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Bored of Boarding
I'm sure that many of us have felt pangs of guilt as we walk past rows of patients on corridors waiting to get into beds. The ‘boarded’ patient is a gentle term for what is an obvious and embarrassing symbol of overcrowding in our emergency departments. I often feel ashamed of our health care systems when we subject patients to the indignity and poor care associated with boarding, but what is it like for patients? Liu et al have examined the experience of boarding from the patient perspective using qualitative methods. They found that patients do find waiting frustrating and characterised by a lack of communication. They conclude that if we are to deliver kind and compassionate care then we must listen to the voices of our patients and eradicate the practice of boarding.
Complications of prehospital intubation
Prehospital airway management is always controversial and so it is again this month with a retrospective review of cases intubated in the field. The data suggests a high complication rate as compared to in hospital airway care. It is interesting to note that the airway assessments suggest that views are often poor in the prehospital setting which will raise the question of whether these are difficult airways, difficult environments, or less skilled operators. No doubt it will generate debate as all papers relating to prehospital airway management appear to do.
Do we need to give antibiotics to every dog bite?
In the UK it is custom and practice to give antibiotics to all dog bites (well it is in Manchester) but the wisdom of this has been questioned many times over the years. Tabaka et al have looked at wound infection rates over a 4.5 year period to determine characteristics of wounds that get infected. The findings are interesting with a relatively low overall rate of infection and a suggestion that those that are closed, or which are puncture wounds are at higher risk. They conclude that these are high risk wounds and should be treated with antibiotics. As for other wounds, it's tricky to say as the vast majority of wounds received antibiotics as a routine. These are interesting results although we arguably still await the randomised controlled trial that might finally answer the question.
UK Paediatric research priorities
Is an interesting study on research priorities for paediatric emergency medicine in the UK and Ireland. Paediatric Emergency Research in the UK and Ireland (PERUKI), is a group of 43 centres aiming to deliver high quality research in paediatric emergency care and they have been very productive to date, but they need to set priorities for the next generation of paediatric researchers. What is heartening is that the results clearly lead towards potential trials in the future which have the potential to significantly improve the care we give to injured and ill children. If paediatric emergency medicine is your thing, this is a must read.
Aspirin in the US
Another database study this month looks at the administration of aspirin to patients with potential acute coronary syndromes. Overall the figures from Tataris et al are a bit disappointing with fewer than half of patients receiving the medication. Beyond this the data has been mined for factors that might predict administration and interestingly race and US location appear to have an influence. However, we must be cautious as studies of this type can show association, but not necessarily causation. Read for yourself and decide.
The hurt of Head Injury Retrieval Trial
Arguably one of the most expensive trials in prehospital care, the HIRT trial has raised many controversies in the prehospital community. Originally set up as a randomised controlled trial of helicopter assisted physician led prehospital care vs. paramedic care in head injury. The final analysis is complex and requires thought on the part of the reader. Overall the data suggests that there is no statistical difference between paramedics and physician responders, though the authors point to some subgroups that may show a benefit to physician care. This study requires careful consideration as one of the largest prehospital physician trials in history. Whether it is or whether it could ever be definitive is as much a question for those interested in research design as it is for the reader.
Do we overinvestigate patients for pulmonary embolus?
Yes we do, or at least that's the claim from Mongan et al in this month's journal. The data supports their view with a prevalence of disease in some groups investigated as low as 0.6%. PE prevalence increases with age and yet we appear to investigate the young fit and healthy as frequently as we do the elderly. This is clearly questionable practice, particularly when the effects of investigation and therapy are associated with harm. This study based on two large data sets suggests modifications to established risk factors to raise awareness of the differences in prevalence between young and old, male and female. It hints at further refinements to diagnostic tools in the future.
Editor's choice
You cannot deliver high quality care without staff. Underpinning this is that you cannot deliver safe care without staff, but how many staff are enough? Pope et al present data collated for the National Institute for Clinical Effectiveness on safe nursing staff levels. This is essential reading for all emergency department staff and highlights the association between low staffing and poor patient experience, quality and outcome. An accompanying editorial outlines why this paper is so important to emergency care and why we must ensure that we have the resources to deliver a safe and high quality service.
Footnotes
Provenance and peer review Commissioned, internally peer reviewed.