St Emlyn’s are on tour once again, this time we’re up in Glasgow (or sat in Manchester watching virtually and getting serious FOMO) for the Royal College of Emergency Medicine Annual Scientific Conference! Glasgow is a fantastic city and always very welcoming. We’re excited to be here and even more excited to share with you our learning over the next three days. Without further ado, here is what went on, on day one!
After a welcome from the organising committee and a representative of the Lord Provost of Glasgow, we got down to business.
Welcome and Keynotes
RCEM President Adrian Boyle kicked off with his review of the year. He highlighted some of the work that has been done by college to get the message across to the government that EM needs to be a priority moving forward. Patients die due to admission delays, and work on an urgent and emergency care recovery plan (pdf) hopes to improve this by continuation of the four hour standard (but at 76%) and focus on ambulance handover delays. They have also worked hard to stop demand management campaigns, and reduce inequality – elderly and mental health patients wait longer for treatment in our EDs.
The long term workforce plan has recently been published with welcome increases to medical student and GP places, but no change in the shortfall of ACCS trainees which RCEM estimates at 120 per year. There’s lots to do to provide the UK with enough EM staff to deliver safe and sustainable care, and it is with this in mind that the college released their general election manifesto yesterday with an unequivocal message to all political parties to #ResuscitateEmergencyCare. Have a read and watch this here.
But what’s next? Adrian is keen to move towards site-specific reporting of targets to ensure focus across the board without an ability to blur the numbers from Type 1 EDs by averaging their figures with co-located Type 3 urgent care services. He also recognises a need to increase the workforce whilst improving retention. It’s going to be a tough winter combined with industrial action, but the College is mindful of the need to continue to push EM as a priority.
A change of tack next with Ellen Weber on research – it has evolved and is still evolving, and EM is a key player. We need to look at integrating the best available evidence with clinical care and patient values, but also work out where we need to go next. In collaboration with the James Lind Alliance, the emergency medicine research priorities have been refreshed this year and fit with some of the themes from Adrian’s talk in improving care for elderly and mental health patients amongst other things. If you’re looking to contribute to the research sphere, think carefully about how what you want to do will improve patient outcomes!
To finish the session, Tim Coats reminded us that in emergency situations, as long as the treating clinician has been trained in consenting patients for a particular study, and follows the study protocol, they can randomise without consent, with completion of the written consent process undertaken later by the research team. It can make us feel better to have a piece of paper with a signature on before we go ahead and enrol a patient into a trial, but in an emergency situation, do we really spend all of the time needed to make that signature part of a truly informed consent process?
Evidence into practice
More research next for Dan, who attended the evidence into practice section. The first speaker was Edd Carlton from Bristol talking about the use of lidocaine patches for isolated chest trauma in an emergency department setting. Was this the right kind of sticking plaster? A good premise, but one in need of further study, not just on effectiveness but on the deliverability of such complex research. Edd presented the first rung on this ladder reporting on delivery of a randomised feasibility study in patients >/=65 with radiologically confirmed isolated rib fractures.
The early message – recruitment looked feasible, with the trial enrolling 100 participants over an 18-month period at 6 sites across the UK. Median age, Rockwood score and STUMBL score were 83, 4 and 21 respectively. A broad and representative cohort. Very few patients declined participation and adherence to the trial was approximately 80%, although there was also a 33% crossover rate in the control arm. Some interesting clinical perspectives, such as the majority of fractures being diagnosed by CT, (>90%) a pulmonary complication rate of around 50% and a stark reminder of outcome for this pathology, with a median LOS 9 days and 35% of patients not discharged to their own home. Do patches work? Sorry, we can’t tell you that from a feasibility study. However, this study suggests further research is feasible, that patches may work, and that they may be well tolerated.
Next up Rachel McLatchie, a previous local TERN Fellow (respect), key member of the emerge research team and investigator for the DASHED study into acute aortic syndrome (AAS). A real challenge for emergency medicine. DASHED was an observational cohort study (allowing prospective and retrospective recruitment) looking to describe the characteristics of ED attendances with suspected AD, the performance of several clinical decision rules to determine need for definitive imaging, and the results of imaging. Participants were approached by 27 emergency departments in the UK and all patients were followed up for 30 days.
The investigators recruited an impressive 5548 people with a potential diagnosis of AAS based on presenting complaint, just under 50% recruited retrospectively. Median age was 54 and median time from symptoms to presentation was 12h. Classic red flags, both in the history and on examination, were present in <5% patients. Of these 5548, only 407 underwent CTA and only 12 patients had a positive CTA result for AAS. An additional 2 cases were diagnosed prior to attendance, making 14 cases overall. Median time from attendance to diagnosis was 6h. The investigators looked at clinical decision rules, with the conclusion that none of them had adequate performance data to support routine clinical use. Some helpful news though – 10% of scans revealed a significant alternative diagnosis such as PE or Pneumonia. There was also some positive news for our Gestalt (hurrah), with the Canadian clinical practice guideline (which includes gestalt) performing well and 12 of the 14 cases of AAS rated as ‘AAS possible’ or ‘Uncertain’ by clinical teams. What next? Not sure. The ASES study (evidence synthesis) is moving forwards led by UK emergency medicine, so that should provide a helpful overview of the evidence, and evidence gaps, in this area.
Last up, Prof Gray from Edinburgh as well, giving us a whistlestop tour of the ABC Sepsis feasibility study. Current guidance suggests 30ml/kg of balanced crystalloid solutions as part of the widely touted but increasingly eyebrow raising ‘sepsis six’. Time for colloids to fight back? Certainly the evidence for fluid therapy in the resuscitation phase is very weak and there is potential biological plausibility for smaller doses of volume expanders (although it should be noted that many experts dispute this potential).
Can we realistically deliver a trial on this topic, given the increasing baggage and uncertainty that comes with use of the word sepsis in our resuscitation rooms? Yes we can.
ABC sepsis recruited 300 patients across 15 hospitals during a study period of 12 months, randomising adults with a NEWS2 >5 and potential infection to receive either bolus fluid therapy with 5% albumin or standard care (crystalloid solution). Over 20% of participants screened were successfully recruited, which is good for a complex resuscitation trial. Very few patients declined to participate when approached and more than 98% of patients received antibiotics prior to randomisation. During the first 6 hours, clear separation was seen between the treatment arms regarding the volume of fluid given. This reached about 10ml/kg in the albumin group compared to 20ml/kg in the crystalloid arm. Separation persisted to 24h. 10% required vasoactive support, 4% required ventilation and mortality approached 20%, in keeping with a sick patient cohort. However, only 13% of this overall population were admitted to critical care;
How do we interpret these results? This feasibility study proves we can deliver this type of research and there was clear separation in fluid volume received between groups. However, there was no signal towards benefit from HAS regarding clinical outcomes or mortality. Would a larger trial be fundable? Would it be supported by the clinical community? Would it make a difference? Lots of questions for the investigator team, highlighted in a manuscript sitting in peer review at present. Fingers crossed for acceptance and more discussion on this interesting topic, even if the result is not for further action and to take albumin off the table for good.
Wellbeing and education
While Dan was getting his research on, Simon was over in the wellbeing and education stream, kicking off with a talk from Chelcie Jewitt on sexism in healthcare. Chelcie talked about sexism in medicine (it happens), and more importantly about what can be done about it. This is a bit of a hobby horse of mine, Basically we have lots of data that problems exist with regard to a range of protected characteristics and more, but we don’t always get to hear suggestions as to what to do about it. For those who remember the suffragettes – remember that we need deeds not words, but what are the deeds that we can do to reduce discrimination in the workplace?
Hopefully you’ve read the sexual assault in surgery report, if not you should. It would also be very naïve to think that it does not happen in other specialties such as EM. See @ScrubSurvivors for more links and info. What would be great is to see this issue recognised as a core issue and maybe a toolkit/best practice guideline to help people/departments take action.
Mo Al-Haddad talked about the incredible value that IMGs add to our workforce. They certainly support the NHS, but do we support them as well as we could? It’s a tough journey to migrate to the UK due to issues relating to language, culture, medical education/training and belonging. I was also introduced to a new word ‘acculturation’ around the experience of connecting (or not) with the new society. Those of us who have worked with IMGs will know a little of this, but there are certainly things we can do better in terms of induction and support for just the normal activities that we take for granted (e.g. housing). Mo talked through a number of interventions championing peer and institutional support, especially in the first few weeks and months of their stay here. Bottom line is that there are many things that do work to support these clinicians, starting before they arrive in the UK, with a real recognition that it’s not just about the medicine, but also about developing spaces for IMGs to develop social networks too (Stevan will be covering similar themes in his keynote on Thursday).
I love listening to Heidi Edmundson as she always speaks fantastically about the practicalities of improving the lived experience of EM staff. Notably, we all get called to meetings about performance, how often is the same focus placed on staff survey/wellbeing results – often never.
Heidi talked about some of the biases that get in the way of innovation. Survivorship bias means that those of us still here see the world in a particular way and we should change to champion innovation, even if we initially don’t think it’s that awesome. We also see wellbeing as an infinite game or wicked problem that can lead to nihilism, but that’s no way forward either. So we need a cultural change to promote the experience of our staff through innovation, effort and in keeping an open mind. If you’re a senior clinician, give the team a bit of time, space and resource to do something different. You never know, it might just work, until it does not, and then do something else.
Sara Robinson talked on peer support, which is something we think is really important in EM. Few people really understand what we do, except our peers and they/we are a resource that we can use in a positive way. I’m not a huge fan of the word burnout as it often seems to blame the individual, but as Sara pointed out these are issues that are a function of the working environment (which is why we like to use the phrase acute/chronic work stress). The peer support project acts as psychological first aid for those in immediate distress back into normal working practice, or to pass on to more in-depth psychological support. It basically involves a confidential process whereby peer support can be requested and given with acute care services. Interestingly it expanded during COVID, for obvious reasons. This sounds like a practical and achievable project that could be widely shared and adopted. There is a 2-day training course so peer supporters should understand and be confident in their actions, but it’s not formal counselling and there are boundaries about what they can and cannot do (but there are additional support exit points available).There are now over 200 peer supporters in Sara’s trust. Wow!
Afternoon sessions now and over in the free papers session Chris got to watch a few quick fire presentations with some interesting outcomes.
First off, antibiotic timing in patients with sepsis might not be as urgent as we think. A systematic review by Colin Graham looking at 42 papers with 191,000 patients presented a huge challenge with various definitions of sepsis and time zero, prospective/retrospective studies and ED vs ICU. They found overall significant improvement in mortality with administration of antibiotics at 3 and 6 hours, but not at 1 hour. Patients without shock only benefitted by 6 hours. Data adjusted for confounders showed improvement throughout these times. Unadjusted data showed no improvement at all.
Next – can salbutamol provide analgesia in patients with renal colic. Short answer: no. Kudos to Graham Johnson for reporting on a negative study.
Susie Roy recruited participants through email and Twitter for a qualitative study and thematic analysis on the impact of crowding on emergency medicine training. Three themes emerged
- Risk – to patients, also professionally with extended management of patients that would normally take place on the wards now happening in the ED
- Pressure – and frustration of not being able to manage patients well
- Work – more work/risk for no more reward
It is important to remember the impact that the difficulties we face in the ED at the moment can have not only on our trainees’ work lives, but also their home lives too.
Finally in this session, a topic well embraced in Virchester – blood borne virus testing in the ED from Emma Young. It’s a great place to do it – everyone comes to the ED, and there is a higher HIV prevalence in EDs (0.6%) vs sexual health services (0.1%). In the last year around 900,000 HIV tests have been performed in EDs across the UK, leading to 341 new diagnoses and 208 previously diagnosed patients reintegrated back into the system. A great step towards the NHS goal of zero new transmissions by 2030.
In the lightning papers session it was good to see a system for teaching HALO procedures which fits with the St Emlyn’s approach. Basically the value of regular lo-fi training to keep skills up and getting it out to a much larger number of people. Basic analysis of satisfaction was positive (as you would expect), but I think there is some face validity here and trainees went on to perform procedures for real following training. Great work from Daniel Day and Jennifer Wood. More on HALO from St Emlyn’s here.
Owen Hibberd described his systematic review of the risks of fat embolism associated with IO infusions. We must admit that I had never really given this any thought in the past, and yet we’ve put many, many IO catheters! FES occurs 12-36 hours after emboli and can contribute to multi organ failure. The available data is in animal (pig) models, and they found fat emboli in 186/224 animals. However, few studies looked at longer term outcomes (such as MODS) and it’s tricky to extrapolate. The take home is that fat embolism probably occurs, but we don’t know whether it is significant (yet).
Big paediatric EM research updates from across the UK in collaboration with the PERUKI team.. Many of these results are in pre-print at the moment so we can’t share them here but what we can say is there are a lot of papers coming to your inbox/letterbox soon and even more trials ongoing or on the horizon.
Ones to watch out for include:
- FIDO – the febrile infant diagnostic observation study – which kids do we need to test, what tests do we need to do, who do we need to watch and who can we think about sending home?
- Child Trauma Recovery – qualitative study on offering psychological support based on CBT principles to children after moderate to severe trauma
- MAGPIE – penthrox for children with moderate to severe injuries
- CRESCENT – pH manipulation with carbogen (CO2/O2 mix) vs oxygen for seizure termination
- CRAFFT – manipulation under sedation/anaesthesia vs backslab only in children with distal radius fractures – will they remodel without treatment?
- TWIST – immobilisation vs no treatment for toddler’s fractures
Similar to adults with the James Lind Alliance, there is an update to the paediatric emergency medicine research priorities in collaboration with PERUKI coming out soon, so keep an eye out for this too!
Well, that’s it for today, a great start to another wonderful conference and we hope you’ve enjoyed reading about what we’ve learnt today and followed the links to read more about everything that’s gone on.
Join us again tomorrow for day 2!