Author: Govind Oliver / Codes: SLO10 / Published: 28/08/2018

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Research within Emergency Medicine (EM) is growing exponentially with a breadth as varied as the patients who present through our front doors. With increasing recognition of the importance that research has, both in terms of patient care and outcomes but also the benefits on performance of having a research active department, more and more research teams are being established. Numerous large and small trials of varying designs are being run in Emergency Departments across the globe and research within the EM community is now leading the field in areas such as trauma and decision rules.

Here we present the top scoring abstracts as presented at EUSEM 2018. Many of the key areas identified as top research priorities in the RCEM and James Lind Alliance research priority setting partnership are represented amongst these top 6-scoring abstract.

How can we improve outcomes in out of hospital cardiac arrest?

Quality of bystander-performed chest compressions and prehospital advanced life support differently affect the outcomes of out-of-hospital cardiac arrests receiving bystander cardiopulmonary resuscitation: a propensity-matched observational study. By Kurosaki Hisanori et al. (BACH, Department of Circulatory Emergency and Resuscitation Science, Kanazawa University Graduate School of Medicine)

All Advanced Life Support (ALS) Providers will be familiar with the chain of survival concept, which highlights the importance of good-quality bystander cardiopulmonary resuscitation (CPR), followed by ALS. This study looked at the impact of the quality of bystander chest compressions and ALS provision by Emergency Medical Service (EMS) paramedics on prolonged return of spontaneous circulation (ROSC) (> 20 minutes), one month survival and neurologically favourable (cerebral performance category of 1 or 2) one-year survival.

The data comes from a large prospective observational study, conducted over four years (2012-2016) in the Ishikawa Prefecture, Japan. Two responding EMS personnel graded bystander chest compression quality as either adequate or inadequate. They assessed the bystander chest compressions from their observation on scene against the standard ALS recommendations of depth, rate and position. 3,004 cases met their inclusion criteria and were analysed using propensity matching and stepwise multiple regression analysis.

Analysis showed that prehospital ALS but not the quality of bystander chest compressions was associated with sustained ROSC (adjusted OR 1.60, 95%CI 1.28-1.99). Neither prehospital ALS nor the quality of bystander chest compressions affected one-month survival. The quality of bystander chest compressions was associated with a higher chance of neurologically favourable one-year survival (adjusted OR 3.33, 95%CI 1.31-14.9). No statistical correlation between the presence of both bystander chest compression quality and prehospital ALS on any outcome measure was identified.

The authors emphasise the importance of the quality of bystander chest compressions in the community on neurologically favourable one-year survival. This is a topical area in the UK with on-going discussion around whether or not CPR should be taught in schools. The findings of this study support the continued activity of organisations encouraging and teaching CPR in the community.

Our take home message

This large prospective cohort study supports the importance of the quality of bystander chest compression quality in improving neurologically favourable outcomes in survivors.

Contact Kurosaki about this work: [email protected]

How can we improve mental health care the ED?

Pathways of care for adult mental health emergency department attendances – Analysis of routine data. By Suzanne Ablard et al. (Research Associate, Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), The University of Sheffield)

Many of us will have experienced the frustration of trying to deliver care to mental health patients within an Emergency Department (ED) environment and with recourses suboptimal to their needs. Optimising the care of mental health patients in the ED is a shared concern amongst Emergency Physicians and was voted number 3 in the top 10 James Lind Alliance and RCEM research priority setting partnership. The authors highlight the limitations of the current evidence in this area and sought to characterise when, why and how mental health patients use the ED in order to better target interventions.

They performed a large multi-site retrospective analysis of routine NHS patient level data for adult attendances across 18 EDs in Yorkshire and Humber in 2014. They categorised mental health attendances into 1) Psychiatric, 2) Overdose/ Self-harm and 3) Anxiety and analysed these alongside non-mental health patients against age, mode and time of arrival, number of investigations and treatments and length of stay.

They found that 3.1% (n=39,594) of over 1.3 million ED attendances were mental health related. The majority of these were self-harm/overdose (56%) followed by psychiatric (32%) and anxiety (12%). Unsurprisingly, mental health patients are more likely to arrive by ambulance (OR 3.25, 95% CI 3.18-3.32), more likely to arrive out-of-hours (OR 1.95, 95% CI 1.90-1.99) and are more likely to leave ED before treatment or to refuse it (OR 2.94, 95% CI 2.85-304). Once in the ED they have a significantly longer length of stay (Median 178 mins vs. 139 mins, p>0.001). Their data on investigations and treatment or advice highlight that a high proportion of mental health patients, particularly in the psychiatric sub-group, do not receive investigations (72.7%) or any advice or treatment (51.2%).

The authors highlight from their evidence the burden these patients place on the Emergency Care Services. They stress the need for better training and referral pathways and alternative mental health services in the community, particularly during the out-of-hours period. The need for change has likely only increased with mounting pressures over recent years and we look forward to further work in this area.

Suzanne’s take home message

“Mental health patients are placing a small but significant demand on emergency care services, particularly in the out of hour’s period.  There is also evidence they are receiving poorer levels of care than other patients in the ED. While a proportion of these attendances will be necessary, for example in instances of genuine emergency such as drug overdoses, high rates of ambulance transportation for conditions such as anxiety identified in our study may be less urgent and amenable to a pre-hospital intervention to reduce an ED attendance.”

Contact Suzanne about this work: [email protected]

Can risk stratification using prognostic biomarkers help to reduce mortality in the crowded ED?

Use of the prognostic biomarker soluble urokinase plasminogen activator receptor in the emergency department does not affect mortality, a cluster-randomised clinical trial. By Martin Shultz et al. (PhD student, Department of cardiology, Herlev Hospital, University of Copenhagen)

Delays and crowding are issues that deeply affect and concern Emergency Physicians. Ways to reduce the harms of crowding and to eliminate exit block was voted the number 1 priority in the top 10 James Lind Alliance and RCEM research priority setting partnership. Building on evidence supporting the role of biomarkers in risk stratification, this trial (TRIAGE III) looked at soluble urokinase plasminogen activator receptor (SuPAR), a membrane bound receptor for urokinase that correlates to immune system activity. They investigated its prognostic ability using a primary endpoint of 10-month all cause mortality after admission and a secondary outcome of 30-day mortality.

The TRIAGE III design was a cluster-randomised interventional trial conducted in EDs across the capital region of Denmark. A consecutive cohort of 16,801 acutely admitted patients were enrolled. The intervention and control group consisted of 6 3-week cluster periods each with 8,900 and 7,901 patients respectively; the intervention consisted of suPAR measurement on arrival.

Their analysis showed a prognostic ability of suPAR for 30-day and 10-month mortality corresponding to an area under the curve of 0.83 (95% CI 0.81 to 0.84) and 0.80 (95% CI 0.79 to 0.82) respectively. Although mathematically this shows reasonable accuracy, it falls far below the accuracy sought after in medical diagnostics (usually 0.95 or higher). Mortality was equal in each arm: 13.9% in the intervention group and 14.3% in the control group, with a hazard ratio of 0.97 (95% CI, 0.89-1.07).

The evidence from this study does not support the use of the prognostic biomarker suPAR to risk stratify patients in the crowded ED, with no significant difference in mortality being found. This is an exciting area of research within Emergency Medicine and we look forward to more work on ways to improve care in the crowded ED.

Martin’s take home message

Accurate and efficient tools for prioritization of patients are pivotal in emergency care. We conducted a conceptual trial of whether biomarker-strengthened early risk stratification on unselected patients would improve the outcome, which was not the case. Prognostic biomarkers may still have potential in emergency medicine, and future research should focus on biomarker-based interventions in selected conditions.

Contact Martin about this work: E-mail: [email protected]

These three abstract represent how varied the research in Emergency Medicine is. They are just the tip of the iceberg of work being done to help our patients and improve our care. We congratulate all the authors on their top scoring abstracts and wish them the very best of luck in their continuing work. Let’s hope we see more from them in the near future!