Primary Survey December 2019

Do we know what older patients want from emergency care?

We are increasingly aware of the preponderance of older patients attending our emergency departments as well as the fact that they are often acutely unwell. It is heartening then to see in this month’s issue some excellent papers pertaining to the care and treatment of our older patients highlighting some aspects of care that need improvement.

Perhaps contrary to longstanding perceptions, older patients are not a homogenous group but have specific and complex needs that can elude staff in a busy department. Understanding what these needs and desires are is important if we are to deliver individualised care. So I would urge you to read a thought provoking paper by Van Oppen and colleagues in the UK who conducted a systematic review evaluating the expectations and preferred outcomes from emergency care among older patients and their care givers. It’s no surprise that older people had the same hopes and desires as younger patients for prompt waiting times, efficient care, and good communication. What is more telling and poignant about this review and something we need to be much more responsive to is the vulnerability expressed by the participants, particularly, fear of being alone in the ED, fear of their illness and fear of losing independence. They also wanted support in decision making. Bear this in mind the next time you rush past an older person looking lost and worried in the ED, simple reassuring gestures will go a long way to imbuing an increased sense of well-being for them.

The best news

We rely on Early Warning Scores (EWS) to identify sick patients and also to predict those at greater risk of adverse outcomes, but do we know which EWS is most suitable for the ED? A number of EWS have been developed for general use but choosing the most suitable EWS for the ED setting is a question Spencer and colleagues in Australia set out to answer. They sought to determine which of 13 EWS based mainly on ED vital signs data best predict important patient outcomes. They conducted a retrospective cohort study over an 8 month period in 2018.They found ViEWS, AbViEW and NEWS have excellent predictive ability for mortality, especially within 2 days, however, no EWS adequately predicted clinical deterioration, admission to either ICU or the hospital. So, back to the drawing board, it looks like more research is needed.

Guideline based care

A fall in an older patient is rarely a “simple fall,” assessing the older patient who has fallen can be perplexing and time consuming for even the most experienced physician. There are ED specific guidelines for the assessment and management of falls patients but it seems ED physicians don’t often use them, if you are wondering why, then you might like to read an intriguing study by Parks and colleagues from Canada. The set out to investigate barriers and enablers in the provision of guideline based care for falls patients. This was a qualitative study using a thematic domains framework (TDF) where interviews were conducted with practicing ED physicians. They uncovered a variety of themes which included heterogeneous self-perceived skills, perceived time and workload, emotions negatively impacting these clinical encounters as well as lack of knowledge among others. Nonetheless physicians overall were supportive of guideline implementation. The authors concluded that future implementation of guidelines both nationally and internationally should focus on improving knowledge and training as well as positive reinforcement for guideline appropriate management and of course further research to support guidelines.

Fever in infants

Infants<3 months old are a vulnerable group at risk of serious infection (SI). Validated assessment tools can provide some reassurance for ED physicians but knowing which tools have the greatest efficacy predicting SI’s in young babies can present a quandary. If this is your area of practice, I would recommend you read the paper by Yao and colleagues from the USA and UK. They undertook a retrospective validation study to test the performance of clinical assessment tools, these being the National Institute for Health and Care Excellence (NICE) and the Severity Index Score (SIS) in predicting SI in infants. They also evaluated the performance of low risk criteria, the Rochester Criteria (RC) Philadelphia Criteria (PC) and Boston Criteria (BC). They found the NICE guidelines achieved high sensitivity in their study population and may provide added insight into the assessment of febrile infants in the ED. The RC had the highest sensitivity in predicting for SI in febrile infants who appeared well. This evidence may just offer that extra reassurance needed when assessing very young babies.

Delayed diagnosis

Serious emergency conditions are often difficult to diagnose and delayed diagnosis in the ED can have serious ramifications because of severity and time critical nature of emergency conditions, this is particularly the case in children where delayed diagnosis can result in morbidity. Improving this has to be a goal for all of us so reading the paper by Michelson and colleagues from Boston USA may get you thinking. Their objective was to develop and pilot a screening tool called DelayDX to identify delayed diagnosis of sepsis and appendicitis in an administrative database testing it against the standard of expert manual health record review. The positive predictive value (PPV) of the automated tool for determination of delayed diagnosis of appendicitis within 1,3 and 7 days was 96.2%,95.1% and 93.6% respectively. For sepsis the results were not as good, the PPV’s being 71.4%,63.6% and 41.2% within 1,3,7 days respectively. Nonetheless they concluded that their automated tool performed well especially for appendicitis as compared with the electronic health records review and that further tool refinement could improve performance. This is an interesting study and well worth a read.


Mary Dawood.

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