Primary Survey August 2016. EMJ

Richard Body, Associate Editor

Editor’s choice: Nurse versus computer for paediatric triage

This month, Takahashi et al present a retrospective cohort study evaluating the impact of allowing nurses to change the triage priority assigned by the computerised Japanese Triage and Acuity algorithm (JTAS), which is based on the patient’s presenting complaint, historical factors and physiological parameters. In particular, the nurses could assign a lower triage category if they felt that the triage category was inappropriately high based on physiological parameters recorded when a child is distressed or looks otherwise well. The re-categorised triage priorities more appropriately predicted the need for hospital admission. This study presents early evidence to suggest that the ‘gestalt’ of experienced triage nurses could be used to avoid over-treatment and it provides an excellent platform for future work that is designed to evaluate safety outcomes.

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Head injury: after the ‘golden hour’ come the danger hours?

It might seem reassuring when patients present late after a head injury. If a patient is going to have an intracranial haemorrhage, in usual circumstances we expect it to become apparent in the first 24 hours after injury. Marincowitz et al investigated the incidence of traumatic abnormalities in 101 late presenters. They also evaluated the performance of the National Institute for Health and Care Excellence (NICE) criteria for computerised tomography (CT) scanning in that group. There were two very interesting findings. First, an astounding 9.9% of late-presenting patients had a traumatic abnormality, 3% required neurosurgery and 1% died. We should bear in mind that the sample size is small and there is potential for selection bias: only patients who underwent CT scanning were included. We therefore wouldn’t expect such a high incidence in undifferentiated late-presenting patients, so it is important that clinicians don’t over-react to this initial finding.

Second, however, is the fact that the NICE criteria for cranial CT scanning missed 30% of traumatic abnormalities. While you may react to that figure by questioning the clinical significance of those injuries, when you read this paper you should note that 25% of patients who required neurosurgery or died were also missed by the NICE criteria. This work therefore appears to clearly demonstrate the need for a bespoke clinical decision rule to guide the management of patients who present >24 h after head injury.

Paediatric procedural sedation: is the UK falling behind?

The literature on procedural sedation for children in the Emergency Department extends back at least 25 years. As long ago as 1998, McGlone et al described the use of ketamine as an alternative to “brutacaine” in the Journal of Accident & Emergency Medicine.1 The benefits of avoiding hospital admission and general anaesthesia are readily apparent. It is alarming, therefore, that the qualitative analysis of focus group data by McCoy et al this month reveals that emergency physicians in the United Kingdom are still experiencing many barriers in delivering this service. In a linked editorial, Krauss and Green provide a number of helpful tips for Paediatric Emergency Departments in the United Kingdom, based on their experience in the United States where procedural sedation protocols are long established. Both papers clearly highlight a pressing need to develop practice in parts of the United Kingdom. They call for a national response to improve training and competency assessment for this important skill.

Do nice doctors get sued?

According to an old medical myth, less skilled surgeons may make up for what they lack in technical ability by being excellent communicators. In this issue of the journal, Smith et al report an innovative randomised controlled trial in which patients in an Emergency Department waiting room were each shown a video of a doctor-patient encounter but were randomised to see a video that included some empathic statements made by the doctor or one that did not. The patients viewing videos of an ‘empathic’ doctor were less likely to report that they would sue the doctor if something went wrong. It seems, therefore, that nice doctors are less likely to be sued. However, before we step up our communication skills training at the expense of honing clinical skills, we should read the full paper and exercise caution. Nice doctors may have been slightly less likely to be sued but the difference was small and some patients would still have sued the ‘nice’ or ‘empathic’ doctors.

The human side of pre-hospital research

Most readers are likely to be familiar with PARAMEDIC, a large cluster randomised controlled trial evaluating the use of a manual compression device in pre-hospital cardiopulmonary resuscitation.2 The trial enrolled 4,771 patients in the pre-hospital environment, which was a huge success. In this issue of EMJ, Pocock et al explored the human factors that influenced delivery of the trial by paramedics. The findings of this survey provide some fascinating insights into the requirements for successful research delivery. This paper is therefore essential reading for anyone contemplating undertaking research in this highly challenging environment.

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