Abstract Introduction This study reports the epidemiology and outcomes from out-of-hospital cardiac arrest (OHCA) in England during 2014. Methods Prospective observational study from the national ...OHCA registry. The incidence, demographic and outcomes of patients who were treated for an OHCA between 1st January, 2014 and 31st December 2014 in 10 English ambulance service (EMS) regions, serving a population of almost 54 million, are reported in accordance with Utstein recommendations. Results 28,729 OHCA cases of EMS treated cardiac arrests were reported (53 per 100,000 of resident population). The mean age was 68.6 (SD = 19.6) years and 41.3% were female. Most (83%) occurred in a place of residence, 52.7% were witnessed by either the EMS or a bystander. In non-EMS witnessed cases, 55.2% received bystander CPR whilst public access defibrillation was used rarely (2.3%). Cardiac aetiology was the leading cause of cardiac arrest (60.9%). The initial rhythm was asystole in 42.4% of all cases and was shockable (VF or pVT) in 20.6%. Return of spontaneous circulation at hospital transfer was evident in 25.8% (n = 6302) and survival to hospital discharge was 7.9%. Conclusion Cardiac arrest is an important cause of death in England. With less than one in ten patients surviving, there is scope to improve outcomes. Survival rates were highest amongst those who received bystander CPR and public access defibrillation.
Summary Background Mechanical chest compression devices have the potential to help maintain high-quality cardiopulmonary resuscitation (CPR), but despite their increasing use, little evidence exists ...for their effectiveness. We aimed to study whether the introduction of LUCAS-2 mechanical CPR into front-line emergency response vehicles would improve survival from out-of-hospital cardiac arrest. Methods The pre-hospital randomised assessment of a mechanical compression device in cardiac arrest (PARAMEDIC) trial was a pragmatic, cluster-randomised open-label trial including adults with non-traumatic, out-of-hospital cardiac arrest from four UK Ambulance Services (West Midlands, North East England, Wales, South Central). 91 urban and semi-urban ambulance stations were selected for participation. Clusters were ambulance service vehicles, which were randomly assigned (1:2) to LUCAS-2 or manual CPR. Patients received LUCAS-2 mechanical chest compression or manual chest compressions according to the first trial vehicle to arrive on scene. The primary outcome was survival at 30 days following cardiac arrest and was analysed by intention to treat. Ambulance dispatch staff and those collecting the primary outcome were masked to treatment allocation. Masking of the ambulance staff who delivered the interventions and reported initial response to treatment was not possible. The study is registered with Current Controlled Trials, number ISRCTN08233942. Findings We enrolled 4471 eligible patients (1652 assigned to the LUCAS-2 group, 2819 assigned to the control group) between April 15, 2010 and June 10, 2013. 985 (60%) patients in the LUCAS-2 group received mechanical chest compression, and 11 (<1%) patients in the control group received LUCAS-2. In the intention-to-treat analysis, 30 day survival was similar in the LUCAS-2 group (104 6% of 1652 patients) and in the manual CPR group (193 7% of 2819 patients; adjusted odds ratio OR 0·86, 95% CI 0·64–1·15). No serious adverse events were noted. Seven clinical adverse events were reported in the LUCAS-2 group (three patients with chest bruising, two with chest lacerations, and two with blood in mouth). 15 device incidents occurred during operational use. No adverse or serious adverse events were reported in the manual group. Interpretation We noted no evidence of improvement in 30 day survival with LUCAS-2 compared with manual compressions. On the basis of ours and other recent randomised trials, widespread adoption of mechanical CPR devices for routine use does not improve survival. Funding National Institute for Health Research HTA – 07/37/69.
Unscheduled return visits (URV) to the emergency department (ED) may be an important quality indicator of performance of individual clinicians as well as organisations and systems responsible for the ...delivery of emergency care. The aim of this study was to perform a rapid evidence assessment policy-based literature review of studies that have looked at URVs presenting to the ED. A rapid evidence assessment using SCOPUS and PUBMED was used to identify articles looking at unplanned returns to EDs in adults; those relating to specific complaints or frequent attenders were not included. After exclusions, we identified 26 articles. We found a reported URV rate of between 0.4% and 43.9% with wide variation in the time period defined for a URV, which ranged from 24 h to undefined. Thematic analysis identified four broad subtypes of URVs: related to patient factors, to the illness, to the system or organisation and to the clinician. This review informed the development of national clinical quality indicators for England. URV rates may serve as an important indicator of quality performance within the ED. However, review of the literature shows major inconsistencies in the way URVs are defined and measured. Furthermore, the review has highlighted that there are potentially at least four subcategories of URVs (patient related, illness related, system related and clinician related). Further work is in progress to develop standardised definitions and methodologies that will allow comparable research and allow URVs to be used reliably as a quality indicator for the ED.
Summary Background Little is known about the effectiveness of treatments for acute whiplash injury. We aimed to estimate whether training of staff in emergency departments to provide active ...management consultations was more effective than usual consultations (Step 1) and to estimate whether a physiotherapy package was more effective than one additional physiotherapy advice session in patients with persisting symptoms (Step 2). Methods Step 1 was a pragmatic, cluster randomised trial of 12 NHS Trust hospitals including 15 emergency departments who treated patients with acute whiplash associated disorder of grades I–III. The hospitals were randomised by clusters to either active management or usual care consultations. In Step 2, we used a nested individually randomised trial. Patients were randomly assigned to receive either a package of up to six physiotherapy sessions or a single advice session. Randomisation in Step 2 was stratified by centre. Investigator-masked outcomes were obtained at 4, 8, and 12 months. Masking of clinicians and patients was not possible in all steps of the trial. The primary outcome was the Neck Disability Index (NDI). Analysis was intention to treat, and included an economic evaluation. The study is registered ISRCTN33302125. Findings Recruitment ran from Dec 5, 2005 to Nov 30, 2007. Follow-up was completed on Dec 19, 2008. In Step 1, 12 NHS Trusts were randomised, and 3851 of 6952 eligible patients agreed to participate (1598 patients were assigned to usual care and 2253 patients were assigned to active management). 2704 (70%) of 3851 patients provided data at 12 months. NDI score did not differ between active management and usual care consultations (difference at 12 months 0·5, 95% CI −1·5 to 2·5). In Step 2, 599 patients were randomly assigned to receive either advice (299 patients) or a physiotherapy package (300 patients). 479 (80%) patients provided data at 12 months. The physiotherapy package at 4 months showed a modest benefit compared to advice (NDI difference −3·7, −6·1 to −1·3), but not at 8 or 12 months. Active management consultations and the physiotherapy package were more expensive than usual care and single advice session. No treatment-related serious adverse events or deaths were noted. Interpretation Provision of active management consultation did not show additional benefit. A package of physiotherapy gave a modest acceleration to early recovery of persisting symptoms but was not cost effective from a UK NHS perspective. Usual consultations in emergency departments and a single physiotherapy advice session for persistent symptoms are recommended. Funding NIHR Health Technology Assessment programme.
Climate change presents a global health threat. However, the provision of healthcare, including dialysis, is associated with greenhouse gas emissions. The aim of this study was to determine the ...carbon footprints of the differing modalities and treatment regimes used to deliver maintenance hemodialysis (HD), in order to inform carbon reduction strategies at the level of both individual treatments and HD programs. This was a component analysis study adhering to PAS2050. Emissions factors were applied to data that were collected for building energy use, travel and procurement. Thrice weekly in‐center HD has a carbon footprint of 3.8 ton CO2 Eq per patient per year. The majority of emissions arise within the medical equipment (37%), energy use (21%), and patient travel (20%) sectors. The carbon footprint of providing home HD varies with the regime. For standard machines: 4 times weekly (4 days, 4.5 hours), 4.3 ton CO2 Eq; 5 times weekly (5 days, 4 hours), 5.1 ton CO2 Eq; short daily (6 days, 2 hours), 5.2 ton CO2 Eq; nocturnal (3 nightly, 7 hours), 3.9 ton CO2 Eq; and nocturnal (6 nightly, 7 hours), 7.2 ton CO2 Eq. For NxStage equipment: short daily (5.5 days, 3 hours), 1.8 t CO2 Eq; 6 nightly nocturnal (2.1 ton CO2 Eq). The carbon footprint of HD is influenced more by the frequency of treatments than by their duration. The anticipated rise in the prevalence of home HD patients, dialyzing more frequently and for longer than in‐center patients, will increase the emissions associated with HD programs (despite reductions in patient travel emissions). Emerging technologies, such as NxStage, might offer a solution to this problem.
Emergency departments (EDs) in many developed countries are experiencing increasing pressure due to rising numbers of patient presentations and emergency admissions. Reported increases range up to 7% ...annually. Together with limited inpatient bed capacity, this contributes to prolonged lengths of stay in the ED; disrupting timely access to urgent care, posing a threat to patient safety. The aim of this review is to summarise the findings of studies that have investigated the extent of and the reasons for increasing emergency presentations. To do this, a systematic review and synthesis of published and unpublished reports describing trends and underlying drivers associated with the increase in ED presentations in developed countries was conducted. Most published studies provided evidence of increasing ED attendances within developed countries. A series of inter-related factors have been proposed to explain the increase in emergency demand. These include changes in demography and in the organisation and delivery of healthcare services, as well as improved health awareness and community expectations arising from health promotion campaigns. The factors associated with increasing ED presentations are complex and inter-related and include rising community expectations regarding access to emergency care in acute hospitals. A systematic investigation of the demographic, socioeconomic and health-related factors highlighted by this review is recommended. This would facilitate untangling the dynamics of the increase in emergency demand.
Abstract Objective The purpose of this study was to systematically review the literature evaluating the reliability and validity of all available methods for measuring active and passive cervical ...range of motion (CROM). Methods Electronic databases (PubMed, MEDLINE, CINAHL, EMBASE, and AMED) were searched through OVID from their inception to January 2008. Articles were selected according to a priori defined criteria. Data were extracted regarding publication details, type of study, movements and device evaluated, subject and observer characteristics, and measurement protocol including blinding and statistical analysis methods. Quality assessment was undertaken using developed criteria to assess internal validity, external validity, and statistical methods. An estimate of the level of reliability and validity was calculated and used to categorize studies as good, moderate, or poor. Results A total of 56 articles fulfilled the selection criteria and were included in the review. Forty-six of these articles described 66 reliability studies and 21 described 21 concurrent criterion validity studies. Twelve different methods were evaluated. Although it was the intention of this review to conduct meta-analysis, this was deemed inappropriate due to studies being too heterogeneous. Most of the reliability and validity studies involved asymptomatic subjects measured by allied health professionals investigating active ROM. Devices that were deemed to have “good” reliability and validity were the CROM device, the Spin-T goniometer, and the single inclinometer. Conclusions A considerable number of reliability and concurrent validity studies have been published for CROM. The CROM device has undergone most evaluation and has been shown to be clinimetrically sound. Further research with significantly improved methodology and reporting is warranted for all devices.
Background. Increased ambulance utilisation is closely linked with Emergency Department (ED) attendances. Pressures on hospital systems are widely acknowledged with ED overcrowding reported regularly ...in the media and peer-reviewed literature. Strains on ambulance services are less well-documented or studied. Aims. To review the literature to determine the trends in utilisation of emergency ambulances throughout the developed world and to discuss the major underlying drivers perceived as contributing to this increase. Method. A search of online databases, search engines, peer-reviewed journals and audit reports was undertaken. Findings. Ambulance utilisation has increased in many developed countries over the past 20 years. Annual growth rates throughout Australia and the United Kingdom are similar. Population ageing, changes in social support, accessibility and pricing, and increasing community health awareness have been proposed as associated factors. As the extent of their contribution has not yet been established these factors were reviewed. Conclusion. The continued rise in utilisation of emergency ambulances is placing increasing demands on ambulance services and the wider health system, potentially compromising access, quality, safety and outcomes.A variety of factorsmay contribute to this increase and targeted strategies to reduce utilisation will require an accurate identification of the major drivers of demand.
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