Graham Johnson

Background: Breaking bad news is a core component of emergency care, but the emergency department (ED) environment of urgency, crowding, and limited privacy presents challenges for sensitive communication. Many communication frameworks originate from other specialities, but the ED has limited evidence and guidance tailored to its context. Objective: This scoping review aimed to map the extent, nature, and characteristics of the literature on delivery of bad news in EDs, including terminology, frameworks, stakeholder perspectives, barriers and facilitators, educational resources, reported metrics, and evidence gaps. Methods: The review followed Joanna Briggs Institute (JBI) methodology and was prospectively registered on the Open Science Framework (OSF https://osf.io/f6q59/overview ). Four databases (MEDLINE, EMBASE, EMCARE, CINAHL) and grey literature sources were searched in July 2025. Eligible sources included empirical studies, training evaluations, reviews, guidelines, consensus statements, editorials, commentaries, opinion pieces, educational articles, conference abstracts, and relevant grey literature reporting on adult patients, relatives, or clinicians in ED contexts. Data were charted and synthesised narratively. Results: From 7985 records, 156 publications were included. Studies originated from 26 countries, though the United States of America (USA) (n = 85) and United Kingdom (UK) (n = 18) dominated the literature. There was a rise in publications from 2010, particularly post–COVID-19. Twenty-five communication frameworks were identified; most were adapted from oncology (with SPIKES most frequently cited). Three frameworks developed specifically for ED practice (GRIEV_ING, 8S, EMTalk) were identified. Stakeholder perspectives were unevenly represented, with a predominance of healthcare professional perspectives. Reported metrics centred on clinician confidence; patient- and family-centred studies were uncommon. Barriers to effective communication consistently included time scarcity, lack of privacy, and insufficient training. Conclusions: Research on delivering bad news in EDs is dominated by educational and simulation-based studies, and is largely clinician-centred, with limited evidence of patient and family perspectives, with no studies examining long-term outcomes. Reliance on frameworks from other specialties risks overlooking the contextual specifics of emergency care. Future research should prioritise ED-centred frameworks, patient outcomes, and systemic enablers to support compassionate, effective communication in this demanding environment.

Objective: To explore drivers of high frequency emergency department (ED) use by children and young people, particularly among those attending EDs most often. Design: A population-based retrospective cohort study using routinely collected linked healthcare data. Setting: EDs in the Yorkshire and Humber region of the UK. Patients: 288 545 children and young people aged 17 and under making at least one ED attendance in the year period 1 April 2016 to 31 March 2017. Main outcome measures: ED attendances made by individuals in the year period. Results: Of the 288 545 distinct children and young people making at least one attendance to an ED, 27 560 (9.6%) were defined as high frequency ED attenders (making 3+attendances in the year) and accounted for 105 063 (25%) ED attendances in the study period. When considering factors associated with ED attendance rates, younger age groups and greater levels of deprivation were found to be associated with higher rates of attendance. This association was amplified in those attending the ED most often. Ethnicity was found to be associated with ED attendance rates, with those reported as mixed and other ethnicities displaying greater rates of attendance than those reported as white and those reported as black ethnicity displaying lower attendance rates in comparison to those reported as white. The interaction between an individual’s deprivation and ethnic status generally displayed lower rates of attendance in ethnic minorities belonging to the most deprived category. Conclusions: When seeking to reduce frequent ED attendance by children and young people this study highlights the need for any approach to be multifaceted, nuanced to age or condition specifics and consider social determinants that drive ED use in more deprived areas.

Introduction: Approximately 600,000 people die every year in the United Kingdom including 24,000 who die in the Emergency Department (ED). The National Audit of Care at the End of Life looks at the care of dying people during their last hospital admission. However, patients who die in the ED are excluded from this audit and therefore little is currently known about this population. Purpose: This service evaluation aimed to describe the population who died in a 12-month period in five NHS EDs, including whether palliative care teams were involved. Patients and methods:: Records from all eligible patients in the 12 months from 1^st June 2022 were reviewed. Anonymised data from each site was collated and compared. Results: There were 704,303 ED patient presentations across the 5 sites, and 852 deaths. The mean age of death was 74.04 with a slight male preponderance of 56.8%. Between sites there was a wide range (0.4%-25%) of involvement from palliative care with these patients whilst in ED. The overwhelming majority had a medical (rather than surgical or traumatic) cause of death. Conclusion: Research is needed in order to ascertain how care can be improved for this group of patients. More UK-centric work is required to understand the characteristics of patients who die in EDs including their cause of death and ethnicity, as well as an exploration of whether greater palliative care collaboration in ED improves patient, family and staff experience.

Objective: To quantify patterns of emergency department (ED) use over two consecutive 12-month periods among children aged 15 and under, and to assess heterogeneity of reasons for attendance in high-frequency users. Design: Population-based retrospective cohort study of routinely collected ED data. Setting: EDs in the Yorkshire and Humber region, UK, from 31 March 2014 to 1 April 2017. Patients: Children aged 15 and under with ≥1 ED attendance. Main outcome measures: Proportion with ≥7 attendances over 2 years and heterogeneity of diagnostic reasons quantified by the Herfindahl index. Results: The cohort included 71 143 individuals. Although only 13.6% were high-frequency attenders in the first year, over half (55.1%) of these made at least one attendance in the second year. A subset (14.1%) remained high-frequency attenders across both years and were more likely to belong to the most deprived deprivation category. Children aged 8–12 were more likely to attend for injury-related issues and showed lower heterogeneity in reasons for attendance, while infants under age 1 had more illness-related attendances and greater heterogeneity. Conclusions: A notable proportion of children and young people frequently attend EDs over a 2-year period. This study introduces a method for quantifying heterogeneity in reasons for attendance, which may support future predictive modelling using electronic health records to identify and support high-frequency ED users.

Background: Delayed or inconsistent administration of N -acetylcysteine (NAC) for paracetamol overdose in the emergency department (ED) poses a risk to patient safety, with current Royal College of Emergency Medicine (RCEM) standards often not being met. The traditional 21-hour NAC regimen is associated with adverse drug reactions, medication errors and prolonged admissions. The Scottish and Newcastle Acetylcysteine Protocol (SNAP) was introduced as a simpler alternative with comparable efficacy. This quality improvement project (QIP) aimed to improve compliance with RCEM standards by implementing targeted interventions while also reducing the length of inpatient stay and maintaining patient safety. Method: This QIP was conducted at Royal Derby Hospital using a multidisciplinary, systematic approach based on Plan-Do-Study-Act cycles. Baseline data were collected from 100 randomly selected patients (November 2021–May 2022) and compared with outcomes during a 52-week intervention period (September 2023–August 2024). Interventions included educational sessions, quick reference materials and enhanced prescribing tools. Data were analysed for compliance with RCEM standards, adverse events (liver function derangement and anaphylactoid reactions) and system-level measures, such as length of inpatient stay and timing of paracetamol plasma levels. Results: A total of 214 patients were included. Compliance with RCEM standard 1 improved from 36% to 43%. No change was noted for standards 2 and 3. Median inpatient stay decreased from 35 hours to 30.5 hours. No significant differences were found in adverse events. Special cause variation was identified in paracetamol plasma level timing, attributed to early sampling in some cases. Conclusion: This QIP addressed problems of delayed or inconsistent NAC administration in the ED by improving compliance with RCEM standard 1 and reducing inpatient stay while maintaining patient safety. Although standards 2 and 3 did not improve, the interventions proved cost-effective, feasible and scalable. Future work should focus on sustaining improvements and exploring patient-centred outcomes across diverse healthcare settings.

Background Healthcare professionals commonly believe that saying the word ‘quiet’ can jinx a shift and lead to increased workload or particularly unwell patients. A previous small integrative review found no effect but had some methodological limitations. This narrative systematic review aimed to synthesise the evidence from studies on the impact of saying ‘quiet’ on clinical workload measures. Methods A comprehensive search was carried out across multiple electronic databases for any studies performed in a human healthcare setting investigating the impact of the use of ‘the Q word’ (or variations thereof) on workload. Outcomes of interest were objective measures of workload, such as patient volume, admissions or tasks. Results Eight randomised controlled trials (RCTs) were included. Settings included EDs, specialised hospital units and clinical support services. Outcome measures varied between studies, so meta-analysis was not possible. Seven RCTs found no significant differences in objective workload measures between intervention groups where ‘q****" was uttered and control groups where it was not. One RCT in orthopaedics reported an increase in overnight admissions when ‘q****" was said but had significant methodological limitations. Two RCTs noted potential impacts on subjective perceptions of workload among believers. Limitations of included studies include small sample sizes, lack of blinding and inadequate control for confounders. Discussion The available evidence does not support the assertion that saying the word ‘quiet’ affects clinical workload metrics. Healthcare professionals should be encouraged to prioritise communication based on evidence rather than myth, and there is insufficient evidence that saying ‘quiet’ while on shift will bring negative consequences for themselves or colleagues.

Background The pain of renal colic, mediated in part by ureteral spasm and inflammation, is often severe and difficult to control. Salbutamol has been shown to cause ureteral relaxation, but its effects on the pain of renal colic have never been studied. The objective of this trial was to investigate whether the use of intravenous salbutamol in addition to standard analgesia was associated with greater pain reduction compared with standard analgesia alone in patients presenting to emergency departments (EDs) with renal colic. Methods This single-centre, double-blind, phase II, randomised, placebo-controlled trial recruited adult (≥18 years) ED patients with clinically suspected renal colic. Participants were randomised in a 1:1 ratio to receive either 250 µg of intravenous salbutamol or a placebo (0.9% sodium chloride). The primary outcome was the difference in the change in pain scores (measured on a 100 mm Visual Analogue Scale) from baseline to 30 min following trial treatment administration in participants with subsequently confirmed renal colic. A modified intention-to-treat analysis was undertaken for the primary population of participants with confirmed renal colic. Results Consent was obtained from 151 patients; 108 participants with confirmed renal colic were included in the primary outcome analysis. There was no statistical difference between groups in median change in pain score at 30 min (salbutamol group −18 mm (IQR −25 to −3), placebo group −13 mm (IQR −33 to −1), difference 5 mm (95% CI −16 to 6, p=0.575)). No significant differences were found in the secondary outcomes related to pain, patient satisfaction or opiate requirement. More adverse events (AEs) were observed in the salbutamol group (65) compared with placebo (42, p=0.02); no unexpected AEs were identified. Conclusions This trial has not identified a clinically or statistically significant benefit from the addition of intravenous salbutamol to standard care for patients presenting to an ED with pain caused by renal colic. Trial registration numbers The trial was registered with the European Union Drug Regulating Authorities Clinical Trials Database (EudraCT), reference 2018-004305-11. It was also registered with the ISRCTN Registry, reference 14552440.

Background The annual incidence of testicular torsion is approximately 1 in 4000 males under the age of 25. Despite the 97% testicular salvage rate when surgical intervention is within 6 hours of onset, orchidectomy is required in 40% of cases. These comparatively poor outcomes are driven by delays to intervention, the majority of which take place prior to presentation to healthcare. This study synthesises existing evidence to understand factors leading to delayed presentation to hospital in individuals with acute scrotal pain. Methods A comprehensive literature search was performed with support from an information scientist. Two authors performed article screening, data extraction and inductive thematic synthesis independently, with disagreements resolved by discussion at each stage. An assessment of confidence in the review findings was performed using the ConQual approach. Results The search identified 1251 unique articles for screening, with five eligible for inclusion; all included publications were drawn from two PhD projects. Synthesis of these articles revealed five descriptive themes with five subthemes. A lack of knowledge and education about testicular health, embarrassment and reliance on others for access to healthcare are major factors leading to delays in presentation. Societal and cultural impacts on health-seeking behaviour and denial were also causes of delayed presentation to healthcare. Discussion A lack of knowledge about testicular anatomy and health among both adults and children is amenable to improvement through education, and would likely impact many of the factors identified as contributory to delays. Communication was an overarching factor connecting the descriptive themes. PROSPERO registration number CRD42023469435.