Day 2 RCEM Annual Scientific Conference: Glasgow 2023. St Emlyn’s

We’re back for day two at the Royal College of Emergency Medicine Annual Scientific Conference. If you want to catch up on day one, you can read about all we learnt here.

Caught up? Good, here comes day two!

David Williams Lecture and Keynote

We started with two talks about home and abroad. First up was Suzanne Mason delivering the David Williams lecture. A hard-hitting half hour about making choices for emergency medicine now to improve things for the future rather than leaving it to chance. We’re the only specialty where patients have unfiltered access at all hours of the day – it’s not sustainable, but what can we do about it?

Sue recommended fully evaluating what it is we do and furthermore how our patients experience this. The four-hour target has been one of the best things to happen in emergency medicine, but it largely benefits lower acuity patients and it’s important to know how it affects those who are on 3hr 59mins and suddenly get moved around. There is work ongoing on defining avoidable attendances as this can have some impact on the care the rest of the department receives too. We also need to be better at accepting that we can’t diagnose everyone.

Next was Si Horne on global health. He had lots of key lessons in this area, and encouraged us to think about how we appreciate and work within the established systems in other countries to make them the best version of that system they can possibly be, rather than trying to change them to something different. You can’t assume that all the hidden mechanics of their system work the same way as yours. In order to do that we need to learn how health systems function – start with your own and go from there! 

Rod Little Prize Papers

A great bunch of talks followed in the Rod Little Prize papers session. Here are the quick fire messages from each one

Cal Doherty presented his qualitative study on emergency care for asylum seekers and refugees. EDs may be the only place they can go, but consultations can be difficult with language and cultural differences impacting on which clinicians they get to see – seniors may feel it takes them away from the shop floor for too long. The structure of the ED is also not conducive to providing the holistic assessment and care they often need. Safe discharge and follow up are key areas to work on.

Natasha Matthews followed on with a great talk on her systematic review of cross-sectional studies from across Europe and the US around emergency department use of migrant patients. Patterns of use varied but overall migrants are not over-represented, and do not have higher utilisation rates. There are significant barriers to primary care access leading to increased self-referral to the ED, potentially meaning they miss out on preventative care. It’s important to try to facilitate access to GP services, potentially reducing the burden on emergency services at the same time.

Tom McKernan reminded us that patients do die, and we need to be better at recognising the ones that are doing so.

Sophie Richter presented her paper on predicting recover after mild TBI using MRI diffusion tensor imaging, however the results are embargoed so sadly that’s all we can really say! What we can say is that it was a great presentation with a narrative style, lovely slides and great sense of humour.

Lastly James van Oppen gave two great talks, firstly on relative hypotension in older people. His feasibility study found it was possible to access old health records in order to establish baseline systolic blood pressures for older patients which may help us to more aggressively treat this if we remember that lower blood pressures in this group increase mortality. In the future this might mean use of AI to create a patient-centred (rather than a population-centred) early warning score.

His second talk looked at whether patient-reported outcome measures for older people could be utilised in the emergency department, and utilised those patients as research partners in order to develop these tool further. This feasibility study showed that these tools can be used well in this setting, and provides a basis for further validity assessment in the future.

Congratulations to James, who won the Rod Little Prize!

Evidence into practice

More research after lunch (at a Scientific Conference? Who’d have guessed? – Ed) as we heard from Ian Pope about the results of the COSTED trial. They approached patients in ED and asked if they smoked, then based on CO levels offered cessation advice, provision of an e-cigarette, and referral to local stop smoking services as an intervention. They found a number needed to treat (NNT) of 9 patient approaches for one to stop smoking at six months. We look forward to reading the full trial results once published.

Next was Heather Jarman with a great refresher on carbon monoxide poisoning – see the St Emlyn’s lesson plan here for some great learning and resources. Her group had looked at patients presenting to ED with the vague symptoms you can get in patients with low-level carbon monoxide poisoning, such as chest pain or headaches, and asked them the COMA screening questions:

• C – co-habitees – is anyone else in the house affected?
• O – outdoors – do your symptoms improve when out of the house?
• M – maintenance – are heating and cooking appliances properly maintained
• A – alarm – do you have a carbon monoxide alarm?

Based on this and COHb levels measured in the department, when there was a clinical suspicion of exposure, they were referred to the gas safety engineers to inspect the house. 137 cases were referred to gas engineers, 1 had a confirmed CO leak, with a further 21 having a probable leak. All of these cases would have been missed going on clinician suspicion alone, and 13 of these patients had a normal COHb.

The key messages here were to keep CO poisoning in your mind when seeing patients with vague symptoms. Ask the COMA questions. Negative COHb levels do not exclude exposure. And of course, finally, get a CO alarm!

You can watch Heather’s talk here as well if you want to see it for yourself.

Last up was our own Dan Horner talking about the upcoming TiLLI trial looking at thromboprophylaxis in lower limb immobilisation. This study will be a pragmatic, open-label, linked pair of RCTs with common outcomes and parallel economic analysis.

TiLLI-High will look at high risk patients (defined as >1% venous thromboembolism risk using either scoring tools or clinician gestalt) and aim to answer whether DOACs are non-inferior to parenteral therapies which are currently licensed for this purpose.

TiLLI-Low will look at low (<1%) risk patients and aim to answer whether intervention (DOAC or parenteral therapy) is superior to no intervention in this group.

Site enrollment is currently ongoing and recruitment should start in May 2024, so this is a great time for your department to get involved in some crucial research to inform how we manage a common problem in our clinical practice.

Evidence into practice – part two

After a quick break we were back with the final research session of the day, starting with Josh Miller talking us through the Major Trauma Triage Study (MATTS). They’ve gone through a three phase process, starting with assessing the trauma triage tools across the country (they’re all different!) in order to try to define what the tool should be, before analysing and amalgamating a selection of these tools to try to calculate an ‘optimal’ trauma triage tool. You can see what that looks like here. They’re currently trialling this in Yorkshire Ambulance Service and we look forward to seeing the results soon, and hopefully progression towards national consistency in this area. 

Next, we had another St Emlyn’s Professor – Rick Body with the results of the PRESTO trial which looks to see if we can combine point of care troponin assays prehospitally with the T-MACS score to rule-out or rule-in type 1 or 2 myocardial infarction in this environment. We’ll definitely have a blog on this once the results have been published, but for now it looks promising that in the near future we might have good enough point of care testing that we can be confident in its use in the prehospital environment. For now though, Rick and team are working with North West Ambulance Service to implement point of care troponin testing in conjunction with a heart attack centre model to take those patients where MI is ‘ruled in’ straight there rather than going via the nearest hospital first. It will be great to follow along with this and see how it affects patient outcomes.

Finally for day 2, Jan Jansen joined us via video link to present the findings of the REBOA-UK trial. We’ve already covered these here at St Emlyn’s so please head over to Zaf’s post for the full breakdown. Spoilers – adding REBOA to standard care increased mortality with high probability.

Well, there we go, a big day full of lots of research and some fantastic presentations from a group of knowledgeable speakers. That’s two days down, one to go.

Join us tomorrow for the final day here at the RCEM Annual Scientific Conference

vb

Chris