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Primary Survey

Primary Survey August 2017.

2 Aug, 17 | by scarley

Clinical pharmacists improve practice in emergency departments

There are 2 studies in this month’s issue which show the benefits of clinical pharmacy input in the setting of an emergency department (ED). One from Spain and one from Belgium. It is a relatively high risk area for drug medication errors as there is a fast turnover of large numbers of patients, the use of drugs which include those with significant toxic effects as well as potentially life threatening impacts, plenty of opportunity of miscommunication and many interruptions to nursing and medical staff whilst carrying out prescribing duties and administrating therapeutic agents. Read the editorial here.

Clinical relevance of pharmacist intervention in an emergency department

The first study looked at the impact of a clinical pharmacist working between 8 am to three pm Monday to Tuesday over a non-consecutive 6 month period in an ED with over 100 000 attendees per year. There was an electronic prescription system and a short stay facility (for 24 hours maximum).

Severity scales that looked at the drug errors and their potential impact of patient’s well-being, the clinical impact of the intervention by the clinical pharmacist were used as outcome measures. About 10% of patients were reviewed, over one fifth of whom were in the short stay facility, of whom 13% were finally admitted to hospital.

The majority of activity was to prescribe drugs that the patient was on at home or to  give  a suitable alternative from the hospital formulary. Other trends noted included the ‘over prescription’ of certain drugs like omeprazole and simvastin. There may have been a Hawthorne  effect as there was not a rise or drop in the error rate of ‘high alert medications and increased errors or interventions’ as compared with other studies.

Developing a decision rule to optimise clinical pharmacist resources for medication reconciliation in the emergency department

The second study produced a clinical decision rule (CDR) for the identification of patients admitted from ED with discrepancy in the initial medical history taking about medications.

This was a study based on looking at 3592 patients and using  variables such as age, gender, the medical discipline who admitted them, when in the year they were admitted and if there were any high risk drugs administered, among other factors. The purpose was to reduce error and to save time in the ED (the gold standard of a complete assessment by a clinical pharmacist was 20 min, with an estimated average number of 20 such assessments being possible in a working shift.

The most common error found in validating this was the omission of drugs that the patient was taken when looking at routine clerkings. In the final CDR chosen for ED, there were the advantages that many of the fields were already included in routine data collection as part of the patient’s journey to being admitted (reducing time and the need for repeated history taking). Key features for future developments are to quantify the potential benefits associated with the use of the CDR from a patient perspective, and as with the first study, health economic modelling would be an important addendum in prospective work.

Validating the Manchester Acute Coronary Syndromes (MACS) and Troponin-only Manchester Acute Coronary Syndromes (T-MACS) rules for the prediction of acute myocardial infarction in patients presenting to the emergency department with chest pain

This observational study was to validate and compare both rules in an Australia and New Zealand ED settings. The results showed that both could determine low risk patients, with sensitivity results of 99%, MACE identifying 10.7% and T-MACS in 19.8% of patients with acute MI at 30 days.

‘The year of first aid’: effectiveness of a 3 day first aid programme for 7–14 year-old primary school children

Can you teach young children adult BLS, use an AED, managing an unconscious patient, deal with haemorrhage and calling for an ambulance?

The answer is yes to most of the parameters recorded- after teaching, by theoretical knowledge and skill teaching, there was a marked improvement in the delivery of performing BLS including giving ventilation and chest compressions and using of an AED in over 90% of children. The height, weight, age and BMI played a part in the ability to deliver adequate force required to have chest compressions. This is not surprising, given the change in muscle bulk and maturation of the fibre types with the onset of adolescence. This links to the annual Restart a Heart Day on 16th October when children across Europe are taught basic life support (; in the UK, last year over 150 000 children received training. The conclusions of the article that ‘beginning first aid education in schools is strongly recommended’ should be legally mandated- other studies have shown that although very young children may not be physically capable of producing adequate force for chest compressions, they are able to instruct others (and often teach their parents at home what to do, after learning about it at school!)

Emergency department care of childhood epistaxis

What works? This review looks at 32 articles after a comprehensive literature search and provides a framework of treating active and recurrent nose bleeding. A very practical and useful guide to a common problem.


Ian K Maconochie, Deputy Editor

Primary Survey June 2017.

8 Jun, 17 | by scarley

This month’s editor’s choice is actually a pair of papers: one, a study on the diagnostic characteristics of the T-MACS chest pain risk stratification score AND the other, a paper explaining a key methodological concept used in this and other studies of diagnostic tests, the receiving operator characteristic ROC) curve (Richard Body (an associate editor of EMJ) and colleagues previously developed the MACS rule, which classifies patients as very low risk or very high risk after the results of an initial set of biomarkers are known, TMACS relies on obtaining both high sensitivity troponin and heart-type fatty acid, but the latter biomarker not widely available. A modified rule, the MACS score, uses only high-sensitivity troponin and in the current study the authors evaluate this new rule’s test characteristics, using the ROC curve. Hui Zhe Hoo, Clinical Research Fellow at the University of Sheffield and a respiratory physician, explains the fundamentals of the ROC curve using this paper as an example. This is the third in EMJ’s occasional series of articles explaining statistical concepts frequently found in the emergency medicine literature.

Still a cinderella service

Demand for mental healthcare in the ED continues to rise. Sadly this rise increasingly includes children and the provision of child and adolescent mental health services (CAMHS) in most emergency departments falls well short of what is needed. Thus, a systemic review in this issue by Newton and colleagues from Canada on children’s mental health crises in the ED makes interesting reading. A previous review undertaken by these authors in 2010 provided some evidence to support the use of specialised care models to reduce hospitalisation, return ED visits and length of ED stay. In the current study they report increase in research over the past few years, yet most of the evidence is limited by weak methodology. It is evident that the specialised resources and skills needed are still not readily available and the authors reiterate the need for high quality evidence to guide mental health screening, early and effective interventions and on-going follow-up care after an ED visit. I suspect few of us would dispute this view.

Ladders or smiley faces?

Accurate assessment of pain due to an acute injury can be challenging especially when the child is distressed and anxious, but providing timely and effective analgesia is key to child and carer comfort and satisfaction.This issue includes an interesting paper by Ffion James and colleagues from Wales who set out to assess the inter-rater agreement of the Royal College of Emergency Medicine (RCEM) composite pain scale. The majority of pain assessment tools for children were designed for post-operative or chronic pain and not for sudden and acute pain due to injury. The RCEM composite tool combines the numerical rating scale (Ladder), a modified Wong –Baker Faces Pain Scale (Faces scale) and a Behaviour score which groups pain into four categories based on severity. To date the reliability of this scale has not been assessed. In their study, pain severity was assessed by the triage nurse doctor and child (depending on their age) using the composite pain scale. The Faces Scale demonstrated greater inter-rater agreement than the Behaviour Scale, while the Ladder demonstrated poor inter- rater agreement in comparison with the Behaviour score. The authors conclude the Ladder score could be omitted from this composite tool.

Using emergency data for public health interventions

Two studies in this issue demonstrate how data from emergency care can be used to inform public health interventions. Acute and chronic alcohol intoxication, a worrying global public health issue, is the cause of many health and social problems. Reunion Island in the South West Indian ocean is no exception. Reunion Island is among the four French regions where premature mortality due to alcoholism and cirrhosis is the highest and foetal alcohol syndrome is seven times higher than that of metropolitan France. Vilain and colleagues undertook an exploratory analysis based on syndromic surveillance data to describe the emergency department visits for alcohol intoxication and factors associated with their variation. Alcohol intoxication attendances were the second most common reason for ED attendances after trauma and these attendances increased significantly on benefit payday, weekends and public holidays. The authors conclude this kind of syndromic surveillance system for monitoring public health data other than infectious diseases can be used to inform initiatives to reduce morbidity and mortality from alcohol intoxication.

According to the WHO, interpersonal violence accounts for around half a million deaths a year globally. This figure will come as no surprise to ED clinicians and may even be regarded as conservative by those caring for victims on a daily basis. Addressing violence has traditionally been a police concern, so it was interesting to read of a cross sectional study by Quigg and colleagues in the UK which explored the potential of ambulance call out data in understanding patterns of violence to inform prevention activity. This paper is well worth a read as ED’s will see similar trajectories and trends. The majority of call outs were at night for young males in deprived and urban areas, and these calls increased on weekends and bank holidays but not for sporting events. 77.3% were assault/sexual assault while 22.7% were stab/gunshot/penetrating trauma. Interestingly, there were significant differences in call out characteristics between the two violence types. The authors conclude that ambulance call out data provides a rich source of information and sharing this data could be key in violence prevention programmes. Any information that can contribute to violence prevention programmes has to be worthy of consideration.


Mary Dawood


Primary Survey April 2017.

18 Apr, 17 | by scarley

This month’s primary Survey is written by Mary Dawood. Don’t forget to visit the journal site to see more and keep in touch with us on Social Media.

Also, don’t forget to listen and subscribe to our podcast to keep you up to date on the journal and topics in emergency medicine.

Organ Donation in the ED

Possibly one of the most sensitive and daunting conversations that takes place in the ED is about organ donation. By virtue of circumstances this conversation usually occurs subsequent to breaking news of death or imminent death. Broaching the subject of organ donation can seem ill timed, insensitive and is difficult for even the most skilled clinicians. Even so, organ donation is a core competency in emergency medicine as is the management of patients in the final stages of life, furthermore we have a duty as healthcare professionals to explore this potential at the end of life. In the UK in 2015–16 a record number of organs were donated and transplanted but the consent rate is still one of the lowest in Europe. At the end of 2015 there were nearly 7000 people waiting for a transplant, 429 died while waiting and a further 807 were removed from the list most likely due to deteriorating health. Despite ongoing teaching of emergency staff and expert support from specialist nurses, opportunities for organ donation can still be lost in the urgency and fast pace of the ED as well as the perceived difficulties of managing the logistics of donation before death (DBD) or donation after circulatory death (DCD). Outcomes from DBD are better but an ongoing shortage of organs is seeing the reintroduction of a long abandoned practice of (DCD). This month’s issue includes a very informative paper by Gardiner and colleagues along with a commentary by Bernard Foex about organ donation. Gardiners paper describes current transplantation practice in the UK, associated ethical and legal issues, the classification of deceased donors and future developments promising greater numbers of organs. Foex’s commentary discusses withdrawal of life sustaining therapy and the case for delay.

Both these papers are a ‘must read’ for ED clinicians everywhere to remind us that the potential to change lives for better is enormous and the urgency for organ donation is greater than ever as we live longer.

Saving money

Containing the ever increasing costs of healthcare is both a challenge and a necessity in all health economies. We are constantly entreated by our ‘money masters’ to find not only more cost effective ways of delivering care but cheaper consumables. In the minds of many clinicians cheaper consumables often equate to poorer quality so it was very interesting to read of a study by Riguzzi et al from San Francisco comparing cost of commercially produced ultrasound gel which is relatively expensive with an alternative corn-starched based gel. They found that the corn starched gel which cost <10 cents per bottle produced images of similar quality to those using commercial gel which costs about $5 dollars. Given that point of care ultrasound is increasingly used in low resource settings, over time, this may represent a tidy sum that could be used elsewhere. Think about this the next time you liberally squirt expensive ultrasound gel!.

Sepsis again

Lifesaving treatment for sepsis is relatively straightforward–so many more lives should be saved every year if treatment is started in a timely way. It is therefore an ongoing concern that so many people still die from sepsis every year. The difficulty is spotting this complex condition as soon as a patient presents so we need to ask whether our triage systems are sufficiently sophisticated to support early recognition. Graff and colleagues in Germany undertook an evaluation of the Manchester triage system (MTS) to assess its effectiveness in identifying septic patients. They found the MTS to have some weakness with respect to priority in patients with sepsis and that discriminators for identifying systemic infection are insufficiently considered. In view of the fact that MTS and similar versions are so widely used it is well worth reading this paper to revisit our triage systems and how we can improve detection of sepsis at triage.

Weighing patients: a guestimate?

Some EDs are fortunate to have high specification trolleys that have built in scales for weighing patients. Most of us probably don’t work with such sophisticated facilities so we resort to roughly estimating a patient’s weight in emergency situations. This is a concern when using time critical drugs that require precise dosing according to weight. I was curious then to read of a study in this issue by Cattermole and colleagues in the UK that aimed to develop and validate an accurate method for estimating weight in all age groups using mid arm circumference.(MAC) They derived a simplified method of MAC based weight estimation from a linear regression equation: weight in kg=4xMAC (in cm)−50. They found that this formula is at least as precise in adults and adolescents as commonly used paediatric weight estimation tools are in children. The authors advise that a gender specific model would improve precision but this would require a tape or smartphone. This study is well worth a read as a more accurate way of estimating weight is to be welcomed especially as rising obesity levels will call for more consistent documentation of weight and precise dosing.

Adaptive design clinical trials in the ED?

Conducting and sustaining clinical trials in emergency settings can be difficult for a variety of reasons. One reason may relate to the fixed nature of the designs that are traditionally used in ED trials, where conduct and analysis are outlined at the outset and are not examined until the trial is finished. This fixed design may in many instances take too long and be costly both to patients and staff. It may be time to consider alternative way of conducting clinical trials in the ED that may be more effective and conducive to the ED setting. In this issue, Flight et al hypothetised that the majority of published emergency medicine trials have the potential to use a simple adaptive trial design where planned interim analysis is factored in to determine whether studies should be stopped or modified before recruitment is complete. Their study reviewed clinical trials published in three emergency medicine journals between January 2003 and December 2013. They found that out of 188 trials, only 19 were considered to have used an adaptive trial design. A total of 154/165 trials that were fixed in design had the potential to use an adaptive design. For those of us grappling with the challenges of clinical trials in the ED, this approach is worthy of consideration.

View Abstract


Mary Dawood

  1. Emergency Department, Imperial College NHS Trust, London, UK
  1. Correspondence to Mary Dawood;

Primary Survey March 2017

23 Feb, 17 | by scarley

It’s March 2017 and time for a quick review of the best of the EMJ this month

Under pressure: does cricoid improve laryngoscopy?

Whether or not we should use cricoid during emergency intubation is fast becoming one of the greatest modern controversies in Emergency Medicine. While we await data from randomised controlled trials, in this month’s issue Caruana et al have provided some important new evidence. In a retrospective analysis of 1195 patients undergoing pre-hospital intubation, cricoid pressure was not found to be associated with difficult laryngoscopy. After propensity score matching, there were no apparent differences in the incidence of complications with or without the use of cricoid pressure, other than an increase in the proportion of patients sustaining airway trauma when cricoid pressure was used. Ultimately we now have further reason to question the routine use of cricoid pressure, but is it sufficient to change your practice?

Statistics made much easier!

Reading the phrase ‘propensity score matching’ may have just made you feel a little uncomfortable. If so, you’re not alone. Most emergency physicians could do with a little help when it comes to interpreting some of the more complicated statistical analyses we encounter in the literature. If you feel that way, I’m sure you’ll be pleased to see that this month we have the first in an occasional series of articles on statistical concepts that go beyond the basics. These articles aim to provide a helpful tutorial to readers to increase their skills of critical appraisal for the future. To help illustrate the concepts, we will link them to original articles that we publish. This month, we’ve linked to the work by Caruana et al, which is free to access as the editor’s choice.

Who calls ambulances and doesn’t wait?

Most of us can appreciate that calling for an emergency ambulance is not to be taken lightly. When emergency services are facing severe and increasing pressure, it can be extremely frustrating to observe that some patients arrive in the Emergency Department by ambulance but don’t wait to be seen. In this issue, Doupe et al explore the characteristics of patients who do just that. Compared with other patients, they found that patients who called an ambulance and did not wait were more likely to have a history of substance abuse ad to live in low income areas. Identifying the characteristics of patients who exhibit this behaviour will help emergency physicians to create individual management plans to deal with apparently unhelpful patterns of seeking healthcare.

A new device to help metrics for ED weighting

Rapidly and accurately estimating the weight of children presenting to the Paediatric Emergency Department is highly important for drug dosing but often challenging. Emergency physicians commonly use formulae or aids such as the Broselow tape. This month, Jung et al report on the accuracy of a novel ‘rolling tape’ electronic device with wireless transmission. They demonstrate that its use enabled faster and more accurate weight estimation than the Broselow tape. However, they go further still: using the rolling tape led to faster orders for resuscitation drugs and defibrillation in cardiac arrest. Could this revolutionise how we measure patients’ weight in the Paediatric Emergency Department?

The trajectory of an academic emergency physician

If you’re a research active emergency physician, you may be interested in tracking your academic progress in relation to other emergency physicians. Is your progress fast or slow? In this issue, Miro et al explore whether we can develop a guide to the progress of researchers in Emergency Medicine. They tracked the h-index of a selected group of academic emergency physicians. The h-index tries to combine an author’s impact with their productivity. If an author has, for example, 5 articles that have been cited 5 times or more, then their h-index is 5. Miro et al have derived a formula to track the rise in h-index for ‘fast’, ‘medium’ and ‘slow’ growth academics. Where do you fit in? Don’t be discouraged, though. All the authors included in this sample were highly reputable academic emergency physicians. Even those in the ‘slow growth’ category may therefore be elite researchers. You may, however, find that this article spurs you on!

Can doctors measure pain in children?

Brudvik et al report a fascinating study in which they asked children to score their pain in the Paediatric Emergency Department, while doctors and parents were asked to estimate the score. How do you think we did? Read the full article to find out the detail, but you may be surprised to find out how much we under-estimate pain and how often we withhold analgesia, even for children with severe pain. It’s a sobering reminder that the pain of an individual is a very personal experience and cannot be accurately measured by others.


Rick Body


Primary Survey: November 2016.

22 Oct, 16 | by scarley


Richard Body, Associate Editor

The Manchester derby for paediatric early warning scores

There is clearly a need for a validated physiological early warning score for specific use in the paediatric emergency department (PED). In this issue, Cotterill et al compare two paediatric early warning scores developed in Manchester: the Royal Manchester Children’s Hospital Early Warning System (ManCHEWS) and a modified version, the Pennine Acute Trust Paediatric Observation Priority Score (PAT-POPS). The modified score incorporates the original physiological scoring system but also takes account of the nurse’s judgement and specific elements of a patient’s background. This Manchester derby was a close call: but will the marginally superior accuracy of PAT-POPS for predicting hospital admission ultimately win over the simplicity of ManCHEWS?

Future emergency care: the (citizen’s) jury has spoken

In Queensland, Australia, Scuffham et al took an extremely interesting approach to patient and public involvement. They convened a citizen’s jury to deliberate on matters relating to the delivery of emergency care. The jury’s verdict is intriguing and highly relevant to the future of Emergency Medicine. The participants were clearly amenable to alternative models of emergency healthcare delivery including care provided by allied health professionals and decisions not to transport patients to hospital from the pre-hospital environment.

What is ‘productivity’?

If you sometimes feel that measuring productivity in the Emergency Department has the potential to create a dehumanized production line (and even if you don’t), this month’s paper by Moffatt et al is a ‘must read’. In a series of semi-structured interviews with healthcare practitioners working in an Emergency Department, this team explores their feelings about the notion of ‘productivity’. The findings are heartening and are sure to kindle a warm feeling in the heart of any emergency physician. Hopefully this important work will lead to greater recognition of the need to retain compassion in our practice, promote an appropriate balance between ‘care’ and ‘efficiency’ and avoid the “sausage factory” mentality, to quote one of the participants.

A SuPAR new biomarker of serious illness?

In Emergency Medicine we are becoming accustomed to the use of biomarkers that may lack specificity for any one particular condition, but that provide important prognostic information. Lactate could be considered one such biomarker, and its interpretation has become an important skill for emergency physicians. This may suggest that we are at the dawn of a new era for biomarkers. Our traditional ‘binary thinking’ about diagnostics, whereby tests can simply tell us whether a patient does or does not have a particular disease, is beginning to seem crude and outdated. In this issue, Rasmussen et al measured SuPAR at the time of admission to an Acute Medical Unit in a cohort of over 4,000 patients. SuPAR was shown to predict mortality and the need for hospital re-admission even after adjustment for confounders. The findings are impressive, and this work must lead on to further research to identify how this interesting non-specific biomarker can be used to guide real life healthcare decisions.

Health inequality and the global importance of emergency care

We know surprisingly little about the relationship between emergency care provision and the impact of emergent conditions on health, internationally. Of course, emergency physicians might expect that failure to provide adequate emergency care would lead to greater mortality and morbidity from such conditions. In this issue, Chang et al quantify this problem. In an analysis from 40 countries, they found that all fifteen of the major global causes of mortality and morbidity can present emergently, and identified that insufficient access to emergency care is clearly associated with higher mortality and morbidity. This makes sobering reading as a demonstration of global health inequality, and highlights the pressing need to develop Emergency Medicine internationally.


Rick Body


Primary Survey August 2016. EMJ

4 Aug, 16 | by scarley

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.


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.


Primary Survey July 2016

4 Jul, 16 | by scarley

Mary Dawood, Associate Editor

“People attend ED because they choose to”

Emergency Department (ED) attendances over the past decade have been rising both in western countries as well as in the developing world. One school of thought attributes this to an increase in patients who would be better managed in primary care. Various initiatives have been put in place in the UK in recent years which include hospital based unscheduled care services staffed by GP’s and other primary care clinicians aimed at diverting patients away from the ED. You could be forgiven for questioning the success of these initiatives if your ED is crowded most of the time.

On this note you might then be interested to read both the editorial by Derek Burke as well as a review of the literature by Ramlackhan and colleagues from Sheffield relating to the impact of GP delivered hospital based unscheduled care services. Their study focused particularly on process outcomes, cost effectiveness, and patient satisfaction. They found a paradoxical increase in attendance and the evidence for improved output to be poor, moreover there was no evidence of improved patient satisfaction. In one study patients actually expressed a preference for care in an ED as opposed to a new co located walk in centre. The authors concluded that there is little evidence to date to support the implementation of co–located urgent care models of care. In the absence of more robust evidence it is worrying to see the on-going proliferation of such alternative models of care. In his editorial, Derek Burke suggests that unscheduled care is a now a consumer item and seen by users as no different to 24 hour shopping. If this is the case then perhaps we should just ask patients where they would prefer to be treated and listen to what they say, now there’s a novel idea!

Doctor Triage?

This can be a contentious issue in the ED, some clinicians abhor the notion citing “not the best use of doctor time” while others enjoy the opportunity. The introduction of multidisciplinary rapid assessment teams (RAT) has in some cases further muddied the waters, so it was interesting to read a systematic review by Abdulwahid and colleagues from the UK to determine if placing a senior doctor at triage (SDT) versus standard single nurse in an emergency department improves ED performance. They reviewed the evidence from 25 comparative design studies using several quality indicators.

They concluded that SDT can enhance performance. This in itself is not entirely surprising as doctors, more than nurses can see, treat and discharge patients at triage thereby reducing the overall load. I would suggest nurse practitioners at triage may have a similar impact. The findings that were perhaps more interesting and warrant further investigation were that STD did not demonstrate benefit in terms of patient satisfaction or cost effectiveness or for that matter change the occurrence of adverse events. So perhaps SDT may be a pyrrhic victory for performance if outcomes elsewhere are unchanged or more expensive. Clearly more research is needed.

Quantity, Quality or both

Quantitative methodology is traditionally the mode of scientific enquiry in medicine. More recently, mixed methods, that is coordinating qualitative and quantitative research is slowly gaining credence in emergency medicine because of its effectiveness in achieving a deeper understanding of complex issues such as medical error, communication and teamwork. In this issue, Hansen and colleagues from Oregon introduce the fundamental concepts and approaches of mixed methods research using specific examples from the Children’s Safety Initiative Emergency Medical Services (CSI-EMS), a large National Institute of Health (NIH) funded project to describe the interrelation and complementary features of quantitative and qualitative methods. This is an interesting paper about the identification and prevention of errors in out of hospital paediatric care in the USA but also, a very comprehensive overview of mixed methodology and well worth reading if you are considering this approach to research.

Snakes alive

Assessing and treating snakebites is not “run of the mill” type presentation in most ED’s but it accounts for 10% of all presentations in the hot summer months in a South African Hospital and this may well be the case in similar climates elsewhere in the world. So it was fascinating to read a study by Wood and Sartorious in this issue describing the use of ultrasound to determine the site and degree of cytotoxic swelling from snake bites in patients presenting to their department.


They scanned the envenomed limb of 42 patients at the point of maximum swelling comparing it with the same site of the unaffected limb. More than half of their patients were children under the age of 12 years. Tissue expansion was noted in both the subcutaneous and the muscle compartments of the envenomed limbs. Their study highlights the benefits of ultrasound as a non invasive and painless procedure which can assist the clinician assessing and monitoring the progress of the swelling. This paper is a good read, it is original and informative especially the incidence and pathology of envenomation, furthermore, the study lends a truly international feel to this issue.

Have fun

We are becoming increasingly aware of the value of simulation training as an effective learning tool in emergency care but its’ use still varies from place to place. This may be due to perceived difficulties in instituting this in busy ED’s or from perhaps less than enthusiastic or even sceptical responses from your colleagues. If you feel this applies to your department then read the paper in this issue a by Spurr and colleagues. It’s a very useful top 10 tips +1 to setting up simulation training in your department. After reading all 10 tips you might find No 11 the “+1” the best tip of all. It recommends having fun! Now this is a great starting and finishing point and a universally recognised essential ingredient for successful team building and surviving the high’s and low’s of an ED career.

Primary Survey June 2016

4 Jun, 16 | by scarley

Mary Dawood, Associate Editor

Helping people do the things they want to do

Figure 1

Being a patient in hospital can be a disconcerting experience, this is especially true for older patients who desperately want to stay in the familiar surroundings of their own homes. Getting frail elderly patients safely discharged from the ED can pose significant risk so it was very reassuring to read in this issue a paper from Scotland about the role and potential of the Occupational Therapist in the ED. In “The view from here” Kristin James opens the window for us on the practicalities of daily living that are suddenly jeopardized for the older person by an emergency admission. She describes how the expert intervention and advice of an occupational therapist can tip the balance and be the difference between safe discharge home or admission as an inpatient. Do read this paper, it conveys a simple message about seeing the patient in the context of their life and not just the presenting problem, but also, how the OT’s in the ED “can help people to do the things they want to do”.

How effective are health promotion campaigns?

I often wonder how effective large scale expensive health promotion campaigns are and to what extent the target audiences are receptive to such information? This thought must have also crossed the minds of Mellon and colleagues from Dublin who undertook a study in a cohort of stroke survivors to examine their knowledge of stroke warning signs, risk factors and help seeking behaviour when faced with symptoms. A secondary aim of their study was to examine the association between patient characteristics, stroke awareness and onset-to-door (OTD) time when stroke symptoms occurred. They concluded that changing health seeking behaviour during stroke onset is not a simple process and indeed is fraught with complexity. Their findings provide a basis for further stroke educational campaigns which suggest the need for multiple interventions at different levels to focus on improving the publics’ stroke knowledge, and recognition of symptoms. This approach hopefully could minimize the delays to hospital arrival that continue to be a barrier to effective treatment.

Also in this issue, the need for health education weaves its way into another paper from the other side of the world. Cullen and colleagues in Australia and New Zealand sought to examine whether time to presentation with possible acute coronary syndrome (ACS) has any association with one year outcome. Well, perhaps unsurprisingly, their findings suggest it does. They collected data from adult patients presenting with suspected ACS to two ED’s in both countries and followed them up prospectively for a year. They found that there is an independent association between time to presentation and one year cardiac outcomes following initial attendance in ED with possible cardiac chest pain. The authors of this paper again reiterate the need for effective public health campaigns to improve health outcomes in these patients.

Appearances can be deceptive

Increasing longevity in western societies has seen a corresponding increase in the incidence of major trauma in the elderly. Traumatic brain injury (TBI) is not uncommon and its severity is traditionally classified using the Glasgow Coma Scale (GCS). One might expect elderly trauma patients to score a lower GCS than their younger counterparts. However two recent small studies suggest that the elderly may present with a higher GCS than younger patients with an equivalent anatomical severity of TBI. In this issue, Kehoe and colleagues in the UK set out to confirm this finding by interrogating the trauma audit research network (TARN) database of all adult cases of severe isolated TBI between 1988–2013. They concluded that the GCS is higher in older patients at each level of injury severity irrespective of mechanism of injury or type of intracranial injury and the difference is more apparent the more severe the injury. This paper is a must read for pre hospital and hospital clinicians managing major trauma, we should not allow an unexpectedly high GCS lull us into a false sense of security. These older patients may be more severely injured than initial findings suggest and irrespective of age, early neurosurgical intervention may be indicated to improve outcomes.

After reading the Kehoe paper I would recommend a thought provoking paper by Battle and colleagues in the UK who investigated current management of the anti-coagulated trauma patient in ED’s. Again this study concerns the older trauma patient where there is a lack of consensus regarding management of this group. A survey exploring management strategies of anti-coagulated trauma patients was developed with two patient scenarios concerning assessment of coagulation status, reversal of INR, management of hypertension and management strategies for each patient. 106 respondents from 166 hospitals replied with 24% of respondents working in major trauma units. The results of the survey highlighted both similarities and variation in practice and the authors felt this may reflect the differences evident in the available guidelines for these patients. Clearly there is a need for consensus and an evidence based guideline to ensure optimal management of this group.

Pre hospital identification of sepsis

Severe sepsis is still the commonest cause of death in critically ill patients making the need for early identification and intervention as urgent as ever. Emergency Medical Services (EMS) practitioners are often the first contact for these patients yet the importance of their role and the crucial part they play in identifying septic patients has not been widely discussed in the literature. So I was keen to read in this issue a systematic review by Lane and colleagues from Canada of studies that evaluated the pre hospital identification or treatment of patients with sepsis by EMS. No randomized controlled trials were found but review of 16 cohort studies suggests that EMS practitioners can identify sepsis patients with modest sensitivity and specificity using vital signs criteria. However the authors caution that the included studies were characterized by high heterogeneity and thus further research in this area is needed. So back to the drawing board on this one!

Be sure to look at the wrist X-ray in the Image section. Wrist injuries are common and very much core business in emergency settings, so we should be competent in interpreting images particularly of common fractures. Every so often there is a variation on a theme and this one is interesting. Read the history and spot the injury.

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 December issue: Emergency Medicine Journal.

11 Dec, 15 | by scarley

Click here for full table of contents.

Even if one does not work in a “major trauma centre,” we all see trauma. Victims of stabbings and bike accidents do not follow “trauma criteria” when they head for the nearest ED. Elderly patients with seemingly minor injuries are brought to a local hospital, only to discover that there are 4 rib fractures, a pulmonary contusion and a subdural haematoma.

2015 marks the silver anniversary of UK’s Trauma Audit Research Network (TARN). For those of you not living in the UK, TARN is a national registry that collects prospectively entered data on the epidemiology, treatment and outcomes from major trauma. TARN serves two major functions: it publicly reports its findings and it allows trauma researchers to use its large, prospectively collected data set to conduct research. Our first editorial, by Fiona Lecky, TARN’s research director, describes the humble birth, development and accomplishments of TARN over the past 25 years. In an accompanying commentary, Dr Karim Brohi, clinical lead for London Major Trauma System, takes the opportunity to pause to consider the challenges created by the growth of TARN from a local audit tool to both a national quality assurance program and a research enterprise.

To celebrate 25 years of TARN, this issue’s research and reviews are centred on the theme of trauma. There are articles from TARN, which illustrate the value of a large, prospectively collected data set. We also include several intriguing articles from France (on telemedicine in head injury), and South Africa, on the role of interpersonal violence in trauma care. Two articles—one on c-spine immobilisation and the other a review of traumatic cardiac arrest—will make you reconsider what you’ve always known.

The changing face of trauma

Using data from the TARN database, Kehoe and colleagues describe how the mechanisms and victims of major trauma have been changing over the past 25 years. Road traffic accidents are down; falls are up. Major trauma patients are increasingly elderly. This could be a matter of better data collection as a result of TARN, and improved detection with the rising use of CT. In either case, the data not only confirm what many of us are seeing, but prompt consideration of whether our systems are adapting as they should.

Editor’s choice: Do anti-coagulated trauma patients have worse outcomes?

It is estimated that 1% of the UK population is anticoagulated, and the prevalence rises with age. A study in Japan showed that about 25% of patients over 80 were on anti-thrombotic therapy. Warfarin remains the most commonly prescribed anti-coagulant, and whether trauma patients on warfarin do worse is controversial. An RCT is impossible of course; but even with multivariate analysis, it is difficult to account for the substantial burden of comorbidity in the patients on warfarin. In this carefully conducted observational study using the TARN database, Battle et al used a matched case-control design to compare the outcomes of trauma patients who were receiving warfarin pre-injury and those who weren’t. The result: warfarin is indeed an independent risk factor for mortality in trauma patients.

The trauma burden of interpersonal violence: a preventable disease

In this descriptive study of a small emergency department in KwaZulu-Natal, South Africa, Bola and colleagues found 41% of surgical admissions were due to trauma, and interpersonal violence accounted for more than a third of this trauma burden. Community assault, not uncommon in the rural areas of this region, was responsible for 14% of traumas and its victims spend longer times in the resuscitation areas. Victims of interpersonal violence stay an average of 9.8 days and require significant amounts of blood (a scarce resource), and the use of imaging and theatre time, a clear additional burden to a health care system that can least afford it.

Traumatic cardiac arrest—time for a paradigm shift?

Most of us were taught that traumatic cardiac arrest had a dismal outcome. However, that may be because we were applying the wrong therapy. In this review of new evidence on traumatic cardiac arrest, Captain Surgeon Jason Smith explains that TCA may really be a low-flow state, for which traditional CPR will not work. A new approach that focuses on stopping haemorrhage and aggressive resuscitation (preferably blood) appears to have substantial promise, as evidenced by the military experience.


So, is there more to be done to control haemorrhage?

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has the potential to bridge patients to definitive haemostasis in patients with noncompressible torso haemorrhage. However its potential for trauma patients is unknown. Barnard and colleagues used the TARN database to determine the number of trauma patients in 2012–13 who might have benefited from the intervention. Out of 72000 patients, 397 were identified. They had a median ISS of 32 and, coincidentally, a mortality of 32%. The authors point out that although the numbers are small, the patients are, without REBOA, quite resource intensive and are largely seen at major trauma centers, making it potentially worthwhile to evaluate the use of REBOA at these hospitals.

Primum non nocere…the growing evidence for self-extrication

Dixon et al placed biomechanical sensors on paramedic volunteers and studied them with infrared motion analysis when being extricated from a test crash vehicle. Compared with equipment-assisted extrication, self-extrication showed the least movement. The authors suggest that it may be time for a “spinal rule-in” policy in for stable patients, where self-extrication is the first option if the paramedics have carefully assessed the victim.

Ellen Weber.

Editor in Chief.

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