Quality and safety in emergency departments

Two articles in this issue focus on Quality and Safety of clinical care within Emergency Departments (EDs).

The International Federation of Emergency Medicine (IFEM) have produced a Quality Framework, and in the article by Hansen et al, the authors provide a summary of this document. This article provides an excellent introduction into the particular issues within Emergency Care when it comes to ensuring high quality and safe care at a strategic level. The patients expectations and the consequent obligations of the system (and clinicians) are described. The article neatly describes the ‘enablers’ and ‘barriers’ to quality of care, and provides suggestions regarding measurement and activities to support delivery of high-quality care. For me, the take-home message is that prioritisation, co-ordination, and integration of emergency care is vital. Further work on measurement and demonstration of quality of care is needed.

While the focus of the Hansen et al article is strategic elements of quality of emergency care, Lim et al have written an article focusing on more operational and tactical elements of this subject. This paper describes how the results of a successful quality improvement initiative can be sustained, in this case over 4 ½ years later. There was an initial multi-modal intervention to reduce unnecessary cannulation in the Emergency Department and the successful outcome was maintained. The discussion highlights interesting considerations for quality improvement activities; that is, how do you change departmental behaviours and culture, and what makes the improvements ‘stick’?

COVID: the Mother of invention

Two papers (Jazuli et al, and Hsu et al) describe the use of box barriers to protect against aerosols, and a commentary by Wells discusses how both these papers illustrate the challenges of research during the pandemic, especially with respect to the generation of ideas, and the need to test these novel concepts.

There are also papers describing some novel processes adopted during the COVID-19 pandemic; including Chua et al on staff rostering challenges and solutions, Noble et al on the deployment of bespoke care areas for COVID patients (‘Accelerated Care Units’), and a letter describing the experience in Iran of screening processes to reduce referral to health services (including EDs). It is refreshing to read how transparent researchers are being at this time; sharing designs, processes and plans on-line.

Two other letters also stimulate thought. First, as we approach ‘dengue season’ with the pandemic ongoing, there is a diagnostic dilemma of having two common, clinically similar diseases, which may co-exist. Second, the description of an increase in methanol toxicity (ingestion for disinfection) highlights the problem of misuse of alcohols during COVID.

Common clinical conundrums

Clinical problems that will be very familiar to all Emergency Department clinicians are discussed in two papers.

The ‘Readers’ choice’ article this month addresses the conundrums surrounding ruling out pulmonary embolism (PE) in pregnant patients. Goodacre et al have performed a secondary analysis on the DiPEP study data to assess the clinical accuracy of the ‘Geneva’ and ‘YEARS’ rule-out algorithms. This paper is interesting both statistically and clinically; the sensitivity and specificity of both algorithms were low, and the authors suggest that PEs would be missed using one of these strategies. The clinical effect of missing these (possibly small) PEs is not known, and the number of radiological investigations that would be avoided by using these strategies is also low. The conundrum continues.

The low success rates of medical therapy in oesophageal food impaction will also be familiar to EM clinicians. Willenberg et al present a small study of nitroglycerin as treatment in this condition. It highlights the further question of whether using a therapy with low chance of success is appropriate.

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And finally…

The article by Aitavaara-Anttila et al looks at the possible reasons for the increased use of Emergency Medical Services (EMS) in areas with lower socioeconomic status. There are many interesting details within the data, and some food for thought in the discussion. While the use of EMS was higher in rural areas and those with lower socioeconomic status, case urgency was no different. The authors suggest that differences in access to preventative care and increased co-morbidity are the causes of this. High-frequency users of EMS also drove a large part of the increased use.

The ‘Editor’s Choice’ article this month will have a familiar feel. This paper by Lee, Kwok and Vaillaincourt adds to the evidence regarding accuracy of Emergency Physicians (EPs) predictions on patient disposition. Many EPs will be aware of the evidence on the accuracy of this prediction- this paper, however, looks specifically at prediction of admission only, and at point of referral to the admitting clinician (accuracy was high- correctly predicted in 92.8% of cases). Of note, this paper excluded the patients whose admission was ‘obvious’ and Paediatric cases. The paper then suggests that a high total number of hours spent by patients on ED stretchers could be avoided, by starting the admission processes earlier, thereby reducing crowding. In addition, one also wonders about whether this would improve patient experience and other quality measures.