NICE Guidance... April 2012

... the Government handbook of everything Medical, ever

A few general points CG (TA, IP etc) Change in format Need for IT No Quick Reference guides Key priorities Mention of protocols

In the ED Breadth of work in EM 11 in 2010, 10 in 2011 Confidential Enquiries etc Who sits on the committee? How do we keep up with these? What do we do already? Can we use these for pressure?

Sentinel Guidance Chest Pain / NSTEMI Alcohol Anaphylaxis VTE Meningococcal disease Transient Loss of Consciousness Epilepsy Sedating children Delirium COPD

Chest Pain & NSTEMI* CG94 / 95 Risk assessment M vs F >3 risk factors Risk >10% offer CT Calcium score >30% functional imaging >61% angio Do not use ETT for stable angina ?What factors make angina unlikely? (4)

Alcohol CG 100/115 Withdrawal Assessment with symptom-triggered score (CIWA) Benzodiazepine (carbemazepine) Early hepatology review Alcohol support services Wernicke’s - high dose thiamine iv ?What AUDIT score triggers intervention? (1)

Anaphylaxis CG 134 Mast Cell Triptase <16 yo - test if due to drugs, venom or unknown cause Observe for 6-12 hrs Offer Adrenaline sc TTO Referral to allergy services Education / patient information ?What is the timing of Mast Cell Triptase? (1)

VTE CG 92 WRT ED: Should be giving prophylaxis if Decreased mobility for >3/7 Decreased mobility and risk factors Avoid dehydration & mobilise early ?What are the risk factors for VTE? (4)

Meningococcal Disease CG 102 Shock / non-specifically unwell Rash CT? - decreased GCS or focal signs ?What antibiotics are recommended in hospital? (1)

TLOC CG 109 How to do Emergency Medicine Red flags ECG abnormality (all ages) Failure Exertional history Family history of SCD <40 SoB Murmur Advice - driving, work ?What indicates vasovagal syncope? (4)

Epilepsy CG 137 First fit Protocols to ensure proper assessment Developmental assessment in children ?What are pseudosezures called? (1)

Sedation in Children CG 112 Training / competencies Levels of sedation Deep sedation Fasting CO2, BP, ECG

Delirium CG 103 Confusion Assessment Method Hypo- vs hyperactive delirium Cognition, Perception, Physical & social Interventions Drugs - research needed ?What are the risk factors for delirium? (4)

COPD CG 101 Admit or discharge? pH <7.35 PO2=8 LTOT Rapid onset Moderate SoB Physical activity Sats <90%, PO2 <7 Confusion / decreased GCS Cyanosis, oedema

Minor Guidance Constipation in children Increasing organ donation Infection control Hyperglycaemia in ACS Urology Hip Fracture Service experience for adults Mental health Physical health

Constipation in Children CG99 Red Flags - From birth No meconium “ribbon” stools >1yo Leg weakness Abdominal distension / vomiting Green flags Change in feed Poor diet Thriving Slow onset Normal meconium

Organ Donation CG135 Consider as part of normal End-of-Life care MDT responsible; Consultant, SNOD, Religious leader Training DCD vs BCD & principles of diagnosis Triggers Law & ethics Physiological optimisation

Infection Control CG 139 WASH YOUR HANDS Training for cannulation etc Catheters - indications for antibiotics Known infection post change Traumatic procedure

Hyperglycaemia in ACS CG 130 Maintain BM <11 Do not use iv Insulin routinely

Lower Urinary Tract Symptoms in Men CG 97 Acute retention - catheterise immediately Offer alpha-blocker prior to removing catheter

Neck of Femur Fracture CG 124 Identify & treat correctable co- morbidities immediately Analgesia for all MRI if xRay negative

Service User Experience Adults (CG 138) One of Nice Quality Standards 14 Quality Statements Adult Mental Health (CG 136) Health and social care providers should support direct self-referral to mental health services as an alternative to accessing urgent assessment via the emergency department.

Conclusion Huge number applicable Timescales? Proof? Implementation