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4-hour standards and staffing. Can we square the circle?

22 Jul, 16 | by scarley


It’s been a turbulent and highly unpredictable few weeks in the UK. The Brexit vote to leave the EU, a new Prime Minister and the main opposition Labour party seemingly at war with itself have dominated the headlines. In amongst this we have seen the retention of Jeremy Hunt as Secretary of State for health  amidst a brutal cabinet reshuffle.  I think it’s fair to say that this was not a popular choice for many NHS workers, but perhaps it does mean that we have a degree of predictability and continuity.

Or do we?

Yesterday I gave a talk at our local trainee’s day about the future of emergency medicine. I suggested that financial pressures in the UK may lead to a change in the targets that currently dominate departments and the experience of those working in them. The 4-hour target (standard as it is formally known) requires emergency departments to admit or discharge 95% of patients within 4 hours. We’ve not been meeting it for some time (and in fact some hospitals have more bespoke targets but let’s not get picky here). Have a look at the graph below, it does not read well.

Perhaps this is a time to bury bad news and so it was that we heard about a revision/relaxation of the standards for hospitals already in crisis. Some will welcome this, but beware, those of us who remember a time before targets a very much aware that they have driven substantial investment in emergency services and in particular staff. Not enough I grant you, but it has had a significant influence.

Similarly concerns around safe staffing followed reports into patient safety events at Mid Staffs hospital leading to increases in staffing and the stretching of NHS budgets. Many hospitals recruited extra staff to meet safe levels following internal reviews or external reviews from organisations such as the CQC. A safe hospital is not a cheap hospital, and safety relies on trained, motivated and capable staff to look after our patients and each other. This is especially the case in emergency care where staffing is a large part of the budget.

You don’t need to read the entire Francis report on Mid Staffs, but it has been highly influential. The tweet below from Shaun Lintern (who is well worth following) rather sums up that report, essentially it raised the major concern that financial and admin targets can pervert the delivery of safe and effective care. Clearly we don’t want to repeat this.

The double whammy yesterday was the less well publicised report from NHS Improvement stating that many UK hospitals had over recruited and would thus have their budgets cut as a result. The report lists trusts who have allegedly overspent in line with increases in activity or inflation. The methodology has been questioned and the reaction from trusts has been fierce.  Click on the link in Shaun Lintern’s tweet to read the hospitals named. You may well recognise them. I certainly know many well and I can assure you that they are not awash with staff. Many are in significant difficulties facing the constraints of finance, targets amidst a desire to care for patients and keep them safe.

It is difficult to see how emergency care services will balance the financial requirements announced yesterday together with a need to maintain patient safety and deliver a quality service. It is even more difficult to see who will be blamed when the equation cannot be met. I suspect that the NHS senior management will be happy to devolve that to trusts and departments, but we shall see.

For now, for anyone celebrating the death of the 4-hour target, beware, it’s bound to be replaced by something else and that may be even less palatable.




The views expressed here are mine and do not represent the position of the EMJ or BMJ publishing.

What’s the future of medical journals?

10 Jul, 16 | by scarley

The future of medical publishing

I had the pleasure of joining a panel discussion at the recent SMACC conference on the future of medical journals. I was delighted to share the stage with some real big hitters such as Richard Smith (ex editor of the BMJ) and Jeff Drazen (current editor in chief of the NEJM), together with some amazing researchers such as Sara Bassin Flavia Machado, Kathy Rowan, John Myburgh, Simon Finfer and Kath Maitland.

As with all panel discussions there was a degree of entertainment generated by our host Simon Finfer, but this is a significant matter. Journals and the publishing process have a huge role and influence on the conduct, funding and dissemination of science. The panel was assembled with deliberately discordant views to challenge the status quo and to look to what may be a fabulous, or perhaps a more dystopian future.

Richard Smith is a vociferous proponent of a post journal world and you can read his thoughts here. It’s really worth a read as a challenge to how we deliver knowledge from primary research out to those that actually need it and then out to practice, and more importantly to those that will benefit from it i.e. our patients.


I found myself at one end of the on stage sofas with Rob MacSweeney who many of you will know from the Critical Care Reviews website, and with whom I share many views. I think we played our role as challengers to the status quo pretty well. Rob in particular is a fantastic exponent of getting research to the bedside in an ethical and fair way. If you’re not following his blog, and getting his newsletter at critical care reviews then follow the link and think about joining in.

There was too much on the day to summarise here, but I’d ask you to have a think about some of the ideas raised on the day. Right or wrong the panel were challenged on the following.

  1. Publishing in high impact journals is a key to academic promotion. Should it be?
  2. Universities are using a proxy measure (impact factors) to determine promotions. That’s outsourcing a really important measure to a system that has huge flaws.
  3. Similarly, funding organisations measure success in terms of publications in high impact journals. Journals thus have a huge influence on research funding priorities and success. Is this right?
  4. Peer review has been repeatedly shown to have huge flaws, fails to detect fraud, fails to detect poor quality and is prone to interpersonal bias and politics. Can we find a better way?
  5. Social media has the potential to produce post publication review, but is it any good, and can we collate it?
  6. Should we have open publishing, followed by widespread open peer review and then publication, and would this be better at detecting fraud, bias and error?
  7. Some journals make their papers open access after a period of time (e.g NEJM) and this is a good thing, but it would be better if it was sooner. Should all funding agencies demand open access (as many now do)?
  8. The relationship between researchers seeking publication, impact factors, promotion and future funding is complex and arguably at risk of a ‘mutualism’ relationship that does not directly benefit patients. How do we break that relationship (and do we need to)?
  9. Many journals believe that they are providing a service by filtering the poor quality out and only presenting research that is worthy of attention. The question was raised as to whether we need ‘other people’ to do this for us. Do we really need journal editors to be our filters and guides or can we do it for ourselves?
  10. Patients enter trials on the understanding that they will benefit healthcare in the future. Is it therefore unethical that that information is behind a paywall and not widely distributed?

We covered many more topics and I’d recommend a listen when it is eventually released from the SMACC website. For me, straddling the traditional world of journals as an EMJ editor, and also as proponent the new world of #FOAMed it was fascinating. I think it’s increasingly difficult to see how journals can survive in their current format with the rise of easy e-publishing and the ability to engage with a much broader audience across the internet. However, thinking that journals will remain as they are and not adapt to a changing world would be similarly naive. Journals will have to adapt and change and I’m sure they will.

My thoughts are that the role of journals as sole publishers of original research will diminsh, taken over by an open publication, hive-mind reviewed, open multi peer review process (I can dream). This will not mean that journals will die. Arguably there will be an increasing need for the  collation and interpretation of science, and arguably this will be a more effective and useful service for readers. The signs of such a change are already here. For example the BMJ has changed format over the years and now serves original research in a more summary style within the paper version. The detail is available, but not in the paper copy. It seems that accessibility, engagement and interpretation are increasingly valued, and that’s no bad thing. Here at the EMJ the primary survey and the podcasts serve a similar purpose and they are popular.

What then is the future of medical publishing? I’m not sure but I’m fairly confident that the status quo will not continue. What do you think?



EMJ Editor and Editor at St.Emlyn’s virtual hospital, blog and podcast.

PS. The debate was fuelled by some rather fabulous on stage drinks. The 25 year old Bushmills as recommended by Rob was truly stunning.

Conference season

24 Jun, 16 | by scarley

Are conferences dead_

Having just returned from Dublin and the SMACC conference, and a few weeks earlier having travelled to the wonderful IFEM conference in Cape Town it’s time to reflect on the worth of the travel, expense and family disruption that ensues. Our work families too have to pull extra shifts and adapt to those of us lucky enough to get away for a few days away from the department.

In an era of web based technologies, podcasts, vodcasts and associated social media it’s questionable whether we need conferences at all. There are surely cheaper, less expensive and more convenient ways of communicating and in an era of social media it is ever easier to make those connections across the planet.

We should of course not forget the enormous environmental impact of many conferences, notably those large international conferences where 100s of tons of jet fuel are burned into the atmosphere to fuel knowledge dissemination that might so easily have been delivered online.

This is a theme we touched on in the EMJ in a paper looking at the future of conferences where the case for future more environmentally aware and better disseminated conferences was explored.

Innovation in the field of medical conferences.

So are conferences dead?

My experience last week and in South Africa would suggest not. Take the SMACC conference which has gained a bit of a reputation for blending social media, education and entertainment. The participants are almost all involved in online learning and so might be expected to shun the traditional travel to meet and great type affair.  Yet it is precisely this audience of online engaged clinicians who seek out the ability to meet, to network, to share, to laugh, cry and share together. This year the conference sold out in a matter of hours with competitions being held for the remaining tickets. The interest and anticipation to meet with like minded enthusiasts from across the globe was palpable and at times a little over the top and uncomfortable. The demographic was young, multicultural and multiprofessional. This is not typical behaviour for medical conferences, and perhaps is more akin to pop concert tickets. It’s a situation that makes some feel uncomfortable, but there is no doubt that it is engaging a worldwide population of learners.

A paradox perhaps, that the conference espousing an online socially connected world is one that sells out in hours and has a waiting list of those wanting to attend.

I’ve not quite got my head round this yet, but I think there may be at least two elements at work. Firstly there is a natural human desire to connect and conferences allow that, online interactions are good, but they are not the real thing and it’s great to meet in person, to explore ideas and to satisfy a human need to put faces to names. Secondly, although I find the online education world fascinating, there is only so much it can do. A live presentation of high quality is unsurpassed as a learning experience and you simply can’t do some things online.

Take the on stage discussion at SMACC on the future of medical journals as discussed by Richard Smith (ex BMJ editor). That was a great session that simply could not work as well in any other setting. A blend of science, politics, fun and entertainment with some really important discussion points and views.

Richard Smith: What will the post journal world look like?

So, the conference is far from dead, but it is changing. It’s role as a prime means of delivering information is perhaps waning, but as an opportunity to form and build social links, collaborations and understanding it is surely on the rise.

So I guess I’ll probably see you in an auditorium soon. If you do then say ‘hi’. After all, the people are just as important as the presentations. Collaborations, discussions and developments come from interaction, not from powerpoint.




DOI: I’ve had supporting expenses to travel to many conferences, including SMACC last week. I am unbelievably lucky and priviliged to do so. I’ve actively supported a range of innovative conferences and believe that the old model of boring lectures given by boring speakers on boring subjects is a waste of time.

OT in the ED

2 Jun, 16 | by cgray

“Occupational therapists help people to do the things they want to do”

In this month’s EMJ, Kirstin James details the work that occupational therapists (OTs) have been carrying out up and down the country’s emergency departments to facilitate a return to normality after an illness or injury. She tells the story of an 87 year old lady called Mrs MacDonald, well known in various guises throughout our profession, and how she assessed her physically, cognitively, and socially to determine her ongoing needs after a fall and humerus fracture. By carrying out her assessment and determining the patient’s needs, Kirstin could enable Mrs MacDonald to go home. She organised care visits by the crisis team whilst more permanent arrangements were being made, procured equipment to make it easier for Mrs MacDonald to get around the house and go to the toilet, and made sure she had the support she needed.

Kirstin made it possible for Mrs MacDonald to do the things she wanted to do, and to do them in her own home rather than a hospital bed.

Whilst my local ED doesn’t have direct occupational therapy input, we can admit patients to our observation unit to be assessed by a multidisciplinary team comprising of physiotherapists, OTs, and discharge co-ordinators who can facilitate access to community nursing and other services. Once they have been assessed, a decision can be made on whether the patient is safe to go home that day (with or without further assessment in the near future), or that they need measures put in place before they go home. Sometimes these measures take time and, after discussing it with the patient, it may be better for them to be admitted to one of the main hospital wards to allow this to take place.

Kirstin’s article is a fantastic reminder that our work in emergency medicine isn’t just about fixing a medical problem. We also have to consider the impact that this medical problem is going to have on our patient when they get home. Are they still going to be able to eat, drink, move around their house, go to the toilet? What help do they need to allow this to happen? Who else is, or can be, at home with them? Thinking about these issues early on may help the patient to get better more quickly, and avoid further ED attendances and subsequent hospital stays.

If you don’t know how to access occupational therapy in your ED, find out! And if you do know, let us know what happens where you are. We’d love to hear.




James K. Occupational therapists in Emergency Departments. Emerg Med J 2016;33:442-443.

Diagnosing Small Bowel Obstruction in the ED: A Role for Ultrasound?

23 May, 16 | by rlloyd

Diagnosing small bowel obstruction (SBO) is bread-and-butter work for the emergency physician. It accounts for 2% of patients presenting to the ED with abdominal pain, and 20% of all surgical admissions[1]. In the developing world the majority of SBO patients have had previous intra-abdominal surgeries causing adhesions… But I won’t delve into aetiology, let’s talk diagnostics.

The May 2016 EMJ issue’s ‘Image Challenge’ is a classic case[2]. An adult male with significant surgical history (caecal adenocarcinoma with subsequent right hemicolectomy) presents to the ED complaining of abdominal pain and vomiting. His abdomen is distended and diffusely tender. Slam dunk.

How would I manage this patient in the ED? Having made them nil by mouth, started IV fluids, and given adequate analgesia, I’ll request the routine plain x-rays (abdominal and erect chest) that almost all of my acute abdomen patients get. A positive AXR for SBO (centrally distributed dilated loops with valvulae conniventes/air fluid levels) will prompt me to insert a nasogastric tube, and call the surgeons with a view to CT/a trip to theatre. I imagine that’s fairly common practice up and down the UK.

The image provided for the discussed case is an ultrasound image showing dilated, fluid-filled loops of bowel – suggestive of SBO. It turns out AXR is pretty useless at detecting SBO, particularly when you consider how much we rely on it traditionally, with a sensitivity of 50-60%[3]. Ultrasound is a quick, cheap, radiation-free option available to us in the ED. And guess what? It’s more reliable than AXR for detecting SBO. Some evidence was published in the EMJ back in 2013 – let’s take a look. 

Jang et al prospectively enrolled 76 adults in the ED who were suspected to have SBO, and going for a CT[4]. All patients had an ultrasound exam performed by an EM resident, along with an AXR interpreted by a radiologist. The reference standard for SBO diagnosis was the CT result.

Each EM resident already had a basic understanding and experience of point-of-care scanning, having all undergone a prior introductory course. They were given only a 10 minute (!!) practical tutorial in SBO ultrasonography, and then 5 practice scans prior to being let loose on the study patients. A 10 minute tutorial is fairly minimal prep I think most would agree.

A positive ultrasound was defined as either:

  1. Dilated loops (>2.5cm) of fluid-filled dilated bowel proximal to normal/collapsed bowel
  2. Reduced peristalsis – back-and-forth movement of spot echoes inside fluid-filled bowel

Participants were taught to scan in the paracolic gutters bilaterally, epigastric and suprapubic regions. This is the standard approach to SBO ultrasound – see this video for a great tutorial on how to perform the scan. Interestingly, in this study the phased array probe was used instead of the curvilinear – the usual option for transabdominal scanning.

Ultrasonography comfortably outperformed plain radiography in detecting SBO. A sensitivity of 93.9% and specificity of 81.4% left AXR trailing behind with a sensitivity of 46% and specificity of 67%. Dilated loops on ultrasound proved to be far more sensitive than reduced peristalsis – probably because reduced peristalsis is generally considered to be a late finding in SBO, often seen with strangulation[5].

Of course there are limitations with this small study. There was a disproportionately high prevalence of SBO in the study population (33 out of 76 patients – 43%), bringing into question its external validity. The doctors performing the US exams volunteered themselves, indicating they were enthusiasts – potentially introducing what the authors describe as ‘ultrasound-interest’ bias. And of course, the participants knew they were being compared to a standard, bringing the Hawthorne Effect into play. Nonetheless, pretty convincing stuff.

And there’s more. Here is some further reading:

Unluer, E.E., et al., Ultrasonography by emergency medicine and radiology residents for the diagnosis of small bowel obstruction. Eur J Emerg Med, 2010. 17(5): p. 260-4.

Schmutz, G.R., et al., Small bowel obstruction: role and contribution of sonography. Eur Radiol, 1997. 7(7): p. 1054-8.

Something else to consider, is that additional information can be picked up when performing a bedside scan on a patient in whom there is a concern for SBO – free fluid between bowel loops, no peristalsis, or >3mm bowel wall thickening suggests bowel wall ischaemia[6]. Gallstones in the presence of dilated loops? Think gallstone ileus. A lurking AAA might even be picked up.

I’m not suggesting that plain radiography no longer has a role in the suspected SBO patient. Surely though, adding bedside ultrasound to our list of investigative options is an opportunity to improve patient care. A negative scan would provide added reassurance when ruling the diagnosis out in less concerning patients; and we can expedite initial/definitive management in the high-risk patients who have an equivocal AXR.

Ultrasound will always be operator-dependent, but Jang et al have demonstrated that scanning for SBO is a relatively easy skill to acquire. Encouraging stuff.

What is your approach? Does ultrasound have a role in these patients? We would love to hear your thoughts in the comments.

Robert Lloyd

Some more online resources

A video with some more discussion on the Jang paper – the Ultrasound Podcast

Tips and Tricks: Clinical Ultrasound for Small Bowel Obstruction – A Better Diagnostic Tool

Ultrasound for Small Bowel Obstruction – emDocs blog


  1. Delabrousse, E., et al., CT of small bowel obstruction in adults. Abdom Imaging, 2003. 28(2): p. 257-66.
  2. John Eicken, S.E.F., Image challenge: Adult male with abdominal pain and vomiting. Emerg Med J 2016;33:5 337 doi:10.1136/emermed-2015-205181.
  3. Dr Henry Knipe, D.J.J., Small Bowel Obstruction, in
  4. Jang, T.B., D. Schindler, and A.H. Kaji, Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J, 2011. 28(8): p. 676-8.
  5. Guttman, J., et al., Point-of-care ultrasonography for the diagnosis of small bowel obstruction in the emergency department. CJEM, 2015. 17(2): p. 206-9.
  6. Alice Chao, M.a.L.G., MD, FACEP, Tips and Tricks: Clinical Ultrasound for Small Bowel Obstruction – A Better Diagnostic Tool? Emergency Ultrasound Section Newsletter – October 2014.

New RCEM Guidelines – Acute Behavioural Disturbance

19 May, 16 | by cgray


The Royal College of Emergency Medicine in the UK has today published new guidelines (PDF) on the management of acute behavioural disturbance (ABD) in the emergency department. This follows a year after NICE guidance was released on the management of violence and aggression, but focuses specifically on ABD. The guidelines have been published in conjunction with the Faculty of Forensic and Legal Medicine.

ABD is a medical emergency, comprising acute delirium in conjunction with autonomic dysfunction. Sudden death occurs in around 10% of presentations. It can be challenging clinically as there is no definitive diagnostic investigation, and symptoms can overlap with multiple severe and life-threatening presentations such as serotonin syndrome and heat stroke.

The main recommendations in the guidelines are:

  • Restraint measures should commence with verbal calming and de-escalation techniques. Physical restraint should be kept to a minimum and used as a last resort option to facilitate chemical sedation.
  • Sedation should ideally be administered intravenously, however this comes with safety considerations and clinicians should keep these in mind. Dynamic risk assessment may prompt intramuscular (IM) sedation followed by cannulation.
  • Intramuscular lorazepam is recommended for first line use by NICE, however benzodiazepines have a variable response between patients and may require active titration. Onset time is also slow and can be unpredictable when given IM. Ketamine has a more consistent profile and has the benefits of airway reflex and respiratory drive preservation, though could theoretically worsen any cardiac instability. Clinicians should use sedatives that they are familiar with, full patient monitoring should be used, and early anaesthetic input should be sought.
  • Patients should be closely monitored for development of hyperkalaemia, rhabdomyolysis and disseminated intravascular coagulation (DIC), both clinically and by utilising appropriate blood tests.
  • Active cooling should be undertaken early and aggressively to treat hyperthermia.
  • Intravenous fluids should be used early to treat hypovolaemia and correct metabolic acidosis.
  • Patients are likely to require ongoing management in a critical care environment. This should be decided on an individual basis.

This is a summary of the guidance. The full document can be read here together with references and a table of dose, onset and duration for commonly used sedatives and tranquillisers.

UK emergency department performance: Failure or Success.

14 May, 16 | by scarley


Recent figures suggest that UK emergency systems are failing to meet the 4-hour standard (aka the 4 hour target). At first glance this is true the data shows that 88.7% of patients are seen and discharged/admitted within 4 hours as compared to the target (I’m going to stick with target) of 95%.

This has been described as ‘worst ever month’ and if we look at simple percentages that’s true.

Sadly, comments such as failure and worst are demoralising for the teams who are working really hard to deliver emergency care in an overworked and stressed system. The key here is in the percentages, they underestimate the number of patients actually seen in a system that is seeing more patients every year.

It is perhaps worthy to note that in the last quarter figures there were 5,867,323 attendances at UK emergency departments. Of these 711,201 waited more than 4 hours.

In other words we managed 5.15 Million patients within the 4 hour target.

Well done all. This is not a failure, it’s an incredible achievement considering the current staffing, political and financial climate. Times are tough, the target may not be met, but let’s keep some perspective.

This is a huge achievement.



Further reading

BBC on worst ever results for UK Emergency care

RCEM response to figures

King’s fund response to latest statistics.

NHS emergency care statistics

Highlights from the May 2016 issue.

11 May, 16 | by scarley

Simon Carley, Social Media Editor


I’m rather hoping that in the Northern Hemisphere at least, our May edition will feel as though summer has arrived with perhaps slightly more time for personal and organisational development. Winter was tough here in the UK, so let’s hope the better weather brings a bit of relief. Even now crowding looms large in our collective memory with an interesting paper and accompanying editorial focusing on its effect on our emergency departments (EDs).

The complexities of measuring crowding in the ED

Adrian Boyle and colleagues examined two scoring systems, NEDOCS and sICMED together with staff perceptions to look at ways of measuring crowding in the ED. Clearly crowding is a multifactorial perception including aspects such as patient load, flow and severity. They collected real time data using these measures demonstrating that some of this data can be collected in real time but that they cannot reflect hour by hour variation. Further work is needed to give us a score that could be used to track and compare ED crowding and it’s inherent dangers to patients and staff.

Parents, paediatrics and perceptions

As a consultant who works in a paediatric ED I can understand why Astha Singal and colleagues decided to examine avoidable paediatric ED visits. Although this study is from the US, with alternative funding and insurance mechanisms the implication here about increasing numbers of primary care visits to the ED for children will be familiar to many of us, regardless of where we work. They found that the families socio-economic position, notably food security, was a strong predictor of attendance. Many parents agreed that alternative health providers could have cared for their children, but difficulties in accessing alternative services led to children being brought to the ED. This is another useful study demonstrating that public health and economic factors have significant impact on our workload and patient mix.

Paediatric early warning score scores and predictions

More paediatrics from the UK this month with an analysis of the ability of paediatric early warning score (PEWS) to predict admission and significant illness. PEWS has certainly been popular in recent years, with several papers published in the EMJ on the subject, but the score was designed to be used in the in patient setting, In this single centre study PEWS performance was assessed in the ED population. Interestingly they found a high specificity, but low specificity which is typically the opposite of what we require of an ED screening tool. The reported sensitivity, as low as 30%, means that it’s ability to screen for significant illness or admission is too low. Perhaps we need something better derived from the ED population.

Tanzanian Gestalt for anaemia

In this study clinicians were challenged to predict the outcomes of a blood count using clinical judgment (described as Gestalt in this paper). In this clinical setting anaemia is common and an important diagnostic finding. Clinically the physicians did well as measured by concordance, but that is to be expected. However, their ability to pick up severe anaemia only had a sensitivity of 64%, and for moderate anaemia only 56%. This may be on the low side for clinical practice and thus laboratory testing will still be needed. The specificity for moderate and severe anaemia was better and may be high enough to guide resuscitation whilst waiting for the lab results.

Tailored training improves CPR performance

Govender and colleagues examined the impact of a tailored teaching programme to teach CPR to paramedics. The addition of tailored pre and post interventions improved performance. The bottom line is that if you teach people more often and with a range of materials they learn more and can do better.

Transcutaneous carbon dioxide

We frequently measure CO2 levels in the ED, with the use of arterial blood gases acting as the gold standard. However, these can be difficult to obtain, painful for the patient and are not without potential complications. A non-invasive method would surely be better and such devices do exist. This month Nicolas Peschanski and colleagues compare transcutaneous readings with arterial samples amongst patients with respiratory problems in the ED (the group we would be interested). Sadly only about a third of readings were within 5 mm Hg between the non invasive method and the blood gas. Clearly we can’t abandon the blood gas yet.

Prehospital referrals for falls

Elderly fallers are a high risk population for all in emergency medicine and in prehospital care. A simple fall may be a harbinger of significant pathology that may be eminently treatable. In this systematic review by Zozula et al the evidence for prehospital teams assessing and referring patients for referral to falls services shows that the evidence base is pretty weak. In this incredibly important area we clearly need better work linked to patient outcomes before we can assess the impact of prehospital referral.

Stress tests after Troponin

There has been a huge amount of work regarding the exclusion of myocardial damage using troponin testing in the ED. However, thee have been concerns that simply troponin testing will miss patients with significant coronary disease, but who have yet not manifest myocardial damage as shown by a troponin leak. In this study by Aldous and colleagues they looked at patients who were negative for troponin tests, but who then had a stress test. Interestingly they identified 34 patients from 709 who subsequently went on to revascularization. It’s tricky to know what this means for clinical practice, and of course we must remember that the new generation of high sensitivity troponins might yield a different result.

Acute Kidney Injury in the ED

Finally, we have a review article from Patrick Nee and colleagues on the recognition of Acute Kidney Injury in the ED. This is a common problem in the ED and one where emergency physicians should have some expertise in. It’s also quite a common question in exams, so there is something for everyone on this important topic.

Highlights from the April 2016 issue.

11 Apr, 16 | by scarley

Ellen J Weber, Editor in Chief



The articles in this issue are about error. Error was rarely discussed “out loud” in the medical journals until the Institute of Medicine (IOM) in the US published its 1999 report “To err is human” documenting the many lives that were lost as a result of errors in the delivery of health care.1 Even today, physicians find it hard to talk about their errors, not simply because of the fear of a lawsuit, but out of embarrassment and their sense of personal failure. In the years since the IOM report, we’ve seen much more in the news, the peer-reviewed literature and from the leadership of our institutions about avoiding errors, much of it couched under kinder terms, such as safety and quality. To avoid laying blame (which might hinder disclosure of errors), the focus has shifted to how systems of care contribute to a patient sustaining harm. Anyone who has attended a patient safety lecture has been entertained by Reason’s diagram of all the holes in the swiss cheese lining up.2

But to face facts, physicians do make errors. And while it is important to engineer the delivery system so that the errors can be caught (and sometimes prevented), we also need to understand how our own thinking processes lead us to make errors in the first place. For this reason, our issue on error begins with an insightful commentary by Pat Croskerry, an emergency physician and psychologist who is an internationally recognised expert on patient safety and diagnostic errors. Cognitive bias, he explains, is lurking behind every patient interaction to potentially trip us up. Finding ways to recognise—and mitigate—that cognitive bias is essential to improving our ability to make good diagnostic decisions.

We then present two ‘studies in scarlet,’ so to speak: investigations of the types of diagnostic errors physicians make. Okafor and colleagues analysed 509 incidents voluntarily reported by physicians and found that 209 were related to diagnostic errors. They classified the errors as cognitive, system related or unremediable; while system factors were found in 34% of cases, cognitive errors were more frequent, occurring in 41% of cases. Medford-Davis and colleagues reviewed the charts of 100 adult ED patients presenting with abdominal pain who were discharged, or who returned within the next 10 days and were hospitalised. 35 of the patients had diagnostic errors, with about ½ of these considered to have the potential for serious harm. Most of the errors could be classified as due to failure to obtain an appropriate history or physical, not ordering appropriate tests, and failure to follow up on the tests.

In a third report by Broder and colleagues, you will undoubtedly identify with the young emergency physician who finds himself in the middle of a procedure with an unfamiliar piece of equipment, and continues the procedure, with a resulting complication. The paper dissects many contributors to error: perceived time constraints, lack of experience, lack of control over the environment (such as equipment choices) over-confidence, and non-intuitively designed and marked devices. This paper, which might rightly be titled “anatomy of an error” also demonstrates what measures can be taken to prevent this from happening again.

Looking at our errors is one way to avoid them in the future. Additionally, we need, as Dr Croskerry writes, to devise strategies to mitigate our cognitive bias. One of these is to improve the accuracy and details of our history and physical examination, as greater understanding of the problem can prompt a wider differential. I would argue this is particularly important for our younger physicians, who have not encountered the breadth of disease or its many manifestations, and who may be too quick to jump to an investigation to answer the question. Two papers in this issue address workplace strategies to avoid errors for cases that may be particularly challenging. Haworth et al created a proforma for the documentation of the exam in patients with facial injuries, resulting in much more detailed description of injuries. Marsh et al took advantage of the imprinting of childhood games by adapting “Rock, Paper Scissors” (in Brooklyn NY it was “rock, paper, scissors, match, actually) to “Rock, Paper, Scissor, OK”, creating an aide memoire for examining nerve function in children with upper extremity injuries.

What about pre-hospital care? Patterson and colleagues, who previously published a study in the EMJ about teammate familiarity in the ED, provide a study demonstrating workplace injuries are far more frequent (100 fold) for paramedics who worked one shift together compared with those who work 10 or more together in a two-year period. Murphy and colleagues describe the development of key performance indicators for prehospital care, going far beyond the traditional focus on response time. While conducted in Ireland, the results of this study have universal application. This month’s View from Here describes a stabbing case in which the victim received suboptimal care—and how they have used this event to make major improvements.

Finally, we present a provocative idea that may allow physicians to acknowledge uncertainty. In our first “Concepts” paper, Whyte and Vincent remind us of the concept of measurement uncertainty (MU) which gives a range of the possible values of the test, rather than single figure. The authors argue that by reporting MU clinicians would need to rely on their clinical impression (based on history and physical) to interpret the result, thereby restoring the power of clinical observation expounded by Sir William Osler.

Given all these articles on error and how we might prevent it, you might wonder how safe emergency medicine is. Ramlakhan and colleagues review the many potential hazards we face, and the data on how they impact patient safety. Surprisingly, they conclude that “when compared with other clinical areas or specialties, the ED is not particularly unsafe.” Perhaps its because, as this issue shows, we are willing to think about thinking, acknowledge our errors, and are continually working to mitigate against the threats we face, even if in the end, we are only human.

Highlights from the March 2016 issue.

11 Mar, 16 | by scarley

Richard Body, Associate Editor



The burden of alcohol

Anyone who works in an Emergency Department (ED) will know how many attendances seem to be related to the use of alcohol. In this issue, the paper by Parkinson et al quantifies the problem, informing us about the proportion of cases that are attributable to alcohol and the most common reasons for alcohol-related attendance. They also estimate the substantial financial cost that this incurs. This fascinating study combined a retrospective chart review of attendances and a prospective evaluation in which breath alcohol concentration was measured in patients attending the ED. The authors found that the peak time for alcohol-related attendances was between 2am and 3am, during which period 59% of patients attending the ED had ingested alcohol. Looking only at attendances on Fridays and Saturdays between 2am and 3am, a staggering 71.9% of all attendances were alcohol-related. One in every six of these patients was admitted to an inpatient ward at a mean cost of £851 per patient, which makes for an expensive night out on the National Health Service. Building on and interpreting those findings, the President of the Royal College of Emergency Medicine asks what we can do to address this problem. In a fascinating commentary, Dr Cliff Mann discusses the potential role of everything from alcohol pricing to licensing hours.

Perimortem caesarean section

There is little doubt that one of the most stressful situations an emergency physician can ever face is to be responsible for treating a heavily pregnant woman in cardiac arrest. Emergency physicians will be fully aware of the need to rapidly proceed to emergent caesarean section, but (given that this is thankfully an extremely rare situation) how many of us are actually prepared to undertake that procedure? Richard Parry provides a comprehensive overview of this procedure including a very practical 25-step ‘how to’ guide that is likely to be an extremely valuable resource for emergency physicians. Dr Parry goes on to appraise the evidence for this procedure, highlighting the ‘4 minute rule’ to deliver the baby and how the evidence supports the time critical nature of peri-mortem caesarean section as a means of preventing neurological sequelae for the baby. Clearly, minutes matter.

Editor’s choice: Can ultrasound confirm central line placement?

Central venous catheter (CVC) placement is another intervention that is often time critical in the ED. Confirming accurate line position can be time consuming, however, when we rely on chest radiographs. This month the Editor’s choice is a prospective cohort study from North Carolina in the United States, which compares the use of ultrasound with chest radiography (the reference standard) for confirming CVC placement. Although the number of line misplacements was small (n=4), this study has described a promising technique (the saline flush echo test) that effectively had 75% sensitivity for detecting suboptimal CVC tip placement. Perhaps the greatest advantage of ultrasound over chest radiography was the time taken to test completion, which was a median of 23.8 minutes faster with ultrasound.

Reader’s choice: Frequent users of the ED

Perhaps at the other end of the spectrum for ‘excitement’ in Emergency Medicine, frequent attendees can account for a significant proportion of the ED workload. When patients attend the ED very regularly, it may be tempting to feel reassured and potentially (heaven forbid) even slightly cynical about the nature of their acute complaint. The systematic review by Moe et al examined prognosis in this group. Perhaps unsurprisingly for experienced emergency physicians, five out of six studies identified reported that frequent attendees have higher mortality than non-frequent attendees with a median odds ratio of 2.2. Frequent attendees were also more likely to be admitted to hospital and to use outpatient services following their ED attendance. The work highlights the need to take this important and vulnerable group of patients seriously and calls us on to undertake further research that may help to address their adverse prognosis.

Procedural sedation: Patient’s choice?

Procedural sedation is a core skill in Emergency Medicine in order to facilitate the undertaking of procedures that may otherwise be unbearably painful for patients. It is tempting to assume that our use of conscious sedation will leave patients blissfully unaware of the procedure afterwards. However, as Dr Gavin Lloyd and Dr Alasdair Gray discuss in a stimulating editorial, this may not be an accurate assumption to make. They discuss a recent report from the Royal College of Anaesthetists and Association of Anaesthetists of Great Britain & Ireland, which recommends avoidance of falsely reassuring terminology when explaining procedural sedation to patients, and they call us on to seek feedback from patients after the procedure in order that we may know how satisfied they were and whether they did, in fact, have any painful recall.

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