Influencing Emergency Healthcare Policy and Practice
Submitting InstitutionsUniversity of Warwick,
Liverpool School of Tropical Medicine
Unit of AssessmentPublic Health, Health Services and Primary Care
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Clinical Sciences, Public Health and Health Services
Summary of the impact
The emergency care team at Warwick Medical School has a strong track
record of high-quality health sciences research encompassing evidence
synthesis, health-services research and clinical trials. Our trials of a
03b2-agonist (salbutamol) in acute respiratory distress syndrome (ARDS)
have influenced therapeutic recommendations in the International Sepsis
Guidelines (2013), reducing the use of this potentially detrimental
therapy. Our cardiac arrest research informed the 2010 international
guidelines on cardiopulmonary resuscitation (CPR) led to the generation of
new intellectual property, and prompted industrial collaborations to build
new technologies, such as TrueCPRTM (2013). These have led to
improved CPR practice and improved patient survival. Furthermore, our
research has led to major policy changes and to a redesign of UK emergency
healthcare, improving cost efficiency, the patient experience and clinical
outcomes (e.g. 95% of patients were treated within 4 hours - up from 65%;
and people leaving without been seen reduced to less than 5%).
Intravenous salbutamol in acute respiratory distress syndrome
Severe sepsis can lead to the life-threatening condition ARDS. Our phase
II trial in patients with ARDS (03b2-agonist lung injury trial [BALTI-1])
found an apparent benefit from the 03b22-adrenergic receptor
agonist salbutamol and led to an increase in its use internationally
[BALTI-1 was principally conducted elsewhere]. Our subsequent phase III
multi-centre, double-blind, randomised controlled trial of intravenous
salbutamol in ARDS (a Warwick study) ran from December 2006 to March 2010
(Gates, Perkins, Gao, Lamb). 1 It was stopped early after
treatment with salbutamol was, found to be poorly tolerated by patients
and associated with increased organ failure and mortality (RR 1·47, 95% CI
1·03-2·08), leading to calls to discontinue the routine use of
03b2-agonists in this condition.
Improving the effectiveness of cardiopulmonary resuscitation (CPR)
Cardiac arrest is the final common event prior to death in a wide range of
emergency conditions. To improve patient survival, our team evaluated
strategies to improve the effectiveness of CPR. We did an in-depth
analysis, which found that the quality of CPR was suboptimal during
in-hospital CPR due to compression of the underlying mattress during chest
compression (Perkins, Benny, Tweed, 2001 and 2004). We found that
recalibration of a device that provides CPR pressure feedback could
overcome this problem (Perkins, 2005). Our subsequent systematic review
found that such devices could improve CPR quality in a number of settings
(Perkins, Yeung, Gao, 2009 and 2010). 2 Furthermore, we
identified that a commonly used accelerometer based feedback device failed
to differentiate between chest and mattress compression (Perkins, 2009),
which led to its redesign, and improvement.
CPR education has a key role in transferring the results of research into
clinical practice. Our research has played a central role in the
development of the Advanced Life Support Course, which is taught to over
20,000 healthcare professionals each year in the UK, Europe and Australia.
We developed and evaluated the formal examinations for this course
(Perkins, Stallard 2007; Napier, Perkins 2009) and conducted a multicentre
randomised trial to evaluate a novel e-learning programme (Perkins,
Kimani, Stallard 2012). 3 We found that the quality of learning
was maintained, while reducing the cost of delivering the course from £585
to £275 per person.
Development of new clinical guidelines for ambulance services
Warwick is the academic centre for the Joint Royal College Ambulance
Liaison Committee undertaking the literature reviews, statistical
modelling, consensus work and drafting of the clinical guidelines for
ambulance services that form the basis of clinical practice for all
paramedics in the UK (Cooke, Fisher 2001-2013). Warwick is currently
undergoing the rigorous National Institute for Health and Social Care
Excellence (NICE) accreditation process for these guidelines.
UK emergency care policy
Our research has had a major influence on emergency care policy over many
years. Specific projects have addressed the causes behind delays in care
and the means for reducing delays, such as the introduction of observation
wards (Cooke, 2004) 4, and fast-tracking of individuals with
minor injuries (Cooke, 2002). We have also demonstrated more efficient and
clinically effective utilisation of new roles for clinicians. For example,
1) the development and introduction of emergency care practitioners
(Adams, 2005) 5 and Advanced Clinical Practitioners (Cooke, in
progress, 2013 but already being across all Accident and Emergency
Departments (AEDs) across the West Midlands in 2014 in a project led by
Cooke & Swann), and 2) how improved facilities such as walk-in centres
can change emergency patient flow (Cooke, 2007) by reducing AED
attendances in specific circumstances and by reducing the patients
transported to AED by ambulance.6 In an evaluation of these
changes, we found a reduction in the number of patients who leave AEDs
without being seen (Cooke, 2012) and changes in the causes of reattendance
related to initial quality of care and improved access to community
services for follow up care.7
University of Warwick Medical School staff:
Professor Matthew Cooke (Professor of Emergency Medicine,
2000-present), Professor Gavin Perkins (Professor of Critical Care
Medicine, 2007-present), Dr Mike Tweed (Senior Lecturer in Medical
Education, 2000-2003), Professor Jeremy Dale (Professor of Primary
Care, 1997- present), Professor Fang Gao (Professor of
Anaesthesia, Critical Care and Pain, 2009-2011), Dr Joyce Yeung
(PhD Student, 2008-2011), Professor Sallie Lamb (Professor of
Rehabilitation and Director of Warwick Clinical Trials Unit,
2003-present), Professor Simon Gates (Professor of Clinical
Trials, May 2005-present), Dr Chetan Trivedy (Academic Clinical
Lecturer in Emergency Medicine, 2012-present) Professor Nigel Stallard
(Professor of Medical Statistics, 2005-present), Dr Ann Adams
(Principal Research Fellow & Director Research Degrees, 2000-present).
References to the research
1. Smith FG, et al. Effect of intravenous 03b2-2 agonist
treatment on clinical outcomes in acute respiratory distress syndrome
(BALTI-2): a multicentre randomised controlled trial. Lancet 2012;
379:229-35. doi:10.1016/S0140-6736 (11) 61623-1. (REF2 UoA2
2. Yeung J, et al. The use of CPR feedback/prompt devices during
training and CPR performance: A systematic review. Resuscitation
2009; 80:743-51. doi:10.1016/j.resuscitation.2009.04.012
3. Perkins GD, et al. Improving the efficiency of advanced life
support training: a randomized, controlled trial. Ann. Intern. Med.
2012; 157:19-28. doi:10.7326/0003-4819-157-1-201207030- 00005. (REF2
4. Cooke, et al. Reducing attendances and waits in emergency
departments: a systematic review of present innovations. [National
Co-ordinating Centre for NHS Service Delivery and Organisation R & D]
5. Adams A, et al. Evaluation of the NHS Changing Workforce
Programme's Emergency Care Practitioners Pilot Study in Warwickshire.
University of Warwick. 2005.
7. Trivedy CR, Cooke MW. Unscheduled return visits (URV) in adults to the
emergency department (ED): a rapid evidence assessment policy review.
Emerg Med J. 2013 Oct 28. doi: 10.1136/emermed-2013-202719. [Epub ahead of
• National Institute for Health Research Service Delivery and
Organisation (SDO292002). Reducing attendance and waits in A&E
departments: A review and survey of present innovations. Cooke (PI),
• NHS Modernisation Agency International emergency department overload
study. Cooke (PI), £30,000 [2003-04].
• Department of Health Policy Research Programme. Cooke (Co-app)
Evaluation of walk-in centres phase 2 £151,264 [2004-05].
• Department of Health. National Survey of Secondary Emergency Care. Cooke
(PI) Principal Applicant, £8,322 .
• National Ambulance Paramedic guidelines, Cooke (PI) JRCALC
• Intensive Care Foundation, Beta Agonist Lung Injury Trial - Gold Medal
Award. Perkins/Gao (PI), £50,000. Co-sponsors: Heart of England
NHS Foundation Trust and University of Warwick. .
• National Institute for Health Research Clinician Scientist Award
(DHCS/06/06/101). Perkins (PI), £683,211. Sponsor: University of
• Canadian Health Services Research Foundation. Waiting with an
emergency. Cooke (Co-app) Can$1.4m [2007-13].
• Resuscitation Council (UK). E-learning evaluation. Perkins (PI),
£ 250,000. Co-sponsors: Heart of England NHS Foundation Trust and
University of Warwick. [2008-10].
• National Institute for Health Research, 03b2-Agonist Lung Injury Trial
Prevention. Perkins (PI), £121,446. Co-sponsors: Heart of England
NHS Foundation Trust and University of Warwick. [2008-11].
• Medical Research Council (G0700478). 03b2-Agonist Lung Injury Trial. Lamb/Gao
(co-PIs), £1,985,025. Co-sponsors: Heart of England NHS Foundation
Trust and University of Warwick. [2008-12].
• Resuscitation Council (UK) PhD Fellowship. Perkins (PI),
£80,000. Sponsor: University of Warwick. [2009-12].
Details of the impact
Our research has informed guidelines that address the very early phase of
emergency care plus the policy and organisation of that care.
Reduced use of 03b2-agonists in patients with ARDS.
A UK survey of practice in 2010 (Scally JICS 2010:11, 36-39) reported that
`all ITUs regularly prescribed 03b2-agonists for their patients'. A
Canadian study (2001-2003) found that at least a quarter of patients with
acute lung injury (ALI) received high dose 03b2-agonists. Following the
announcement of our results from the BALTI study in December 2011, the
Lancet journal editorial concluded `For now, the results of the
truncated BALTI-2 trial are sufficient to change practice. 03b2-2
agonist treatment in patients with ARDS should be limited to the
treatment of clinically important reversible airway obstruction and
should not be part of routine care'. a The impact of our
study on reducing drug use was demonstrated in an international
point-prevalence survey, performed in 2012, which showed that 03b2-agonist
use in patients with ARDS had fallen to 7.9% in the UK and 13.9% in China.
This study concluded that, based on our extrapolation of study results,
389 potential deaths per year could be avoided in the UK alone by ceasing
usage of 03b22-agonists for ARDS.b The impact of our research
has been further extended through personal communication with the
International Surviving Sepsis Guideline group who have now published
guidelines, which `recommend against the routine use of beta agonists in
ARDS' (Feb 2013). c These guidelines have been endorsed by 30
organisations, translated into six different languages and are widely
implemented around the world.
Improvements to CPR feedback devices. Perkins led the
International Liaison Committee for Resuscitation (ILCOR) review of CPR
feedback devices (sensor devices that optimize the quality of CPR). The
resulting international recommendations, which were published by ILCOR and
adopted by the American Heart Association, European, Asian, South Africa,
and Australian Resuscitation Councils, drew substantially on the
systematic review and primary research undertaken at Warwickd,
Implementation of CPR feedback devices into clinical practice has been
associated with improved CPR performance and increased survival (adjusted
odds ratio of 2.72 (95% CI 1.15 to 6.41). e Our finding that
accelerometer-based CPR feedback devices were inaccurate when used on a
patient lying on a bed were described as having `an enduring impact on
the fundamental understanding of current CPR technology".e
and led to the development (with a Medical Technology Company -
PhysioControl) of the new technology TrueCPRTM, which uses
magnetic fields to overcome the limitations we identified with
accelerometers. TrueCPRTM has been granted CE (Conformité
Européenne) mark approval from the EU and approval from the US Food and
Drug Administration (USFDA). It is now available for sale in most
countries.f Since learning about our findings, Laerdal Medical
(Norway) has started developing a smart backboard to overcome the
limitations we identified in our research.
Improvements to training in CPR. Our research on training
and assessment methods for CPR has led to direct changes to the
competency-based performance tests used within the Advanced Life Support
(ALS) and have been implemented in the UK, Europe and Australia,
facilitated by Perkins' leadership of the UK Resuscitation Council ALS
Working Group. Our development work on e-learning showed that it was
possible to replace face-to-face training with e-learning material, thus
reducing the cost of delivering the course without compromising learning
quality. This led to the launch of a new course, which draws heavily on
the e-learning material developed by our research.g The new
course has been delivered to more than 10,000 doctors and nurses in the UK
and reduced costs by approximately £3 million in the first 18 months.
Improvements to guidelines for emergency care. Our
systematic review of emergency care, underpins the Joint Royal College
Ambulance Liaison Committee Clinical Guidelines, published in 2013h,
for which Matthew Cooke acted as the academic director. These guidelines
are used by all NHS ambulance staff (approx. 5000 paramedics) and have
been adopted in United Arab Emirates. The Royal National Lifeboat
Institute reversed a national policy decision to limit the duration of
search and rescue operations to 20 minutes when our evidence showed that
survival was possible beyond that time (2011). The new evidence from our
systematic review and scoping exercise on falls prevention informed the
decision, in 2013, to revise the NICE guidelines for falls prevention by
demonstrating the new evidence and the variability in practice.i
Our research from the team at Warwick has influenced the evolution of new
roles in emergency care, such as emergency care practitioners (Adams,
2005) and Advanced Clinical Practitioners (Cooke, in progress, 2013) and
an expansion of the workforce by using non-doctors. Our evaluation of the
National Emergency Care Practitioner (ECP) Programme demonstrated the
safety and clinical effectiveness of this new role led to the
dissemination of ECP programmes throughout the UK, with the majority of
ambulance services adopting such roles. This programme is widely linked to
improved efficiencies such as reduced ambulance transport to the emergency
department reducing cost and improving efficiency.
Changes to national policy on A&E departments. As
National Clinical Director Urgent and Emergency Care, Cooke led the
development of new National Quality Indicators for A&E 2010j
based on his Warwick research. Many of the results were utilised before
publication because of Professor Cooke's national role. Reviews of
patients who leave AEDs without being seen (Clarey & Cooke, 2012) and
reattend (Trivedy, 2013) informed the development of two of the eight
national indicators (i.e. per cent reattending A&E and per cent
leaving without being seen). National guidance on reducing waits was
informed by a systematic review of effective approaches to wait- time
reduction (Cooke et al, 2004), by research on the use of observation wards
(Sibly, 2007) and by understanding the types of patients who suffer long
delays (Downing, 2004). Work conducted with Bristol University, on walk-in
centres (Chalder et al, 2007; Salisbury et al, 2007) has changed policy
whereby walk-in centres are no longer considered to be effective in
diverting care. The changes implemented on the basis of this research have
led to a substantial reduction in waiting times: Department of Health
statistics show number of patients seen within four hours increasing from
60% in 2002 to 95% in 2013. Others have demonstrated the link between the
waiting time and mortality. Cooke's work (2002) provided guidance and
support for the implementation of fast- track systems in A&E and is
now standard practicek, Multiple studies have showed that this
system can reduce waits for those with minor injuries by 50%. l
Sources to corroborate the impact
a. Thompson BT. 03b2-agonists for ARDS: the dark side of adrenergic
stimulation? Lancet 2012; 379:196-8.
b. Howes, M. I. et al. The Use of Beta 2 Agonists for the
Treatment of Acute Respiratory Distress Syndrome. J. Int. Care Soc. 2013;
c. Surviving Sepsis International Guidelines (2012)
d. Mancini M. E. et al 2010 International Consensus on
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
With Treatment Recommendations. Circulation 2010; 122:S539-S581.
e. Bobrow BJ.J. et al. The influence of scenario-based training
and real-time audio-visual feedback on out-of-hospital cardiopulmonary
resuscitation quality and survival from out-of- hospital cardiac arrest.
Ann Emerg Med. 2013; 62:47-56.e1.
f. Supporting Statement: Vice President, Physio-Control, Inc.
g. Resuscitation Council (UK): e-learning programme
h. UK ambulance services clinical practice guidelines. Eds Fisher, Brown,
Cooke: London 2013
i. Lamb, S. et al. Report to the National Co-ordinating Centre
for NHS Service Delivery and Organisation R&D (NCCSDO), 2008
(http://bit.ly/1igK2rz). Supporting Statement from NICE
Communications Executive (Identifier 2).
j. Dept. of Health Checklists to help achieve four hour A&E target.
k. Supporting Statement: Deputy Director Acute Episodes of Care,
NHS England (formerly Policy Lead, Urgent & Emergency Care, Department
of Health, Whitehall). (Identifier 3).
l. Total time spent in A&E. Dept of Health Statistics archive.