Derby Hospital Emergency Department. Body-worn cameras were introduced to the Royal Derby Hospital emergency department in 2021. This study assesses staff and patient perceptions of body-worn camera use in the emergency department, both prior to and after the camera introduction to practise using survey methods recruiting ~1200 participants. Analysis of the survey data is currently taking place; findings will be made available later this year.

Body camera use in the emergency department: an exploration of governance, data management and confidentiality

Date of award: 2020
Lead applicant: Dr Andrew Tabner
Summary of project:
Grants were awarded for both sister studies led by Dr Andrew Tabner and Dr Nicholas Tilbury, the first being a survey study, the second being a focus group study. This study will explore the governance framework for the use of body cameras in emergency departments relating to data storage, confidentiality and ethics. Three focus groups with purposively selected participants will examine governance frameworks and regulatory issues as well as exploring issues of confidentiality and ethics. This study is taking place within an interpretivist research paradigm using a phenomenological approach. Focus groups will be audio recorded and transcribed, transcriptions will be independently coded by two researchers and analysed using template analysis. A priori themes will be developed and considered but disregarded if found to be irrelevant. The analysis for both studies is set to take place in June 2023, with findings set to be made available towards the end of this year.

A qualitative study of trainee experience of academic clinical fellowship in emergency medicine in the UK

Date of award: 2020
Lead applicant: Dr Thomas Shanahan and Dr Anisa Jafar
Summary of project:
This study explored emergency physician’s experiences of and views about ACFs over the last 5 years to enable us to understand what works well and what does not, and importantly: why? The focus was on experience in terms of recruitment, structure of the ACF, supervision arrangements and academic career after the ACF, using a survey and semi-structured interviews. The data analysis was based upon grounded theory, the analysis has been finalised and has been submitted to a peer reviewed journal.

The findings from this study will help us develop a better understanding of the experiences of emergency physicians to develop ACFs schemes further. Not only can this improve the recruitment of emergency physicians into ACFs, but it may help identify ways in which the ACF structure could be modified/standardised to encourage further progress into successful PhD and academic clinical lecturer applications. It is envisaged this research could lead to further exploration of the formal (and indeed informal) academic environment for emergency physicians.

Publications/presentations:
Shanahan T, Barret L, Fish R, Newcombe V, Body R, Jafar A. Survey of current and former academic clinical fellows in emergency medicine in the UK. European Journal of Emergency Medicine, August 2022, volume 29, issue 4. 2022.

The COVID-19 Emergency Response Assessment Study: A prospective longitudinal survey of Doctors in the UK and Ireland

Date of award: 2020
Lead applicant: Dr Tom Roberts
Summary of project:
This study examined the effect of COVID-19 on frontline doctors using a cross-sectional electronic survey distributed via established specialty research networks, within a three-part longitudinal study. Findings indicate that during the acceleration phase of the COVID-19 pandemic, almost half of frontline doctors working in acute care reported psychological distress as measured by the GHQ-12.

Findings from this study should inform strategies to optimise preparedness and explore modifiable factors associated with increased psychological distress in the short and long term. The study has been published and presented at academic conferences, as well as receiving extensive media coverage at the point of publication. It has now extended into work looking at models for psychological care for doctors.

Publications/presentations: https://emj.bmj.com/content/38/6/450

Validation of the National Emergency Department Overcrowding Score (NEDOCS) in a UK non-specialist emergency department

Date of award: 2020
Lead applicant: Dr Colin Dewar
Summary of project:
Using single-centred sampled data from four periods of 2018, this study looked to validate the National Emergency Department Overcrowding score (NEDOCS) (range 0–200 points), which uses routinely collected ED data. The outcome against which NEDOCS performance was assessed was a composite of clinician opinion of crowding (physician and nurse in charge). Area under the receiver operating characteristic curves (AUROCs) and calibration plots were produced and stratified sampling was added to adjust for temporal correlation of clinician opinion.

From 905 sampled hours, 448 paired observations were obtained, with the ED deemed crowded 18.5% of the time. The findings from this study support the good discriminatory power of NEDOCS for clinical perception of crowding.

Publications/presentations: https://emj.bmj.com/content/37/12/801

The mortality effect of relative hypotension in people with emergency care needs

Date of award: 2022
Lead applicant: Dr James van Oppen
Summary of project:
The National Early Warning Score (NEWS2) is used throughout the NHS; yet it is known to underestimate mortality risk. Hypotension is recognised as a predictor of deterioration and mortality. However, people with hypertension can have markedly reduced blood pressure from their baseline and yet have apparently ‘normal’ observations and warning scores based on population ranges. This retrospective cohort study focused on ‘relative hypotension’ – the difference between a person’s blood pressure on attendance and at their previous baseline captured from a large data set of electronic health records.

The study demonstrated the feasibility of comparing ED vital signs with recent hospital data for 10% attendees in year 2019 and externally validated a finding of higher 30-day mortality among ED attendees with relative systolic hypotension exceeding 7mmHg from baseline. With additional modelling, the study found that any relative hypotension to be associated with higher mortality. This is believed to be due to these individuals having impaired compensatory physiology, either due to their illness process itself or their premorbid health status. This study demonstrated that NEWS2 underestimates mortality in older people and those living with frailty; comparing current vital signs with baseline data may alert clinicians to individuals at higher risk of poor outcomes.

Publications/presentations: Relative hypotension in emergency care (protocols.io)

An expert Delphi study to derive an ED triage tool for patients aged 65 and over who fall less than 2 metres.

Date of award: 2020
Lead applicant: Dr Sarah Midgley
Summary of project:
Preliminary work for this study indicated that the frailty trauma triage tools developed by different regions do not have acceptable sensitivity and specificity for the older patient who has fallen. The tools that were examined had many triage positive patients who subsequently had very minor injuries, placing a heavy demand on senior medical staff, and resuscitation room space within emergency departments. Equally there were patients with significant injuries who were not identified by current triage tools. The aim of this study was to develop a triage tool that allows early identification of those patients with significant injuries who are likely to require admission for their injuries or who die within the ED. Senior clinicians are experts in assessing which patients require further investigations and this study will harness this knowledge. The skills nursing staff possess in triage were also used to develop this tool.

The data for this study has been collected and analysis to determine whether the new triage tool has improved sensitivity and specificity compared to pre-existing tools is currently ongoing. Given the number of triage criteria identified in the Delphi study the tool is likely to need refinement to further develop it.

The Troponin-only Manchester Acute Coronary Syndromes (T-MACS) Choice Feasibility Study

Date of award: 2019
Lead applicant: Dr Patricia van den Berg
Summary of project:
A recent shift in how we deliver patient-centred care has brought shared decision making (SDM) to new attention. However, relatively little is known about how to apply SDM in the emergency department (ED). The objective of this study was to establish if conducting a full-scale stepped wedge cluster randomised controlled trial evaluating the impact of SDM aided by the decision aid T-MACS Choice is feasible based on a composite of feasibility outcomes including eligible patient per time period of recruitment, recruitment rate, compliance with intervention and retention. A feasibility stepped wedge cluster randomised controlled trial was conducted using opt-out consent in adult patients presenting to the ED with suspected cardiac chest pain.

The two ED’s, representing the two clusters, will begin recruitment as ‘controls’ using standard care protocols based on T-MACS for 2 months. After a 1-month training period, the sites then implement the SDM intervention using T-MACS Choice calculating the probability of a major adverse cardiac event and sharing that with patients through SDM. Feasibility data will be recorded throughout the study through different measures including the T-MACS database and a dedicated opt-out log. Clinical and study outcome data will be collected during the initial ED visit through a post-encounter patient survey measuring control preference and decisional conflict. Participants will be followed up at 30 days, considering their permission, for relevant secondary outcomes. Physician experience will be evaluated in a clinician post encounter survey and a survey following the SDM teaching session in the transition stage. A trial steering committee will decide on feasibility informed by predetermined criteria. If shown to be feasible, we will proceed to apply for funding for a larger, definitive stepped wedge RCT.

Headache in the Emergency Department (HED)

Date of award: 2019
Lead applicant: Dr Thomas Roberts
Summary of project:
Most headache presentations to emergency departments (ED) have benign causes; however, approximately 10% will have serious pathology. International guidelines recommend that patients describing the onset of headache as ‘thunderclap’ undergo neuroimaging and further investigation. The association of this feature with serious headache cause is unclear. The objective of this study was to determine if patients presenting with thunderclap headache are significantly more likely to have serious underlying pathology than patients with more gradual onset and to determine compliance with guidelines for investigation.

This was a planned secondary analysis of an international, multicentre, observational study of adult ED patients presenting with a main complaint of headache. Proportion of patients with serious pathology in thunderclap and non-thunderclap groups were compared by χ² test. Thunderclap headache presenting to the ED appears to be associated with higher risk for serious intracranial pathology, including SAH, although most patients with this type of headache had a benign cause. Neuroimaging rates did not align with international guidelines, suggesting potential need for further work on standardisation.

Estimation of cardiac preload in emergency care using non-invasive monitoring

Date of award: 2019
Lead applicant: Dr Thomas Roberts
The aim of this study was to define the normal response to passive leg raise monitored by thoracic electrical bioimpedance and determine its diagnostic accuracy in predicting fluid responsiveness in emergency care. Passive leg raise (PLR) can be used as a reversible preload challenge to stratify patients according to preload response. This study evaluated the accuracy of PLR, monitored by a non-invasive cardiac output monitor in predicting response to fluid resuscitation in emergency department (ED) using diagnostic accuracy research and exploratory data analysis.

The study recruited adult patients planned to receive a resuscitation fluid bolus. Patients were monitored using a thoracic electrical bioimpedance (TEB) cardiac output monitor (Niccomo, Medis, Germany). A 3-min PLR was carried out before and after fluid infusion. Stroke volume changes (ΔSV) were calculated, and a positive response was defined as ≥ 15% increase. The findings showed that none of the standard parameters showed a better predictive ability compared to PLR, therefore it was concluded that the PLR test was a better predictor of fluid responsiveness than the parameters commonly used in emergency care (such as heart rate and blood pressure). This suggests the potential for a clinical trial in sepsis comparing TEB monitored, PLR directed fluid management with standard care.

Publications/presentations: Elwan et al. Can passive leg raise predict the response to fluid resuscitation in ED? BMC Emergency Medicine (2022) 22:172 https://doi.org/10.1186/s12873-022-00721-6

Ahead 2: Risk of significant traumatic brain injury in adults with minor head injury taking direct oral anticoagulants: a cohort study and updated meta-analysis

Date of award: 2015
Lead applicant: Professor Suzanne Mason
Summary of project:
Patients taking direct oral anticoagulants (DOACs) commonly undergo CT head imaging after minor head injury, regardless of symptoms or signs. However, the risk of intracranial haemorrhage (ICH) in such patients is unclear, and further research has been recommended by the UK National Institute for Health and Care Excellence head injury guideline group.

An observational cohort study was performed in the UK South Yorkshire major trauma centre between 26 June and 3 September 2018. Adult patients taking DOACs with minor head injury were prospectively identified, with case ascertainment supplemented by screening of radiology and ED information technology systems. Clinical and outcome data were subsequently collated from patient records. The primary endpoint was adverse outcome within 30 days, comprising: neurosurgery, ICH or death due to head injury. A previously published meta-analysis was updated with the current results and the findings of other recent studies.

148 patients with minor head injury were included, patients were elderly (median 82 years) and most frequently injured from ground level falls (n=142, 96%). Overall risk of adverse outcome was 3.4%. Five patients had ICH, of whom one died within 30 days. One patient was treated with prothrombin complex concentrate, but no patient received critical care management or underwent neurosurgical intervention. Updated random effects meta-analysis, including the current results and two further recent studies, showed a weighted overall risk of adverse outcome of 3.2% (n=29/787, 95% CI 2.0% to 4.4%). The risk of adverse outcome following mild head injury in patients taking DOACs appears low. These findings would support shared patient-clinician decision making, rather than routine imaging, following minor head injury while taking DOACs.

Publications/presentations: Fuller G, Sabir L, Evans R, et al. Risk of significant traumatic brain injury in adults with minor head injury taking direct oral anticoagulants: a cohort study and updated meta-analysis. Emergency Medicine Journal 2020;37:666-673.

Patient perceptions of provider communication in the minors area of a UK ED: An assessment using the mCAT-T survey

Date of award: 2014
Lead applicant: Dr Blair Graham
Summary of project:
Identifying weaknesses in emergency department communication may highlight areas where quality improvement may be beneficial. This study explored whether the Communication Assessment Tool-Team (CAT-T) survey can identify communication strengths and weaknesses in a UK setting, aiming to determine the frequency of patient responses for each item on the CAT-T survey and to compare the proportion of responses according to patient and operational characteristics.

Adults presenting to the minors area of a semi-urban ED between April and May 2015 were included. Those lacking capacity or in custody were excluded. Multivariate analysis identified associations between responses and demographic/operational characteristics. A total of 407/526 eligible patients responded (77.3%). Items most frequently rated as ‘very good’/’excellent’ (strengths) were ‘ambulance staff treated me with respect’ (86.7%), ED staff ‘let me talk without interruptions’ (85%) and ‘paid attention to me’ (83.7%). Items most frequently rated as ‘poor’/’fair’ (weaknesses) were ‘encouraged me to ask questions’, ‘reception treated me with respect’ (10.4%) and ‘staff showed an interest in my health’ (6.8%). Arrival time, analgesia at triage and time to assessment were associated with significantly increased odds of positive perception of team communication for a range of items. It was concluded that the CAT-T survey may be used within a UK setting to identify discrete strengths and weaknesses in ED team communication.

Publications/presentations: Graham B. Smith JE. Enki D. Strengths and weaknesses in team communication processes in a UK Emergency Department setting: findings using the Communication Assessment Tool- Team. European Journal of Emergency Medicine 2017; 24; 6: e1—e5. (Accepted March 4, 2016).