Long-term cardiovascular risk prediction in the emergency department: a mixed-methods study protocol

INTRODUCTION

Cardiovascular disease (CVD) remains one of the leading causes of preventable death in Europe, therefore any opportunity to intervene and improve care should be maximised. Known CVD risk factors are routinely collected in the emergency department (ED), yet they are often not acted on. If the risk factors have prognostic value and a pathway can be created, then this would provide more holistic care for patients and reduce health system inefficiency.

METHODS AND ANALYSIS

In this mixed-methods study, we will use quantitative methods to investigate the prognostic characteristics of routinely collected data for long-term CVD outcomes, and qualitative methods to investigate how to use and implement this knowledge. The quantitative arm will use a database of approximately 21 000 chest pain patient episodes with a mean follow-up of 7.3 years. We will use Cox regression to evaluate the prognostic characteristics of routinely collected ED data for long-term CVD outcomes. We will also use a series of semi-structured interviews to co-design a prototype care pathway with stakeholders via thematic analysis. To enable the development of prototypes, themes will be structured into a logic model consisting of situation, inputs, outputs and mechanism.

ETHICS AND DISSEMINATION

This work has been approved by Research Ethics Committee (Wales REC7) and the Human Research Authority under reference 19/WA/0312 and 19/WA/0311. It has also been approved by the Confidentiality Advisory Group reference 19/CAG/0209. Dissent recorded in the NHS' opt-out scheme will be applied to the dataset by NHS Digital. This work will be disseminated through peer-review publication, conference presentation and a public dissemination strategy.

TRIAL REGISTRATION NUMBER

ISRCTN41008456.

PROTOCOL VERSION

V.1.0-7 June 2021.

833 Using the GEMLR as a proxy for global health engagement of emergency care practitioners

Aims/Objectives/Background

There is broad involvement of emergency medicine (EM) practitioners in global EM (GEM) research. However this work is often siloed, reducing efficiency of collaboration and impeding healthy critical appraisal. The purpose of this novel longitudinal study is to identify the GEM research undertaken by those in EM. Quantifying, displaying and understanding the ‘who’, ‘what’ and ‘where’ of such research is a key step to facilitate collaboration and highlight important gaps to ultimately drive quality in GEM research as a whole.

Methods/Design

The Global Emergency Medicine Literature Review (GEMLR) is an annual summary of the top-ranked GEM literature. A spreadsheet of all papers identified by each initial search (before ranking) is freely available. We searched the past six years of GEMLR’s 3,634 initial titles to identify authors with EM affiliations. We also collected data on author institutions, country focus, topic, funding sources and if co-authorship included local collaborators.

Results/Conclusions

From 2014–2019 the GEMLR found over 800 individual papers with at least one EM affiliated author. Authors were from over 600 different institutions (see figure 1) and research focused on over 100 countries.

Abstract 833 Figure 1

Author spread

Approximately 60% had no funding/documented and 5% papers did not include a local author.

There are limitations, including the GEMLR search strategy and EM practitioners omitting their EM affiliations (a take home message, if we wish to strengthen EM’s perceived research presence). However this study serves as a robust start-point to map GEM research engagement. Interestingly, the study demonstrates a modest UK author slice with 20 being identified, contributing to 12 papers over 6 years.

Further analysis will target the sociodemographic association between the most/least researched countries, expanding to include further years of data. Using a data visualisation strategy we will make the work accessible online to provide leverage in areas of much-needed GEM research growth.

809 Survey of current and former academic clinical fellows in emergency medicine in the UK

Aims/Objectives/Background

Academic emergency medicine (EM) is a young field in the United Kingdom (UK) with a small critical mass of clinical academics, who have protected time to conduct research alongside clinical duties. There is a little published information on the academic training available to emergency physicians.

In the UK, academic clinical fellowships (ACFs) offer a structured opportunity for trainees to develop skills and experience in research alongside clinical training. We aimed to capture information on the prior experience of emergency medicine (EM) fellows, as well as how the ACFs were structured and the next career steps for fellows upon completion.

Methods/Design

A ten-question survey was designed by the project steering committee and circulated UK wide to all current fellows in EM and those that completed the programme in the last five years. Fellows were identified by contacting programme leads in every region. Data was collected via SurveyMonkey® between 18thFebruary 2021 and 25th March 2021.

Results

We approached a total of 34 EM ACFs. The survey yielded a 91% (n=31) response rate (13 current, 18 completed within 5 years). One university from Wales and ten from England have supported EM ACF schemes. 59% (n=10) of those who have completed the scheme had their clinical training extended to accommodate research time. In the remainder, fellows were expected to achieve clinical competencies in the same time as trainees who did not spend time on research. In those who had completed the ACF programme (n=18), one third of respondents are doing PhD training (n=6) and one is an academic clinical lecturer.

Conclusion

We found variation in how the schemes are implemented. Future research is required to explore the experiences of those undertaking EM ACFs in more detail to identify the features of successful ACF training schemes, and whether any aspects may benefit from standardisation.

Advanced cardiovascular risk prediction in the emergency department: updating a clinical prediction model - a large database study protocol

BACKGROUND

Patients presenting with chest pain represent a large proportion of attendances to emergency departments. In these patients clinicians often consider the diagnosis of acute myocardial infarction (AMI), the timely recognition and treatment of which is clinically important. Clinical prediction models (CPMs) have been used to enhance early diagnosis of AMI. The Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid is currently in clinical use across Greater Manchester. CPMs have been shown to deteriorate over time through calibration drift. We aim to assess potential calibration drift with T-MACS and compare methods for updating the model.

METHODS

We will use routinely collected electronic data from patients who were treated using TMACS at two large NHS hospitals. This is estimated to include approximately 14,000 patient episodes spanning June 2016 to October 2020. The primary outcome of acute myocardial infarction will be sourced from NHS Digital's admitted patient care dataset. We will assess the calibration drift of the existing model and the benefit of updating the CPM by model recalibration, model extension and dynamic updating. These models will be validated by bootstrapping and one step ahead prequential testing. We will evaluate predictive performance using calibrations plots and c-statistics. We will also examine the reclassification of predicted probability with the updated TMACS model.

DISCUSSION

CPMs are widely used in modern medicine, but are vulnerable to deteriorating calibration over time. Ongoing refinement using routinely collected electronic data will inevitably be more efficient than deriving and validating new models. In this analysis we will seek to exemplify methods for updating CPMs to protect the initial investment of time and effort. If successful, the updating methods could be used to continually refine the algorithm used within TMACS, maintaining or even improving predictive performance over time.

TRIAL REGISTRATION

ISRCTN number: ISRCTN41008456.

117 COVID-19 RCEM research summaries: taking the burden off busy clinicians

Aims/Objectives/Background

Entering lockdown on 23rd March 2020 due to the COVID-19 pandemic marked an unprecedented period for healthcare evidence. An exponential increase in published work, pre-prints, guidelines, online information portals and more, has been overwhelming especially when combined with the ever-changing local emergency department responses to COVID-19. Many research projects were either suspended in favour of clinical work or re-routed into pandemic-oriented studies. All the while, the gap between clinical providers and a mountain of information was growing. Our team developed a strategy to deliver the most pertinent evidence to those working in emergency medicine, taking some stress out this aspect of COVID-19 working.

Methods/Design

Each week a search was conducted using PubMed of everything produced in the previous 7 days. The number of titles varied from approximately 800 to 2500. A 3 to 5 person team distilled titles and then reviewed abstracts for papers of importance and relevance to emergency medicine. Relevant and high impact journals were individually searched over the same time period. Summaries of the short-listed papers were produced and the weekly editorial team selected 5 for inclusion in the weekly RCEM Top 5 and others were combined for extra reading as part of a 2–3 weekly ‘Director’s Cut’.

Results/Conclusions

The RCEM Top 5 (at time of writing) has been run for 13 weeks. The summaries themselves were accessed by between 3000 and 6000 RCEM members/fellows each week. The work has also fed into online journal clubs and blogs (combined views of over 30,000) and has attracted interest from wider colleagues nationally and internationally to both join and even replicate the approach to other relevant areas. The positive feedback is best summarised in the following quote: ‘when I’m too mentally overcooked to do any reading on my own this helps me feel I am doing some keeping up. Please continue!’

131 Rapid and sustained increase in #FOAMed based education during COVID-19 on the St Emlyn’s blog and podcast

Aims/Objectives/Background

COVID 19 has resulted in a rapid and unplanned change in the way that education is delivered and consumed. The St Emlyn’s team published a range of webinars, blogs, podcasts and critical appraisal articles specifically focused on COVID-19 during the pandemic. Some webinar content was published in conjunction with the Royal College of Emergency Medicine and the University of Manchester.

We reviewed how engagement with the free and open access medical education (FOAMed) St Emlyn’s blog and podcast changed as a result of the pandemic

Methods/Design

We compared the number of visits for the last 12 months against the previous 12 months. We obtained data from Wordpress and Podbean platforms for the blog and podcast respectively. We did not add data from other social media platforms such as Twitter and Facebook. Differences are expressed as a ratio to indicate an increase or decrease in the number of engagements from the previous year.

Abstract 131 Figure 1

Results/Conclusions

The data shows similar levels of between year activity from July 2018 through to February 2019. It then shows a rapid and profound increase in activity from March 2019, coinciding with the rapid spread of the pandemic in Europe and an early blog/podcast with colleagues from Northern Italy. Since then activity has fallen but still remains roughly 1.5 times higher than in previous years. Combined visits to the blog and podcast peaked at 162,019 engagements, representing a near 6.9 fold increase in podcast engagement and a 2.7 increase in blog activity during May 2019.

The COVID-19 pandemic resulted in a rapid and sustained engagement with the St Emlyn’s platform. The reasons for this are unclear from the data presented here, but we believe reflect the superior agility of modern educational tools such as blogs and podcasts to share and disseminate information as compared to traditional academic publishing methods.

Prevalence of cigarette smoking in the Rafsanjan urban population

This study determined the smoking rate in the urban population of Rafsanjan, Islamic Republic of Iran, in a random community sample of 491 adults (247 males and 244 females) aged > 20 years. The overall prevalence of current smoking (1+ cigarettes per day) was 24.2%; 38.5% in males and 9.8% in females. The mean number of cigarettes consumed per day was 12.1 [standard deviation (SD 8.6)]; 13.6 (SD 8.9) in men and 6.5 (SD 4.5) in women. The prevalence and mean number of cigarettes smoked per day increased significantly in older age groups.