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Background: Guidelines for sepsis recommend treating those at highest risk within 1 hour. The emergency care system can only achieve this if sepsis is recognised and prioritised. Ambulance services can use prehospital early warning scores alongside paramedic diagnostic impression to prioritise patients for treatment or early assessment in the emergency department., Objectives: To determine the accuracy, impact and cost-effectiveness of using early warning scores alongside paramedic diagnostic impression to identify sepsis requiring urgent treatment., Design: Retrospective diagnostic cohort study and decision-analytic modelling of operational consequences and cost-effectiveness., Setting: Two ambulance services and four acute hospitals in England., Participants: Adults transported to hospital by emergency ambulance, excluding episodes with injury, mental health problems, cardiac arrest, direct transfer to specialist services, or no vital signs recorded., Interventions: Twenty-one early warning scores used alongside paramedic diagnostic impression, categorised as sepsis, infection, non-specific presentation, or other specific presentation., Main Outcome Measures: Proportion of cases prioritised at the four hospitals; diagnostic accuracy for the sepsis-3 definition of sepsis and receiving urgent treatment (primary reference standard); daily number of cases with and without sepsis prioritised at a large and a small hospital; the minimum treatment effect associated with prioritisation at which each strategy would be cost-effective, compared to no prioritisation, assuming willingness to pay £20,000 per quality-adjusted life-year gained., Results: Data from 95,022 episodes involving 71,204 patients across four hospitals showed that most early warning scores operating at their pre-specified thresholds would prioritise more than 10% of cases when applied to non-specific attendances or all attendances. Data from 12,870 episodes at one hospital identified 348 (2.7%) with the primary reference standard. The National Early Warning Score, version 2 (NEWS2), had the highest area under the receiver operating characteristic curve when applied only to patients with a paramedic diagnostic impression of sepsis or infection (0.756, 95% confidence interval 0.729 to 0.783) or sepsis alone (0.655, 95% confidence interval 0.63 to 0.68). None of the strategies provided high sensitivity (> 0.8) with acceptable positive predictive value (> 0.15). NEWS2 provided combinations of sensitivity and specificity that were similar or superior to all other early warning scores. Applying NEWS2 to paramedic diagnostic impression of sepsis or infection with thresholds of > 4, > 6 and > 8 respectively provided sensitivities and positive predictive values (95% confidence interval) of 0.522 (0.469 to 0.574) and 0.216 (0.189 to 0.245), 0.447 (0.395 to 0.499) and 0.274 (0.239 to 0.313), and 0.314 (0.268 to 0.365) and 0.333 (confidence interval 0.284 to 0.386). The mortality relative risk reduction from prioritisation at which each strategy would be cost-effective exceeded 0.975 for all strategies analysed., Limitations: We estimated accuracy using a sample of older patients at one hospital. Reliable evidence was not available to estimate the effectiveness of prioritisation in the decision-analytic modelling., Conclusions: No strategy is ideal but using NEWS2, in patients with a paramedic diagnostic impression of infection or sepsis could identify one-third to half of sepsis cases without prioritising unmanageable numbers. No other score provided clearly superior accuracy to NEWS2. Research is needed to develop better definition, diagnosis and treatments for sepsis., Study Registration: This study is registered as Research Registry (reference: researchregistry5268)., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/136/10) and is published in full in Health Technology Assessment ; Vol. 28, No. 16. See the NIHR Funding and Awards website for further award information.

Background: We explored the urgent care axis across EDs in Yorkshire and Humber (Y&H) for patients aged ≥75 years to identify where interventions could be targeted to prevent ED attendances and inpatient admissions., Methods: Hospital Episode Statistics (HES) data for attendances across 18 EDs in Y&H from April 2011 to March 2014 were retrospectively analysed. HES A&E and Admitted Patient Care patient records data were linked to describe the entire patient pathway. The population studied was adult patients attending type 1 EDs, comparing those ≥75 years with those under 75. Data analysed included arrival mode, presentation time, time in ED, outcome (admitted/discharged), admission length of stay, International Classification of Diseases 10th Revision (ICD-10) and cause codes related to admission. Short-stay admissions and admissions with potentially avoidable conditions (identified by ICD-10 codes and cause codes) were identified. Comparative analysis was undertaken between sites., Results: There were 3 736 541 ED attendances, of which 625 772 (16.7%) were ≥75 years. Older patients were significantly more likely to attend via ambulance than the younger cohort (OR 7.7, 95% CI 7.6 to 7.7), and had significantly longer median stays within ED (195 vs 136 min, p<0.001) and increased likelihood of admission (OR 4.5, 95% CI 4.5 to 4.6). Short-stay admissions accounted for 28.3% of older adult admissions. 37.3% of older adult admissions were with conditions that were potentially avoidable, accounting for 42.3% of short-stay admissions. There was regional variation in the proportions of older adults admitted (between 34.3% and 40.9%)., Discussion: Large numbers of older adults present to EDs mainly by ambulance. Significant proportions are admitted for short periods with conditions that might potentially be managed outside of hospital. Variation across the region warrants further study., Competing Interests: Competing interests: The authors report grants from NIHR, inside and outside the submitted work., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Globally, the rate of emergency hospital admissions is increasing. However, little evidence exists to inform the development of interventions to reduce unplanned Emergency Department (ED) attendances and hospital admissions. The objective of this evidence synthesis was to review the evidence for interventions, conducted during the patient's journey through the ED or acute care setting, to manage people with an exacerbation of a medical condition to reduce unplanned emergency hospital attendance and admissions., Methods: A rapid evidence synthesis, using a systematic literature search, was undertaken in the electronic data bases of MEDLINE, EMBASE, CINAHL, the Cochrane Library and Web of Science, for the years 2000-2014. Evidence included in this review was restricted to Randomised Controlled Trials (RCTs) and observational studies (with a control arm) reported in peer-reviewed journals. Studies evaluating interventions for patients with an acute exacerbation of a medical condition in the ED or acute care setting which reported at least one outcome related to ED attendance or unplanned admission were included., Results: Thirty papers met our inclusion criteria: 19 intervention studies (14 RCTs) and 11 controlled observational studies. Sixteen studies were set in the ED and 14 were conducted in an acute setting. Two studies (one RCT), set in the ED were effective in reducing ED attendance and hospital admission. Both of these interventions were initiated in the ED and included a post-discharge community component. Paradoxically 3 ED initiated interventions showed an increase in ED re-attendance. Six studies (1 RCT) set in acute care settings were effective in reducing: hospital admission, ED re-attendance or re-admission (two in an observation ward, one in an ED assessment unit and three in which the intervention was conducted within 72 h of admission)., Conclusions: There is no clear evidence that specific interventions along the patient journey from ED arrival to 72 h after admission benefit ED re-attendance or readmission. Interventions targeted at high-risk patients, particularly the elderly, may reduce ED utilization and warrant future research. Some interventions showing effectiveness in reducing unplanned ED attendances and admissions are delivered by appropriately trained personnel in an environment that allows sufficient time to assess and manage patients.

Introduction: Making an effective telephone referral is an important skill for an emergency department (ED) clinician. It is essential for patient safety that the information is conveyed in a succinct manner to the correct inpatient specialty. The aim of this study was to assess: the impact of grade of staff making the referral; specialty referred to; and condition or patient problem. It also aimed to identify current problems or barriers in the referral process., Methods: This prospective study took place in one large teaching hospital in the UK. There were two parts: data collection to obtain information on each referral made by ED staff; and questionnaires administered to obtain opinions on the current referral process from both staff making and receiving the referrals., Results: Data were collected over 6 days and included 362 referrals. The mean evaluation of the referral process (scored 0-4) for all referrals was 3.34 (SD 0.95). 22 ED staff responding (64.7%) felt that some specialties were more difficult to refer to than others. 60.6% of non-ED staff accepting referrals felt they would like some form of senior ED screening process prior to referral compared with 20.6% of ED staff. The most common topics commented on were communication, education and process., Discussion: There are differences in understanding and opinion between ED and non-ED staff about the referral process. There are also factors which influence ease of referral: specialty referring to and patient problem. More intervention studies are required to identify solutions that can be implemented and sustained in routine practice., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

A questionnaire was designed to measure junior doctors' experience of performing practical procedures and was distributed to all junior doctors working in our emergency department during June 2005 and June 2006. The junior doctors were subjectively less experienced in all the procedures measured in 2006 compared to 2005. There were statistically significant reductions in experience of shoulder manipulation, suturing and wound exploration. Junior doctors are becoming less experienced in performing some practical procedures.

Objectives: To assess the confidence of junior doctors in managing minor injuries, compared with other common acute conditions., Method: A questionnaire designed to elicit areas of confidence and subjective competence was distributed to junior doctors working in the emergency department in December 2004., Results: Junior doctors felt most competent and confident working with medical trolley patients and least competent working with patients with minor injury. A lack of teaching and experience in handling minor injuries (which are seen by nurse practitioners in a separate unit during the day) was highlighted., Conclusions: Nurse-led minor injury units may have an effect on junior doctors' experience and confidence in minor injury care. Further effort needs to be made to increase the training of junior doctors in minor injury care.

We describe an unusual sports injury in a young man, a combination of obturator hip dislocation with an ipsilateral anterior cruciate ligament injury. Traumatic non-prosthetic hip dislocations, particularly obturator hip dislocations, are extremely rare sports injuries and have not previously been reported in conjunction with a knee ligament injury. The severe pain and obvious deformity from the hip injury can distract from other injuries, particularly to the ipsilateral knee. This case reinforces the need for a thorough assessment of the knee joint, before hip reduction if possible and certainly after reduction of the dislocation.