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Balancing Resources in the Emergency Department

22 Sep, 15 | by rradecki

Predictions are tricky, especially whenThis month, Kreindler et al report a review of patient-level predictors of protracted Emergency Department length of stay. These sorts of reports are critical, not solely due to the relative importance of the topic, but also because of the gaps revealed in the current literature. To wit, despite reviewing 30 investigations of Emergency Department length of stay, a partial conclusion of these authors is the available information is insufficient to facilitate its use in service planning.

The value of such predictive tools would be profound. If, based on information readily available during triage, the LOS and resource utilization of a patient might be predicted, the effect spans the entire hospital. Nursing staff needs can be informed for the downstream wards and locations for general and specialty care, not simply for ongoing ED care. The ongoing presence of technical resources might be predicted, such as radiology or laboratory, and staffing maintained in anticipation of future orders. Finally, a prediction of increased LOS may influence models predictive of ED crowding, and prompt additional resources targeted at traditional bottlenecks in care. Clearly, predicting LOS results in a cascade of value.

However, as these authors note, it is simply too challenging to distill simple predictors from these data. Predictors of long LOS include eventual admission, patients with mid-acuity levels, older adults, and certain socioeconomic factors. However, some of these features are colinear with others, and some – like eventual admission – are frequently evident only at the conclusion of an ED stay. Increased intensity of diagnostic testing also predicts increased LOS, which brings to mind another confounding variable: the physicians themselves. Every ED has a range of clinicians, with variable diagnostic skills and risk tolerance, and identical patients with the same complaints may be assessed as immediately safe for discharge by some clinicians, while other clinicians might perform resource-intensive evaluations. This almost certainly ties into the general observation of presenting patient complaint only inconsistently associated with LOS.

What are the ramifications, then, for pursuing models for ED LOS? Essentially, there’s no simple shortcut. And, this is clearly clinically reasonable – as physicians we intrinsically know the vast constellation of patient factors relating to our decision-making process. It does not make sense to suggest a model of reasonable accuracy can be built from such broad brush strokes. Help, however, may yet be on the way from the realm of Clinical Informatics. As EHR data proliferates, the “undifferentiated” ED patient is gradually becoming a thing of the past. No longer would such a model be restricted to the basic triage information, but, perhaps include coded features of the medical history heretofore unavailable to prior models. Alternative analytic approaches, such non-linear, cluster-based techniques – those which best handle “big data” – may also be enabled by access to vastly more robust substrate.

The need for further study is apparent – but it is clear these previously pursued analyses should not be fruitlessly re-replicated. A new approach is necessary.



The Alteplase Controversy Goes Prime Time

19 Sep, 15 | by rradecki

Alteplase & Stroke

Just a few months ago, alteplase for acute ischemic stroke was assaulted in the pages of the BMJ. Academic debate on this subject is hardly novel, as the controversy within the ivory tower has dragged on almost since thrombolytics for stroke received therapeutic approval.

However, as the use of alteplase grows, the number of patients harmed by its use has correspondingly increased. Regardless of the perceived benefits of the treatment, the resulting harms have accumulated into a full public outcry, with family members of those harmed petitioning the government for increased oversight. There are now two ongoing reviews in the United Kingdom – the Medicines and Healthcare products Regulatory Agency review has been joined by the Academy of Medical Sciences. A full 38 minute segment on BBC Radio 4 details several personal stories, and contains snippets of interviews with the renowned David Newman, among others.

In the same vein, the American College of Emergency Physicians has finally released their revision to the highly-conflicted 2012 policy statement regarding treatment of acute ischemic stroke. Substantially altered from the 2012 version, ACEP has dramatically weakened the prior recommendations to reflect the paucity of randomized trial evidence. While two pivotal trials demonstrated significant absolute benefit, such trials enroll simply a few hundred patients in the setting of vastly heterogenous presentations and prognoses for acute stroke.

The new policy statement issues two recommendations for offering alteplase to qualifying patients, both under the “Level B” classification – representing “recommendations” for patient care subject to “moderate clinical certainty”. This is a change from the previous guideline, which provided concise recommendations favoring treatment within three hours as Class A. The new recommendations:

      With a goal to improve functional outcomes, IV tPA should be offered and may be given to selected patients with acute ischemic stroke within 3 hours after symptom onset at institutions where systems are in place to safely administer the medication. The increased risk of sICH should be considered when deciding whether to administer IV tPA to patients with acute ischemic stroke.

Despite the known risk of sICH and the variability in the degree of benefit functional outcomes, IV tPA may be offered and may be given to carefully selected patients with acute ischemic stroke within 3 to 4.5 hours after symptom onset at institutions where systems are in place to safely administer the medication.

It remains to be seen whether these recommendations substantially alter clinical practice or encourage additional investigation. Beyond 3 hours – the timeframe most critiqued by Alpers et al – alteplase remains unapproved for use by the FDA, and by these guidelines need not be offered to patients.

As always, the hope is these developments will spur further, prospective, independent evaluation. We need thousands, not hundreds, of patients in well-designed trials devoid of conflict-of-interest. Otherwise, we continue to place patients at risk, both from the harms of alteplase or the harms of potentially not receiving a truly beneficial therapy.




Social Media is Exploding – But is it Effective?

10 May, 15 | by rradecki

About a year ago, I posted about accelerating knowledge translation using Twitter, blogs, and other social media. In some respects, the embrace of social media was still in its infancy – originally, #FOAMed, powered by an independent group of individuals passionate about sharing knowledge and teaching Emergency Medicine. The Emergency Medicine Journal, driven in part by Prof. Carley’s efforts, was one of the first journals to add social media, discussion, and dissemination to their official scope and formally appoint Editors in this domain.

Now, to put it mildly, the scene has exploded.

Each of the major Emergency Medicine journals in the U.S. has at least one social media editor (Annals)(AEM), or an entire social media team. The major conferences, in Emergency Medicine and other specialties, have adopted hashtags (e.g., #ACEP14) and live tweeting by meeting participants as part of knowledge dissemination and promotion. Indeed, an upcoming conference in Chicago, USA, specifically addresses Social Media and Critical Care. Finally, even previously small, individual efforts at knowledge translation, like Academic Life in Emergency Medicine, have gathered momentum and become online clearinghouses of peer-reviewed editorial and educational content, along with their own online Journal Clubs.

The Council of Emergency Medicine Residency Directors (CORD) issued a long statement on the professional use of social media in by training programs, including a statement that “social media can be a powerful tool”. The American Congress of Obstetricians and Gynecologists recently issued guidelines on physicians’ use of social media. The United Kingdom Diabetes Professional Conference broadly covered social media use by endocrinologists to learn from and communicate with patients in a new context. Even other health professional disciplines, such as research nurses, have recognized the power of social media for unexpected viral promotion of clinical topics.

However, despite this enthusiasm, it remains a challenge to measure tangible benefits associated with social media use. Anecdotal stories of professional networking via social media abound – but, ultimately, patient-oriented outcomes as result of knowledge translation ought be the true measure of success. A recent study in Circulation randomized newly published articles to traditional knowledge translation or specific social media promotion – and there was no difference in online views between the two cohorts. The lesson, despite the authors’ conclusion, is not that social media is limited – but the content trumps the distribution method. If a social media stream consists of solely unfiltered noise, rather than useful signal, the entire effort will fail.

While increasing numbers of clinicians and patients are accessing information through alternative digital means, and the potential for education and accelerated knowledge translation through social media exists – individuals and organizations should recognize significant challenges remain. No amount of investment or effort into “social media” replaces useful content, and as more sources contribute to the pool of online information, the more difficult it will be to build a following or measure successful effects.

Emergency Medicine for medical students world wide!

17 Apr, 15 | by scarley


A guest blog from Larshan Perinpam (President of ISAEM) and Anh-Nhi Thi Huynh (Vice president of external affairs, ISAEM)


ISAEM is an organization established to take Emergency Medicine student Interest groups (EMIGs) extracurricular activities to a whole new level, not only locally or nationally but also worldwide.

ISAEM is the abbreviation of the International Student Association of Emergency Medicine. It is the first international Student organization of it’s kind within Emergency Medicine (EM) and was founded in Denmark in October 2013. ISAEM’s primary aim is to create International relations between EMIGs all over the world.

In the United States, EM was founded more than 40 years ago, and today it is a well-established specialty that occupies the Emergency Department (ED), which in most cases is the front door into the hospital. By having an individual specialty within EM you are able to provide a better and more optimized patient care. In many countries (Norway, Denmark, Brazil, etc.) EM does not exist as an individual specialty. In such countries EDs are occupied by the already established individual specialties (cardiology, general surgery, infectious diseases, primary physicians, orthopedic surgeons etc.) and many EDs does not have its own physician staff.

In order to develop a department the first step is to have its own staff, a staff that is continuous and present in the department on a daily basis. These are just some of the few challenges that are being faced in the EDs worldwide. Some countries already have an established specialty within EM, but it is still under development. Furthermore these countries are also facing recruitment problems due to the rough working conditions.

Larshan1 2

Larshan Perinpam

The members of ISAEM are local and national EMIGs around the world. ISAEM believes that the best possible way to recruit future staff into EM is through the EMIGs that are already established in many medical schools. We need to optimize the extra curricular activities in comparison to all other medical student interest groups, who have their interest within another established specialty.

In ISAEM we believe that by connecting every EMIG on a international level we will be able to; exchange ideas, find inspiration in activities created by different EMIGS, be able to further develop the local EMIGs and create a foundation for the next generation of physicians who wishes to pursue a careare in EM

Anh-Nhi Thi Huynh(1)

Anh-Nhi Thi Huynh

Since the establishment of ISAEM we have strived to promote ISAEM in the best way possible by attending international EM meetings (ACEP, EuSEM14, ESEM2014 etc.); finding the right collaboration partners (EMRA, DASEM, EuSEM, ESEM etc.) and focused on creating a stable and strong infrastructure of the organization. Recently ISAEM launched its latest initiative to further develop EM among medical students by creating the ISAEM National Ambassador program. The National Ambassadors will play the part as bridge-builders between the local EMIGS and ISAEM.

The practice of EM is extremely diverse and various internationally and ISAEM wishes to create opportunities in order to expand the experience and understanding for students with an interest in EM. Therefore ISAEM decided to develop an international ED Observership program in order to give medical students the opportunity to see how EM is practiced in different cultures and settings. This will also help to inspire the individual student to further develop Emergency Medicine in their home country.

Currently ISAEM is represented by five countries/members (Denmark, Netherland, Brazil, US and the Netherlands.) These already represent more than 2000 EM interested medical students. In the end of April 2015, ISAEM wish to enroll more EMIGs and by the end of 2015, ISAEM aim to represent more than 20.000 EM interested medical students worldwide! We want to create the biggest international student network within EM.

ISAEM is slowly developing and our current achievements is all because of our members, partners and the medical students who dedicate their free time in order to develop ISAEM. This work is what defines ISAEM and the future of ISAEM. In ISAEM we believe “alone we can go fast but together we will go far”.


If you find this interesting, please don’t hesitate to contact us:

Website:, facebook:, twitter: or email:


We are looking forward to further develop EM among medical students with you.

More Trouble For tPA at the BMJ

30 Mar, 15 | by rradecki

The BMJ recently stirred the pot again on a subject near and dear to our hearts – no, not exit block – but intravenous thrombolysis for acute stroke. For a therapy that’s been approved within 3 hours for nearly two decades, and was extended to 4.5 hours by guidelines in Europe and the United States since 2008, it ought be surprising there is still serious discussion regarding the validity of the results.

Just two years ago, the BMJ allowed members of the Australasian college to debate the risks and benefits for tPA in acute stroke. The accompanying unscientific poll of readers came out in favor of skepticism, with 54% of the 612 respondents stating the risks outweighed the benefits. Now, in the context of the UK regulators re-examining the evidence in support of alteplase, the BMJ has published an examination specifically regarding the 3 to 4.5 hour time window.

In contrast to the individual-patient meta-analysis, the Cochrane Review, and many other interpretations of the applicable data, this work is unique in that is led by an outsider – neither a professionally entrenched stroke neurologist or emergency medicine physician. The author, Brian Alper, is a family physician whose professional affiliation is with a knowledge translation medical reference product. Rather than carrying the baggage of twenty years of contentious debate, colored by pharmaceutical sponsorship, his take is of one, colloquially, without a horse in the race.

Dr. Alper et al critques three different interpretations of the evidence regarding the extended time window: The American Heart Association guidelines, the 2014 Cochrane review, and the 2014 individual patient meta-analysis. The crux of each analysis focuses on ECASS III, IST-3, and the integration of such data sources. ECASS III, he points out, enrolled twice as many patients with prior stroke into the control arm – and excluding those with prior stroke from the final analysis diminishes the treatment effect to a 95% CI of 0.89 to 1.59 for mRS 0-1. The 3 to 4.5 hour cohort from IST-3, then, found no benefit to alteplase with a 95% CI of 0.50 to 1.07 for mRS 0-2. These two data sources are then combined to make up the bulk of the individual patient meta-analysis, and despite their seeming contradiction, their synthesis remains strongly positive in favor of thrombolysis.

The critique of the Cochrane review is couched in quite revealing language, noting “Cochrane reviews usually provide the most valid syntheses of evidence of effects of interventions”. As previously critiqued, these authors again take Wardlaw et al to task for discrepancies between their ultimate conclusions and the data presented beyond 3 hours. Dr. Wardlaw has already responded at to begin what will hopefully be a provocative and enlightening discussion.

Dr. Alper et al make a call for data sharing such that all can examine the individual patient results, similar to the fascinating third-party re-analyses undertaken of the osletamivir data. They also call for additional research to further independently evaluate efficacy. Unfortunately, a paucity of new data is forthcoming. A cursory search of stroke trials indicates a 200 patient trial from China enrolling in the 3 to 4.5 hour time window, with little additional information. Other potentially forthcoming data includes TESPI, an open-label trial from Italy whose recruitment ended last year. The remaining trials, rather than further enlightening us regarding safety under the existing license, aim to expand eligibility by time window or elimination of other exclusions.

Will this most recent dissent produce any meaningful result? It is too early to tell – but, certainly, for our patients’ sake, I hope so.

What Happens When Conflict-of-Interest is Stripped Out of Guidelines?

30 Jan, 15 | by rradecki

Nearly 20 years after hitting the prime-time following publication of the findings of the NINDS rt-PA Study Group, tPA use has become widespread.

However, there yet remain many vocal opponents. To say there is sometimes a hearty debate over the use of tPA in acute stroke would be a dramatic understatement. Indeed, even as select groups of stroke neurologists push tPA use beyond the limits of current guidelines, other groups remain steadfast in opposition.

This post is neither pro- nor con- in this ongoing controversy. Rather, this simply draws attention to a relatively interesting development over on the U.S. side of the pond. In 2013, the American College of Emergency Physicians published a new Clinical Policy regarding the use of tPA in acute ischemic stroke – giving tPA under 3 hours a “Level A” recommendation, and 3-4.5 hours a “Level B” recommendation. The uproar that ensued, however, was not entirely based on clinical grounds – it was regarding the composition of the guideline panel, co-written with the American Academy of Neurology, and stacked with experts with professional and financial conflicts-of-interest with the manufacturer of tPA. This gave rise to a BMJ investigative report, delving into the corrupting effect of COI on guideline writing. This further spun off another BMJ consensus publication regarding the evaluation of “red flags” for guidelines, dovetailing nicely with previously published Institute of Medicine recommendations.

The story, however, does not end there. ACEP’s council voted to reconsider the tPA guideline and implement a due, COI-free process, with a focus on methodology rather than content expertise, and an open review policy. The product of the revised process recently became available in draft format – and the difference is striking. The administration of tPA is no longer a “Level A” recommendation – both time windows are “Level B” in the current revision. However, there is a new “Level A” – a mandate to discuss the 7% average observed incidence of harmful intracranial hemorrhage prior to administration of tPA. Finally, a new “Level C” recommendation states, as consensus, to involve patients in shared decision-making during the process.

Whether one agrees with such changes is almost certainly tied to their view regarding the benefits and harms of tPA. It is, however, quite interesting to see how attempts to mitigate bias and COI change how the evidence is graded and the ultimate recommendations. Perhaps this demonstrates, at the least, hope is not necessarily lost regarding purifying the practice of medicine – and guidelines may yet regain the trust of physicians and patients.

Primary survey Highlights from the January 2015 issue. Mary Dawood, Editor

16 Jan, 15 | by scarley


A mask tells us more than a face (Editor’s choice)
As ED clinicians we often pride ourselves on recognising the sickest patients by how they look, this skill is tacit and one that is the result of experience and longevity in emergency care. Our psychiatric colleagues have long accumulated significant research into disturbances in affect recognition in patients with mental illness, so I was intrigued to read in this issue a study by Kline and colleagues from the US which explored the variability of facial expression in patients with serious cardio pulmonary disease in emergency care settings. They found that patients with serious cardio pulmonary disease lacked facial expression variability and surprise affect. They suggest that stimulus evoked facial expressions in ED patients with cardiopulmonary symptoms may be a useful component of gestalt pre-test probability assessment. So, there may be some substance in one of the many satirical remarks made by Oscar Wilde that “A mask tells us more than a face” though I doubt his context was clinical.

It’s not the age that matters
Accurately measuring weight in children presenting to the ED is essential and particularly crucial in resuscitation situations where interventions and drug dosages are calculated by weight. The APLS formula, 2× (age+4) has been widely used in western ED’s, but as obesity in our young people is becoming more common and children are taller than previous generations , this formula may fall short in terms of accuracy and patient safety. An alternative formula (3×age)+7 by Luscombe and Owens (LO) has been suggested as more accurate than the APLS formula. Skrobo and Kelleher in Cork University Hospital Ireland undertook a retrospective study of 3155 children aged 1–15 years comparing both formulas to identify which one best approximates weight in Irish children presenting to the ED. They conclude that the LO is a safe and more accurate age based estimation over a large age range. Maybe it’s time to review our practice but do read this paper and weigh up your own thoughts, no pun intended!

Not all suffering is pain
Pain is the commonest reason patients attend the ED. Our sometimes lack of appreciation and subsequent under-treatment of pain is often a source of distress and dissatisfaction which can result in uncharacteristic behaviour. However not all suffering is pain and we may find ourselves wanting when the cause of distress is emotional rather than physical. This issue features a prospective cohort study by Body and colleagues in Oxford which sought to describe the burden of suffering in the ED. Of the 125 patients included in the study many reported emotional distress particularly anxiety as well as physical symptoms. Indeed only 37 patients reported that pain was causing their suffering. It should not come as any surprise that being seen, information, reassurance, explanation, care by friendly staff and closure were the key themes reported as relieving suffering. This approach just represents best practice but in the mounting pressures of ED’s worldwide it is all too easy to lose sight of the person and their need for compassion and understanding. Dismissing emotional suffering as perhaps someone else’s problem is detrimental to our patients and ultimately ourselves. Do read this paper; it is a timely and salutary reminder of what we should be about, why we do the job we do and what patients expect of us. There is also a podcast with the Editor in Chief and the author. Find this online alongside this issue.

Best evidence or clinical acumen (Readers’choice)
As demands for emergency care and acuity of patients presenting continues to rise globally, ED clinicians are increasingly faced with making decisions to discharge patients from high acuity areas of the ED. Patient safety and well being should govern any decision to discharge a patient but many cases are complex and weigh heavily on clinicians making such decisions. Calder and colleagues in Canada conducted a real time survey of experienced ED physicians to determine how they perceive their discharge decisions and the impact on adverse events. The authors concluded that ED physicians in their study most often relied on clinical acumen rather than evidence based guidelines and that neither approach was associated with adverse events. They recommend further research which focuses on decision support solutions and feedback interventions.

The greater good
Pulmonary embolism (PE) is a leading cause of death in pregnancy and the post partum period and a devastating event for mother and baby. When accurately diagnosed and treated the risk of an adverse outcome is low. In this paper Goodacre and colleagues explore the options for imaging and discuss the evidence for using clinical features and biomarkers for the selection of women for imaging. Their review of the literature suggests that the harm of investigation with diagnostic imaging may outweigh the benefits but that clinical predictors could be used to identify women at higher risk who could be appropriate for imaging. They also state the need for further research around clinical predictors and particularly the use of D-dimer at a pregnancy—specific threshold.

Pearls of wisdom
There is little doubt that the emergency department is a quite unique environment that offers abundant opportunities for learning. Seizing and exploiting these opportunities is not always as straightforward as we would like it to be. The constant pressure to manage multiple patients and make decisions to refer, admit or discharge against the backdrop of a ticking clock often mitigates against the teachable moment however genuine our desire or commitment to teaching is. It’s easy to feel impatient and exasperated by the seemingly slow pace of some learners when you are trying to maintain safety in a crowded department. On the plus side, however, learning in such an environment can instill a sense of urgency, something that cannot be learnt from a textbook. Nonetheless teaching and learning is integral to all our roles and so it was refreshing to read in this issue “Top 10 ideas to improve bedside teaching in a busy emergency department” by Green & Chen from California. We have probably all used some or all of these methods to teach in different circumstances but the authors imaginative use of a framework, of ‘mnemonics’ and easy to remember names such as “Aunt Minnie” and “Snapps” is amusing and lighthearted. In reading this paper, you may just find that pearl of wisdom for the next teachable moment.


Mary Dawood

The view from the F2…..

14 Jan, 15 | by scarley

The view from the F2

As an aspiring emergency physician I have been keeping a close eye on the latest media frenzy regarding the NHS crisis. My own feeling is that from working in the NHS over the Christmas and New Year period is that the hospitals are considerably busier than this time last year.

Headlines such as ”hospital declares ‘major incident’ in NHS A&E crisis”1 have become common place and mutterings from GPs, consultants and juniors alike are saying the NHS is at breaking point.

Is it clear that the A&E departments across the country are facing an unprecedented number of admissions than ever. It is worrying that the strains demonstrated by hospitals declaring themselves as ‘major incidents’ could indicate the demise of the NHS , unable to cope with the extra demand.

Why is this? I wish to explore this topic and discuss some of what I believe to be the most crucial contributing factors to this NHS crisis.

I have asked myself, my colleagues and scoured the reports on this ‘ NHS crisis’. Why has there been such a high demand on the NHS this winter? What can I or my colleagues do to alleviate this?

The following are some of contributing factors which I believe have placed the NHS under more strain than ever. I have also discussed action plans that we as physicians could implement to try to alleviate some of these pressures.


  1. Ageing population: Medical advances have allowed an extended life expectancy for our population. 30 years ago a myocardial infarction carried a mortality rate of over 40%, now with advances such as PCI, time limits of 60mins from onset of chest pain to catheter table , cardiac rehabilitation & medications the mortality rates have significantly improved. This has consequences for the health service in other ways – people are living longer in the community with now more chronic illness. Our population is also living for longer , there are over ten million adults aged over 65 years living in the UK currently and this is projected to increase by an additional 5.5 million in twenty years time.2 We are now experiencing the conse of this situation with more patients with chronic illnesses unable to cope in the community and requiring hospital admission.
  2. Four hour target in the A&E department – The government and media have publicised the 4 hour target in the Emergency department. This is a potentially lucrative enticement to a patient who cannot get an immediate appointment from their GP in that they can be seen / investigate / treated / admitted or discharged within 4 hours from the emergency department. Should this target be abolished? – there does not appear to be much evidence that it improves healthcare and it seems that it in fact has created additional waiting / clinical assessment unit type wards in the hospital. If the targets were dropped and patients were seen purely on clinical need, perhaps not so urgent / acutely unwell patients would attend and instead try and attend their GP.
  3. GP out of hour’s service access – Since the GP contract changed in 2004, it has placed an extra strain on access of healthcare ‘out of hours’. Patients often think that after 6pm there are no GP services available and therefore present directly to the emergency department as they know its open 24/7. Some patients are unaware that a GP out of hour’s services exist. Is there an opportunity to educate patients in the community about accessing healthcare out-of-hours?
  4. NHS budget – in the financial climate, austere measures have been placed upon all public services. The NHS has also been affected by this. The NHS budget has been frozen for around 5 years, more productivity has been demanded from it and as the population has risen demand upon it has increased. The NHS is paid for by the taxpayer, and it is difficult to ask more from the taxpayer to contribute to the NHS. This calls into question privatisation of the NHS (I do apologise if this word causes offence to anyone reading). Should some fees be introduced to the NHS? e.g. fines for those who continually fail to attend appointments , recurrent drunks in the ED , a small fee for calling upon ambulance services and attending the ED?? Imposing fees could have major consequences. It is known that those who are in the lowest socio economic state have the poorest health. If fees were placed would we be neglecting those who could not afford a small payment towards their health? What do we do if patients refuse to pay? Do we set litigation against them? Would fee for service environment result in a more litigious society?
  5. Societal attitudes to illness and health – With the advent of social media , constant and instant information is available from Twitter , Facebook and Google. Society has become more risk averse. People are generally unwilling to accept any health risks (and why should they accept risk?). Therefore attending the hospital /emergency department whereby health can be assessed quickly with bloods & imaging and quick decisions can be made is now an expectation. It is not uncommon to hear colleagues complain that more patients are attending the emergency department for non emergency ailments such as simple coughs and sore throats. I don’t think there is any solution to this rather than acceptance of society’s shift in their health beliefs and health seeking behaviours. Perhaps its time we roll with this change and consider making healthcare more accessible to people’s lifestyles e.g. running more evening clinics in general practice when people can attend after work.


Rant over, I feel like a weight has been lifted off me however the gravidity of this situation is bearing down on the NHS and it appears to be unravelling before our eyes (maybe I am being a tad dramatic here but it is a pressing issue all the same).

I realise that this is a complex issue that will require time, money and patient education. What can we do as physicians? What can I do as a budding emergency medicine doctor? I suppose for now its patient education. Information empowers our patients and perhaps the next time we encounter a patient in the emergency room who you felt may have benefited from a visit to their general practitioner rather than the emergency room, inform them of this. There is no need to chastise patients but pointing out the resources available such as walk-in centres and out of hours GP services towards the end of the consultation may be worthwhile.

So from a foundation doctors perspective the above factor are what I belief are contributing to the current crisis however , what do you think? Are there other factors I have not considered? Does anyone have any remedies for this NHS ailment?

Yours comments and opinions are greatly appreciated.

Thanks for reading.

Aine Keating



  1. BBC news article Nick Triggle (06/01/2015). A&E waiting is worst for a decade. UK
  2. Government document. (2007). Ageing population. Available: Last accessed 06/01/15.




Clinician Abuse: Electronic Health Records

5 Dec, 14 | by rradecki

This month, the print version of the Emergency Medicine Journal features an article from a group including Jeffrey Perry and Ian Stiell on a topic near and dear to our hearts – Electronic Health Records. While the next generation of physicians will never remember a time of charting on paper, the majority of practicing physicians recall such times – and many office-based practices may yet still use paper.

In the Emergency Department, however, one of our most valuable assets is time – and all such times are increasingly measured and under greater scrutiny as quality and efficiency metrics. With an eye towards this, Perry et al performed an observational, before-and-after, study comparing time spent in documentation on non-traumatic chest pain between paper charting and electronic charting. Paper charting required a mean of 6.1 minutes per patient, while electronic charting required 9.6 minutes. If one assumes this charting differential is generalizable to other complaints, and multiply such by a very reasonable 2 patients per-hour on an 8- or 9- hour shift – suddenly you’re looking at an additional hour of documentation time. Unsurprisingly, qualitative survey of clinicians found universal disfavor of electronic charting.

I shine a light on this article in the context of the ongoing American Medical Informatics Association Annual Meeting in Washington, DC (#AMIA14). If you spend any time perusing the social media or press releases from the meeting, all the hype is about “Big Data”, FHIR, and hackathons – advanced applications of clinical informatics, essentially, assuming an integrated Electronic Health Record infrastructure. What’s been utterly lost in the rush to the future are the basic considerations clinicians struggle with on a daily basis – carving out enough face-time with patients to deliver the best possible care. With initiatives such as “Meaningful Use” in the United States providing mandates for EHRs, the emphasis has clearly been on checking boxes for federal reimbursement – and hardly responsive to clinician concerns.

Patient satisfaction” is an overwhelming industry mandate – what happened to clinician satisfaction?

Reference: “Assessment of the impact on time to complete medical record using an electronic medical record versus a paper record on emergency department patients: a study

Highlights from the December edition: EMJ

5 Dec, 14 | by scarley

Paul Middleton: Associate Editor EME

Editor’s Choice: ED and GP patients

Causes of Emergency department crowding are complex, but the proportion of ‘inappropriate GP patients’ has often dominated the debate. Recent Australian research suggested that ∼10% of patients could be classified as appropriate for general practice, whilst demonstrating that the preferred government methodology doubled these figures.

In this issue, Harris and McDonald investigate the case-mix of patients attending ED, GPs, a walk-in clinic (WIC) and an out-of-hours (OOH) telephone service. There was a similar case-mix of presentations to the WIC, OOH and GP, with the only difference being respiratory illness presented more frequently to GPs. Injuries were 12 times as likely to be seen in ED, whereas non-traumatic musculoskeletal conditions were twice as likely to be seen in GP practice. Patients were also 4 times more likely to present to ED with chest pain suggestive of myocardial ischaemia as compared with non-ED sites.

These findings, although based on a small sample of a highly diverse population, demonstrate that patients are making relatively sophisticated choices. This paper highlights that, rather than concentrating on the blunt tools of “reducing ‘inappropriate’ attendances”, governments need to take note of Gerry Fitzgerald’s comment that there are “…not general practice patients or ED patients; there are just patients, who need medical care”, and our job is “…to understand those needs and to provide accessible, affordable and quality services that meet those needs. Patients should not be blamed for our failure to do so.”

Sepsis survey

Almost 13 years ago, Manny Rivers changed the paradigm for the sepsis syndrome with the outcomes of Early Goal Directed Therapy (EGDT). Since then, studies from PROCESS to ARISE have suggested that EGDT is not in itself more successful in preventing sepsis mortality, but that a high-quality, process-of-care approach results in the best outcomes. Jiwaji et al surveyed ED and ICU consultants across Scotland, with a 2/3 response rate, and compared approaches to sepsis resuscitation. Almost 90% of ED consultants used normal saline to resuscitate, compared to only a quarter of ICU consultants; many of the ICU group preferred Hartmann’s, but 63% used gelofusine, despite little evidence for its benefit. Half as many again ICU consultants initiated central venous and intra-arterial monitoring in the ED compared with ED consultants, and similar proportions used specific transfusion triggers. This variability suggests the need for harmonisation of approach with the patient remaining the central concern, whoever is providing care. In a time-critical environment, recognition of which is an undoubted result of Rivers’ work, ED and ICU need to work towards common skill sets and protocols to ensure that early recognition, source control, antimicrobial therapy, fluid resuscitation and escalation remain the fundamental goals of sepsis treatment.

Basic Life Support

Exponentially growing levels of evidence supports the primacy of early recognition of cardiac arrest, immediate instigation of high-quality CPR and urgent defibrillation. In the last 20 years, ubiquitous courses in BLS train essential psychomotor skills, but these skills deteriorate in weeks or months. Video-based Practice While Watching (PWW) programs, with participants observing a standardised video with an instructor, have been successful in initial skill teaching and maintenance, but Na and colleagues investigated a novel small group discussion and debriefing (SGD) program, allowing participants to watch themselves and discuss with an instructor. 2000 people were studied. Healthcare professionals’ (HCPs) performance of compression skills was better using SGD compared to PWW methods, but showed no difference in non-compression skills (ventilation, AED use etc). In non-HCPs there was a significant improvement in both sets of skills using the SGD method. This interesting study points the way to possible mass-instructional methods that could be highly useful in community and HCP education in order to improve the often dire outcomes of cardiac arrest.

Capillary refill

Although normal finger capillary refill time (CRT) is considered to be less than 2 seconds, upper limits of 4 seconds may be seen at the chest or foot, and in the upper CRT limit in neonates may be up to 5–7 seconds. Longer times are seen in lower extremities and lower skin temperatures. Schriger and Baraff also showed that CRT varied with age and gender, with approximately 2 seconds for children and men, and longer times for women and the elderly.

We know that turning a continuous variable into an ordinal or categorical variable loses both information and precision, but clinical practice often demands these simplifications. Mrgan and colleagues assessed the relationship between CRT and with mortality as both categorical and continuous variable in 3000 patients. Although based on limited data, multivariate analyses showed no relationship between CRT and either 1 or 7 day mortality when used as a categorical variable, as in the Trauma Score, but when used according to the Schriger and Baraff definitions, CRT was associated with odds ratios of mortality of 5.8 and 4.2, with, however, very wide limits of agreement. The authors concluded that CRT should really be used as a continuous variable, but implementation of this statistically sound approach will be challenging without substantial further research.

Light rather than heat in stroke?

Stroke treatment over recent years has generated a lot more heat than light, but no one can disagree that stroke evolution is time-dependent. The PIL-FAST study casts an intriguing light on the challenges of research into a time-dependent pathology, seeing the patient journey as an emergency care continuum and implementing pre-hospital interventions.

This pilot study by Shaw et al investigates the ability of an ambulance service to implement a randomised controlled trial (RCT) in the prehospital phase of stroke care, treating hypertension using lisinopril or placebo The truly illuminating aspects of this study are the difficulties encountered, and the subsequent limitations imposed on this research. Of 1463 suspected stroke admissions only 40 fulfilled inclusion criteria, and of these only 14 were recruited; some missing enrolments were caused by the attendance of a PIL-FAST trained paramedic to only one third of cases, with only 58% of those patients being enrolled. 76 from an eligible 200 paramedics volunteered to be trained in the research protocol. Paramedic concerns about longer scene times among those recruited did not materialize. A new paramedic record system was introduced during the study, preventing the investigators to review the entire trial period. Most worrying, these groups identified concerns relating to ‘professional boundaries’ despite apparent ‘enthusiasm for research’.



Paul Middleton

EMJ Associate Editor

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