While computed tomography scans (CT scans) undoubtedly provide
valuable information to
physicians caring for emergency department (ED) patients, there is growing
concern that many studies
are performed unnecessarily resulting in significant radiation exposure
for limited actual
clinical benefit. Excluding indications for acute trauma, CT scans are
commonly obtained in the ED to
detect acute appendicitis, renal colic, bow...
While computed tomography scans (CT scans) undoubtedly provide
valuable information to
physicians caring for emergency department (ED) patients, there is growing
concern that many studies
are performed unnecessarily resulting in significant radiation exposure
for limited actual
clinical benefit. Excluding indications for acute trauma, CT scans are
commonly obtained in the ED to
detect acute appendicitis, renal colic, bowel obstruction,
diverticulitis, pancreatitis and
undifferentiated causes. For some of these entities imaging is certainly
essential. For others, especially
with typical presentations or in patients who experienced similar episodes
in the past with documented CT scans which revealed the etiology of
pain, CT imaging may not add benefit (1).
In the past decade the risk of radiation exposure from CT scans was
considered minimal compared to the risk of a missed catastrophic illness.
The current controversy rests on the hypothesis that the radiation dose
from CT scans produces a nonnegligible increase in the probability of
lifetime cancer mortality from CT scans. However, these calculations are
based on the controversial extrapolation of data from the Life Span
Survival cohort from the Hiroshima bombing that assumes a linear
relationship between radiation dose and cancer risk. The clinical
importance of the low-level radiation exposure is and will likely remain
unknowable, since any study that could identify the risks with precision
would require an impossibly large sample size.
Although the clinical importance of the radiation exposure from each
scan is uncertain, it seems evident that physicians be mindful of the
possible adverse lifetime risk for cancer, especially when imaging
children or ordering repeat CT scans for a recurrent disease such as renal
colic. Similarly, it is wise to consider carefully the radiation exposure
of a test with high dose of radiation with likely small clinical benefit,
such as high energy chest CT scans in younger women to exclude coronary
artery disease. In contrast, the radiation risk is less important for
older patients when very serious diseases, frequently occult, may be
present that can be detected by CT scanning. Emergency physicians have the
responsibility to weigh the risks and benefits of each CT scan requested
and determine whether the radiation exposure is truly justified (1-3).
Competing interests- none to declare
References
1. Smith-Bindman R, Miglioretti DL, Larson EB. Rising Use of Diagnostic
Imaging in a Large
Integrated Health System. Health Aff. 2008;27(6):1491-1502.
2. Brenner DJ, Hall EJ. Computed Tomography-An Increasing Source of
Radiation Exposure. N Engl J Med. 2007;357:2277-2284.
3. Hall EJ, Brenner DJ. Cancer risks from diagnostic radiology. British J
of Radiol.2008;81:362-378.
Junior doctor: "Hi, I am one of the junior doctors in A&E. I have a
35 year old lady
presenting with 3 hours of worsening right iliac fossa pain..."
Registrar: "What is the urine HCG."
Junior doctor: "Negative, and she does not report any PV bleeding or
discharge."
Registrar: "What are the inflammatory markers?"
Junior doctor: "Well white cells are marginally raised at 12.6 and CRP is
normal,
however I think we s...
Junior doctor: "Hi, I am one of the junior doctors in A&E. I have a
35 year old lady
presenting with 3 hours of worsening right iliac fossa pain..."
Registrar: "What is the urine HCG."
Junior doctor: "Negative, and she does not report any PV bleeding or
discharge."
Registrar: "What are the inflammatory markers?"
Junior doctor: "Well white cells are marginally raised at 12.6 and CRP is
normal,
however I think we should rule out..."
Registrar: "Does she have an acute abdomen?"
Junior doctor: "She has mild tenderness in the RIF however I don't think
there is any
guarding or percussion tenderness but..."
Registrar: "I don't need to see her, send her home or refer her to gynae.
This is not
appendicitis. Thank you."
Junior doctor documents in the notes 'discussed with Surgical Registrar
who advised
to send patient home.'
Many junior doctors have probably found themselves in a similar situation.
The
example highlighted is not to pick on any specialty specifically - this
could have
easily been a senior doctor in any speciality. The question is, if your
patient was
brought back by ambulance in a critical condition, would your
documentation of this
advise be adequate? When push comes to shove in court, what would happen
if the
registrar denies having spoken to you, what legs do you have to stand on?
From an
objective point of view, it may equally be ficticous documentation on
behalf of the
junior doctor.
If one requests advise from a senior doctor, one should ideally request
the senior to at
least document their opinion in the notes themselves with their signature
and details.
If this is practically difficult due to time pressures etc, then I propose
that everyday,
bleep holders oncall who are contacted for advise are allocated a specific
unique code
which is different everyday. Every time advise is sought from this
individual, to
formalise and authenticate the information, this code should be sought by
the person
seeking advise; otherwise the senior advisor should document his/her
findings
themselves having reviewed the patient. Although this does not totally
eliminate
aberrancies in documentation, it may be a positive step in ensuring
responsibility for
advise given over the phone. Prudent doctors who have given advise would
be wise to
briefly record the details of the referrer, patient and advise given.
I read with interest the article by Dr Durge. I agree this is an
important issue and feel that I can improve this technique. In the
presence of secretions or vomit the tube tie can easily slip on the tube
and cause migration of the tracheal tube. However with the use of a
similar amount of pink elastoplast the tube tie and if tied directly onto
the applied tape it is almost impossible to slip and there...
I read with interest the article by Dr Durge. I agree this is an
important issue and feel that I can improve this technique. In the
presence of secretions or vomit the tube tie can easily slip on the tube
and cause migration of the tracheal tube. However with the use of a
similar amount of pink elastoplast the tube tie and if tied directly onto
the applied tape it is almost impossible to slip and therefore migrate.
And with the tape as Dr Durge described, it would be easy to recognise any
migration.
In the methodology Kirby and Roberts in suggesting their methodology
is likely to create bias have surely underplayed the risk of bias.
Whilst research may often been based on convenience samples this surely
takes this to extremes.
Survey Monkey fatigue has set in for me with the number of requests
recieved for surveys apparently aimed at supporting a clinical topic
review of a FCEM candidate.I know I am not alone in thi...
In the methodology Kirby and Roberts in suggesting their methodology
is likely to create bias have surely underplayed the risk of bias.
Whilst research may often been based on convenience samples this surely
takes this to extremes.
Survey Monkey fatigue has set in for me with the number of requests
recieved for surveys apparently aimed at supporting a clinical topic
review of a FCEM candidate.I know I am not alone in this.
Surely there is way of braodening the data collection whilst only
making itmarginally less convenient to collect that could give some
validity to conclussions on what is at the heart of things an important
topic.
RE: Coats, Timothy J.: Future research in emergency medicine:
explanation or pragmatism? Large or small? Simple or complex? Emerg Med J.
2011 Dec;28(12):1004-7.
Emergency Medicine Can! Response to Coats, Timothy J.: Future
research in emergency medicine: explanation or pragmatism? Large or small?
Simple or complex.
Coats highlights the potential role of emergency medicine in
conducting large pragmatic t...
RE: Coats, Timothy J.: Future research in emergency medicine:
explanation or pragmatism? Large or small? Simple or complex? Emerg Med J.
2011 Dec;28(12):1004-7.
Emergency Medicine Can! Response to Coats, Timothy J.: Future
research in emergency medicine: explanation or pragmatism? Large or small?
Simple or complex.
Coats highlights the potential role of emergency medicine in
conducting large pragmatic trials and the shortcomings of the more
traditional complex randomized controlled trials. He correctly points out
that traditional phase III trials are difficult to run, extremely
expensive, and restricted by highly competitive funding mechanisms. While
many of the points made in the article are valid, the premise that
emergency medicine researchers are not capable, or competitive in an arena
of rigorously conducted clinical trials is disconcerting and inaccurate.
Emergency physicians can compete, create niches, and succeed! The trial
design is irrelevant.
Over the last 10 years, the number of emergency physicians conducting
high quality RCTs has risen steadily1,2. These include both industry-
sponsored and federally funded trials. As the specialty matures, it is
only logical that emergency medicine expands its research footprint and
relevance.
The concept that traditional clinical trials or research are
restricted only to specialties that have narrowed their scope to a
particular disease state, organ system, technical skill, or type of
research is unsound. Emergency Medicine's uniqueness is that there are
diverse interests and a broad base of expertise. Science in general, and
clinical trials is particular, is a TEAM sport. The emergency physician
is ideally poised to take the reins of the RCT team, since emergency
medicine holds the key to the door (literally) and is the entry point for
many diseases and conditions into the system. Indeed, emergency medicine's
recent success in high-quality research has garnered substantial attention
at NIH. Just in the past 3 years, a number of requests for proposals
(RFPs) are targeted at emergency medicine researchers3. The Neurological
Emergencies Treatment Trials (NETT) network4,5 is constructed primarily of
emergency physicians as principal investigators. The NETT is being
heralded as one of the most successful acute trials networks in the
history of the NIH, and it has proven that emergency physicians not only
can run complicated RCT's, but that they excel at it. Fortunately for
other specialties, emergency medicine is collaborative by nature and seeks
out the participation and expertise of its colleagues. Non-EM researchers
now actively engage emergency physicians in acute trials because they
realize EM's critical role (e.g. Stroke Hyperglycemia Insulin Network
Effort (SHINE) Trial, Albumin in Acute Ischemic Stroke (ALIAS) Trial6).
Despite the specialty's relative young age and limited research
infrastructure, EM researchers are leading the pack in many fields of
research including traumatic brain injury, stroke, status epilepticus,
asthma and others. The ProTECT III trial is one of the highest funded
NINDS clinical trial ever awarded for TBI research, and the PI is an
emergency physician. The RAMPART study was multimillion-dollar clinical
trial for status epilepticus that recruited patients so fast and
efficiently that, even with an expanded sample size, it was completed 2
years ahead of schedule...and the PI was an EM researcher7. There are
numerous other examples. Clinical specialization based on a particular
organ system does not inherently confer any unique talents or exclusive
skills. Emergency medicine can compete with good science, training, and a
passion to succeed.
The type of trial design that one chooses depends on the question to
be answered. The distinction between efficacy and effectiveness is
clearly an important one (treatments may be efficacious, but when employed
to the broader population are not effective), but there are many reasons
for why this may occur; not all are encompassed in the term
generalizability. The small sample size in RCTs is more a function of
poor trial design than a fundamental flaw in any particular trial
methodology.
Even though the apparent underlying intent of Coates' article is to
justify large simple trials, the argument is lost on the contention that
emergency medicine is not competitive in disease-based sciences and
therefore should become "known" for a particular methodology. There is no
doubt that substantial inequalities in funding with our non-EM colleagues
exist8 and numerous challenges abound for EM researchers. But, emergency
medicine is making significant strides as the specialty matures.
Furthermore, trial design does not trump good science. Both types of
trials have merit, and emergency physicians can be great at and compete
for both!
REFERENCES
1. Rosenzweig JS, Van Deusen SK, Okpara O, Datillo PA, Briggs WM,
Birkhahn RH. Authorship, collaboration, and predictors of extramural
funding in the emergency medicine literature. Am J Emerg Med. Jan
2008;26(1):5-9.
2. Birkhahn RH, Van Deusen SK, Okpara OI, Datillo PA, Briggs WM, Gaeta TJ.
Funding and publishing trends of original research by emergency medicine
investigators over the past decade. Acad Emerg Med. Jan 2006;13(1):95-101.
3. Funding Opportunities. 2011;
http://search2.google.cit.nih.gov/search?q=Emergency+Medicine&Search.x=22&Search.y=1&site=GRANTS_ALL&client=GRANTS_ALL_frontend&proxystylesheet=GRANTS_ALL_frontend&output=xml_no_dtd&filter=0&getfields=*,
2012.
4. Hill MD, Martin RH, Palesch YY, et al. The Albumin in Acute Stroke Part
1 Trial: an exploratory efficacy analysis. Stroke; a journal of cerebral
circulation. Jun 2011;42(6):1621-1625.
5. Silbergleit R. Response to Food and Drug Administration draft guidance
statement on research into the treatment of life-threatening emergency
conditions using exception from informed consent: testimony of the
neurological emergencies treatment trials. Acad Emerg Med. Apr
2007;14(4):e63-68.
6. Ginsberg MD, Hill MD, Palesch YY, Ryckborst KJ, Tamariz D. The ALIAS
Pilot Trial: a dose-escalation and safety study of albumin therapy for
acute ischemic stroke--I: Physiological responses and safety results.
Stroke. Vol 372006:2100-2106.
7. Silbergleit R, Lowenstein D, Durkalski V, Conwit R. RAMPART (Rapid
Anticonvulsant Medication Prior to Arrival Trial): a double-blind
randomized clinical trial of the efficacy of intramuscular midazolam
versus intravenous lorazepam in the prehospital treatment of status
epilepticus by paramedics. Epilepsia. Oct 2011;52 Suppl 8:45-47.
8. Bessman SC, Agada NO, Ding R, Chiang W, Bernstein SL, McCarthy ML.
Comparing National Institutes of Health funding of emergency medicine to
four medical specialties. Acad Emerg Med. Sep 2011;18(9):1001-1004.
Acknowledgements: The author thanks the members of the editorial
board of Academic Emergency Medicine who participated in an email
discussion of the source paper; particularly Drs. David Cone, Jill Baren,
Clifton Callaway, Don Yealy, Christopher Moore, Lowell Gerson, Michelle
Biros, and Gary Gaddis.
RE: Coats, Timothy J.: Future research in emergency medicine:
explanation or pragmatism? Large or small? Simple or complex? Emerg Med J.
2011 Dec;28(12):1004-7.
Emergency Medicine Can! Response to Coats, Timothy J.: Future
research in emergency medicine: explanation or pragmatism? Large or small?
Simple or complex.
Coats highlights the potential role of emergency medicine in
conducting large pragmatic t...
RE: Coats, Timothy J.: Future research in emergency medicine:
explanation or pragmatism? Large or small? Simple or complex? Emerg Med J.
2011 Dec;28(12):1004-7.
Emergency Medicine Can! Response to Coats, Timothy J.: Future
research in emergency medicine: explanation or pragmatism? Large or small?
Simple or complex.
Coats highlights the potential role of emergency medicine in
conducting large pragmatic trials and the shortcomings of the more
traditional complex randomized controlled trials. He correctly points out
that traditional phase III trials are difficult to run, extremely
expensive, and restricted by highly competitive funding mechanisms. While
many of the points made in the article are valid, the premise that
emergency medicine researchers are not capable, or competitive in an arena
of rigorously conducted clinical trials is disconcerting and inaccurate.
Emergency physicians can compete, create niches, and succeed! The trial
design is irrelevant.
Over the last 10 years, the number of emergency physicians conducting
high quality RCTs has risen steadily1,2. These include both industry-
sponsored and federally funded trials. As the specialty matures, it is
only logical that emergency medicine expands its research footprint and
relevance.
The concept that traditional clinical trials or research are
restricted only to specialties that have narrowed their scope to a
particular disease state, organ system, technical skill, or type of
research is unsound. Emergency Medicine's uniqueness is that there are
diverse interests and a broad base of expertise. Science in general, and
clinical trials is particular, is a TEAM sport. The emergency physician
is ideally poised to take the reins of the RCT team, since emergency
medicine holds the key to the door (literally) and is the entry point for
many diseases and conditions into the system. Indeed, emergency medicine's
recent success in high-quality research has garnered substantial attention
at NIH. Just in the past 3 years, a number of requests for proposals
(RFPs) are targeted at emergency medicine researchers3. The Neurological
Emergencies Treatment Trials (NETT) network4,5 is constructed primarily of
emergency physicians as principal investigators. The NETT is being
heralded as one of the most successful acute trials networks in the
history of the NIH, and it has proven that emergency physicians not only
can run complicated RCT's, but that they excel at it. Fortunately for
other specialties, emergency medicine is collaborative by nature and seeks
out the participation and expertise of its colleagues. Non-EM researchers
now actively engage emergency physicians in acute trials because they
realize EM's critical role (e.g. Stroke Hyperglycemia Insulin Network
Effort (SHINE) Trial, Albumin in Acute Ischemic Stroke (ALIAS) Trial6).
Despite the specialty's relative young age and limited research
infrastructure, EM researchers are leading the pack in many fields of
research including traumatic brain injury, stroke, status epilepticus,
asthma and others. The ProTECT III trial is one of the highest funded
NINDS clinical trial ever awarded for TBI research, and the PI is an
emergency physician. The RAMPART study was multimillion-dollar clinical
trial for status epilepticus that recruited patients so fast and
efficiently that, even with an expanded sample size, it was completed 2
years ahead of schedule...and the PI was an EM researcher7. There are
numerous other examples. Clinical specialization based on a particular
organ system does not inherently confer any unique talents or exclusive
skills. Emergency medicine can compete with good science, training, and a
passion to succeed.
The type of trial design that one chooses depends on the question to
be answered. The distinction between efficacy and effectiveness is
clearly an important one (treatments may be efficacious, but when employed
to the broader population are not effective), but there are many reasons
for why this may occur; not all are encompassed in the term
generalizability. The small sample size in RCTs is more a function of
poor trial design than a fundamental flaw in any particular trial
methodology.
Even though the apparent underlying intent of Coates' article is to
justify large simple trials, the argument is lost on the contention that
emergency medicine is not competitive in disease-based sciences and
therefore should become "known" for a particular methodology. There is no
doubt that substantial inequalities in funding with our non-EM colleagues
exist8 and numerous challenges abound for EM researchers. But, emergency
medicine is making significant strides as the specialty matures.
Furthermore, trial design does not trump good science. Both types of
trials have merit, and emergency physicians can be great at and compete
for both!
REFERENCES
1. Rosenzweig JS, Van Deusen SK, Okpara O, Datillo PA, Briggs WM,
Birkhahn RH. Authorship, collaboration, and predictors of extramural
funding in the emergency medicine literature. Am J Emerg Med. Jan
2008;26(1):5-9.
2. Birkhahn RH, Van Deusen SK, Okpara OI, Datillo PA, Briggs WM, Gaeta TJ.
Funding and publishing trends of original research by emergency medicine
investigators over the past decade. Acad Emerg Med. Jan 2006;13(1):95-101.
3. Funding Opportunities. 2011;
http://search2.google.cit.nih.gov/search?q=Emergency+Medicine&Search.x=22&Search.y=1&site=GRANTS_ALL&client=GRANTS_ALL_frontend&proxystylesheet=GRANTS_ALL_frontend&output=xml_no_dtd&filter=0&getfields=*,
2012.
4. Hill MD, Martin RH, Palesch YY, et al. The Albumin in Acute Stroke Part
1 Trial: an exploratory efficacy analysis. Stroke; a journal of cerebral
circulation. Jun 2011;42(6):1621-1625.
5. Silbergleit R. Response to Food and Drug Administration draft guidance
statement on research into the treatment of life-threatening emergency
conditions using exception from informed consent: testimony of the
neurological emergencies treatment trials. Acad Emerg Med. Apr
2007;14(4):e63-68.
6. Ginsberg MD, Hill MD, Palesch YY, Ryckborst KJ, Tamariz D. The ALIAS
Pilot Trial: a dose-escalation and safety study of albumin therapy for
acute ischemic stroke--I: Physiological responses and safety results.
Stroke. Vol 372006:2100-2106.
7. Silbergleit R, Lowenstein D, Durkalski V, Conwit R. RAMPART (Rapid
Anticonvulsant Medication Prior to Arrival Trial): a double-blind
randomized clinical trial of the efficacy of intramuscular midazolam
versus intravenous lorazepam in the prehospital treatment of status
epilepticus by paramedics. Epilepsia. Oct 2011;52 Suppl 8:45-47.
8. Bessman SC, Agada NO, Ding R, Chiang W, Bernstein SL, McCarthy ML.
Comparing National Institutes of Health funding of emergency medicine to
four medical specialties. Acad Emerg Med. Sep 2011;18(9):1001-1004.
Acknowledgements: The author thanks the members of the editorial
board of Academic Emergency Medicine who participated in an email
discussion of the source paper; particularly Drs. David Cone, Jill Baren,
Clifton Callaway, Don Yealy, Christopher Moore, Lowell Gerson, Michelle
Biros, and Gary Gaddis.
We were intrigued to read that procedural sedation by emergency
physicians is safe and effective whilst admitting that complications do
occur. To us this is a contradiction in terms. Following the NAP4 project
into airway complications we know that aspiration is still the commonest
cause of death (1,3). Furthermore, patients undergoing airway manoeveres
in the ED and ICU are generally more challenging, with a higher inci...
We were intrigued to read that procedural sedation by emergency
physicians is safe and effective whilst admitting that complications do
occur. To us this is a contradiction in terms. Following the NAP4 project
into airway complications we know that aspiration is still the commonest
cause of death (1,3). Furthermore, patients undergoing airway manoeveres
in the ED and ICU are generally more challenging, with a higher incidence
of airway complications than that in theatres (2,3). Jacques study,
despite recognising that verbal contact be maintained, found 30% of
patients were deeply sedated or unconscious. Consultants were responsible
for 28% of sedations but we do not know how many clinicians had the
recommended skill level for general anaesthesia.
Numerous aspects of this study were worrying. No protocol was
included in the publication, there was no mention of assessment (and one
would expect exclusion) of patients with potential difficult airway/high
aspiration risk, whether a difficult airway trolley was readily available,
nor vitally whether end tidal carbon dioxide monitioring was used.
Similarly, whilst we recognise that many procedures involved the use of
propofol (n=293), a larger number were still using arguably 'older' drugs
i.e midazolam alone (n=950) or even a combination of the two.
Fortunately no patients suffered long term morbidity despite 1 in 30
suffering some airway/respiratory complication. If powered to look for
rare complications such as failure to ventilate or aspiration the study
conclusions might not have been so rosy. The fallacy about rare
complications is that if one has got away for many years then it won't
happen. Whilst agreeing that procedural sedation can be delivered in the
ED, we owe it to ourselves as a specialty and more importantly to our
patients, to ensure we are aware of our limitations and are at all times
prepared for the 'worst case scenario'!
While studying for my upcoming FCEM critical appraisal examination I
happened to use this paper, with it's table of sensitivities,
specificities, PPV and NPVs, to practice some calculations. Unfortunately
it would appear that some errors have made it into the final publication
of this data (I am unsure whether they were simply transcribed
incorrectly). In the first line of the table the...
While studying for my upcoming FCEM critical appraisal examination I
happened to use this paper, with it's table of sensitivities,
specificities, PPV and NPVs, to practice some calculations. Unfortunately
it would appear that some errors have made it into the final publication
of this data (I am unsure whether they were simply transcribed
incorrectly). In the first line of the table the sensitivity and
specificity values seem to have been reversed. However (more worryingly as
it refers to the primary outcome) in the second line of the table the
specificity presented should be 94% based on the numbers given. Given that
the PPV and NPV remain unchanged when calculated this would appear to be a
genuine miscalculation and unfortunately this has also been published in
the results section of the abstract. Although this still would be below
the threshold sensitivity of 98% which had been set by the authors, it is
clearly far closer than one would otherwise have been lead to believe.
We thank Prof. Cooke for his interest in our article [1], and are
glad that our analysis has provoked debate. We would like to take this
opportunity to address his response to these analyses. His major
criticisms seem to be:
1. " ...they fail to address the key issue of whether it benefits
patients"
2. "...their conclusion that this shows more patients are waiting for
care is imprecise and possibly...
We thank Prof. Cooke for his interest in our article [1], and are
glad that our analysis has provoked debate. We would like to take this
opportunity to address his response to these analyses. His major
criticisms seem to be:
1. " ...they fail to address the key issue of whether it benefits
patients"
2. "...their conclusion that this shows more patients are waiting for
care is imprecise and possibly wrong"
3. That performance against the 4-hour target is inadequate as an
isolated measure.
An initial response is that as 98% of patients waited less than
4hours in the past and now 95% of patients wait less than 4hours (i.e.
throughput is reduced), and the load on the system has not changed (i.e.
input is the same) then necessarily the numbers waiting longer have
necessarily increased.
Our analyses [1] did not set out to address whether the standard
benefits patients but refer to literature that indicates:
(i) Longer time in ED is associated with access block [2-4]
(ii) Access block causes delays to care [5,6]
(iii) Delays to care lead to poor outcomes [5-8]
Therefore, if there are longer times in ED there is access block that
causes delay to care, leading to poorer outcomes. This argument is based
on the referenced research evidence in the main article and this reply.
We acknowledge that focussing on time alone, rather than the quality of
care can affect patient outcomes adversely, and urge not the attainment of
the standard alone, but attainment of the target through high quality care
Prof. Cooke says that care starts earlier, and because of this, a
longer ED wait does not imply a delay to care. We argue that:
(i) Delays in ED are symptomatic of a wider issue with the whole
system, and relating to delays in care both within and without ED [3,6,9].
(ii) Regardless of a 10-year shift to more care in ED, the gradual
shift towards this model will be negligible over the short timescale of
the step change exhibited in the data we analysed. That is to say if this
gradual shift towards more care in ED did affect waiting times, we might
have expected to see a gradual decline in the performance level over the
same period. This is not seen in the data, which fluctuated about the 98%
performance level, only dropping (and rapidly) upon announcement of the
change in operating standard.
(iii) Furthermore, treatment in ED can increase human resources needs
[9], increasing length of stay in ED, thus because of the increase in
resource need for these patients, less resource can be utilised elsewhere
thereby increasing the waits of others. Hence, new arrivals to a crowded
ED will wait longer, building a positive feedback loop.
(iv) There have been concerns about the rises in ambulance to
hospital handover times (at least in London), which could represent an
embodiment of access block [4,11].
Prof. Cooke refers to the median in some "time to care" measures, in
doing so he puts undue emphasis on shorter waits (those below the median)
since the measure is strictly positive and thus bounded by zero below but
essentially unbounded above. This means that with a median of 4 hours 50%
of patients would be seen in less than 4 hours, and another 50% will
continue to wait for an amount of time that is not indicated by the
median. The median and the mean are problematic, both introducing biases
that take no account of the length of the long waits. Distribution of the
values is of more importance in assessing system performance.
That "...the use of a single target was subject to much criticism" is
of less concern once a systems-thinking approach is adopted [12,13]. To
attain the 4-hour target for waits in ED, the whole hospital system must
be operating efficiently (i.e. without access block) to ensure that a
patient is admitted, transferred, or discharged from the ED. If these
throughputs are not achieved, because of other processes in the system not
operating efficiently, then the patients will necessarily have waited
longer - as found in our analyses - and as aforementioned suffer worse
outcomes. In addition, we have found (unpublished data) that measures of
these processes and sub-processes are no more or less sensitive than the
single measure of ED waiting time, the additional granularity adds nothing
to the understanding of the overall performance of the system. Consider:
if to exit the ED A, B, and C must happen then measuring how long it takes
to complete A, B, C separately is the same as measuring the time taken to
complete all three. If one suspects that A is taking too long, one should
measure A, but to assess the system the "global" measure of ED waiting
times is more pertinent, because of its ties with overall hospital
performance. Examination of the distribution of waiting times would be
valuable in determination of flows.
Fifth, the comparison of the 95% standard to lower standards in other
countries , whilst useful background information is neither an argument in
criticism of this analysis, nor in support of lowering the standard in
this country; and recall that Scotland has kept the target at 98%. Whilst
it is the actual performance level that matters, the level at which the
target is set is relevant: we show that following the lowering of the
target for England, the performance level dropped. This occurred upon
announcement of the new lower standard and in advance of the official
adoption [1]. Consequently, we note a lower target level has resulted in
lower performance with lower throughputs and thus longer waits, meaning
worse outcomes [1,9,14].
Additionally, the impact of increased time in ED on patient
experience should not be forgotten, nor should the additional economic
cost; not just to the hospital and its staff, but also to the patient in
lost time.
References
1. Woodcock T, Poots AJ, Bell D (2012) The impact of changing the 4 h
emergency access standard on patient waiting times in emergency
departments in England. Emergency Medical Journal doi:10.1136/emermed-
2012-201175
2. Dunn R (2003) Reduced access block causes shorter emergency
department waiting times: An historical control observational study.
Emergency Medicine (Fremantle) 15(3):232-238
3. Richardson DB, Mountain D (2009) Myths versus facts in emergency
department overcrowding and hospital access block. Medical Journal of
Australia 190(7):369-374
4. Fatovich DM, Nagree Y, Sprivulis P (2005) Access block causes
emergency department overcrowding and ambulance diversion in Perth,
Western Australia. Emergency Medical Journal 22:351-354
5. Richardson DB (2006) Increase in patient mortality at 10 days
associated with emergency department overcrowding Medical Journal of
Australia 184(5): 213-216
6. Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U,
McCarthy M, John McConnell K, Pines JM, Rathlev N, Schafermeyer R, Zwemer
F, Schull M, Asplin BR and Society for Academic Emergency Medicine,
Emergency Department Crowding Task Force (2009) The Effect of Emergency
Department Crowding on Clinically Oriented Outcomes. Academic Emergency
Medicine 16: 1-10
7. Mir? O, Antonio MT, Jim?nez S, De Dios A, S?nchez M, Borr?s A,
Mill? J (1999) Decreased health care quality associated with emergency
department overcrowding. European Journal of Emergency Medicine 6(2):105-
107
8. Richardson DB (2002) The access-block effect: relationship between
delay to reaching an inpatient bed and inpatient length of stay. Medical
Journal of Australia 177(9):492-495
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safety? Medical Journal of Australia 184(5):203-204
10. Drummond AJ (2002) No room at the inn: overcrowding in Ontario's
emergency departments. Canadian Journal of Emergency Medicine. 4(2):91-
97
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ambulance handover times at London A&Es. 26 May 2011 [accessed 30 Aug
2012]: http://www.hsj.co.uk/hsj-local/acute-trusts/homerton-university-
hospital-nhs-foundation-trust/continued-under-performance-on-ambulance-
handover-times-at-london-aes/5030315.article
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Richardson DB (2010) Access block and ED overcrowding. Emergency Medicine
Australia 22(2): 119-135
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Krikscionaitiene et al. 1 reported that lightweight rescuers require
special attention during CPR (cardiopulmonary resuscitation) training,
with an emphasis on correct body posture and positioning of body mass to
ensure CCs (chest compressions) are performed according to the European
Resuscitation Council Guidelines for Resuscitation 2010. We routinely
educate rescuers with regard to appropriate postu...
Krikscionaitiene et al. 1 reported that lightweight rescuers require
special attention during CPR (cardiopulmonary resuscitation) training,
with an emphasis on correct body posture and positioning of body mass to
ensure CCs (chest compressions) are performed according to the European
Resuscitation Council Guidelines for Resuscitation 2010. We routinely
educate rescuers with regard to appropriate postures for high quality
chest compressions including kneeling as closely beside the victim as
possible, body positioning directly above the victim's chest,
straightening of both arms, and placing the heel of the palm on the lower
half of the sternum with the fingers interlocked. Despite teaching these
postures to the rescuers to encourage adequate CCs during CPR training, we
have encountered CCs of insufficient depth performed by low-weight adults,
especially women and young students. As a result, the eleven of us, who
are AHA (American Heart Association) Basic Life Support instructors,
shared our educational experiences and discussed how we could motivate
these trainees to perform CCs of the recommended depth. Positioning of the
rescuer more than 90 degrees above the victim's chest might enable the
rescuer to use his or her body weight more effectively to achieve
sufficient CC depth. However, this method could prevent complete chest
recoil, which is an important component of CCs.2 The "lifting the heel of
the hand slightly off the chest" technique might compensate for the
incomplete recoil.3 Above all, we believe that trainees should be given
sufficient time during CPR education to observe and put into practice a CC
depth of 5-6 cm. We would like to get from the authors some insight and
information regarding good methods related to the rescuer's posture or
instructor's teaching skills to ensure sufficient CC depth.
Reference
1. Krikscionaitiene A, Stasaitis K, Dambrauskiene M, et al. Can
lightweight rescuers adequately perform CPR according to 2010
resuscitation guideline requirements? Emergency medicine journal?: EMJ.
2012:2011-2013. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22345324.
Accessed July 6, 2012.
2. Niles DE, Sutton RM, Nadkarni VM, et al. Prevalence and
hemodynamic effects of leaning during CPR. Resuscitation. 2011;82 Suppl
2:S23-6.
3. Aufderheide TP, Pirrallo RG, Yannopoulos D, et al. Incomplete
chest wall decompression: a clinical evaluation of CPR performance by
trained laypersons and an assessment of alternative manual chest
compression-decompression techniques. Resuscitation. 2006;71:341-51.
Youngsuk Cho* and Jaehoon Oh* contributed equally to this letter
While computed tomography scans (CT scans) undoubtedly provide valuable information to physicians caring for emergency department (ED) patients, there is growing concern that many studies are performed unnecessarily resulting in significant radiation exposure for limited actual clinical benefit. Excluding indications for acute trauma, CT scans are commonly obtained in the ED to detect acute appendicitis, renal colic, bow...
Junior doctor: "Hi, I am one of the junior doctors in A&E. I have a 35 year old lady presenting with 3 hours of worsening right iliac fossa pain..." Registrar: "What is the urine HCG." Junior doctor: "Negative, and she does not report any PV bleeding or discharge." Registrar: "What are the inflammatory markers?" Junior doctor: "Well white cells are marginally raised at 12.6 and CRP is normal, however I think we s...
Dear sir
I read with interest the article by Dr Durge. I agree this is an important issue and feel that I can improve this technique. In the presence of secretions or vomit the tube tie can easily slip on the tube and cause migration of the tracheal tube. However with the use of a similar amount of pink elastoplast the tube tie and if tied directly onto the applied tape it is almost impossible to slip and there...
In the methodology Kirby and Roberts in suggesting their methodology is likely to create bias have surely underplayed the risk of bias. Whilst research may often been based on convenience samples this surely takes this to extremes. Survey Monkey fatigue has set in for me with the number of requests recieved for surveys apparently aimed at supporting a clinical topic review of a FCEM candidate.I know I am not alone in thi...
RE: Coats, Timothy J.: Future research in emergency medicine: explanation or pragmatism? Large or small? Simple or complex? Emerg Med J. 2011 Dec;28(12):1004-7.
Emergency Medicine Can! Response to Coats, Timothy J.: Future research in emergency medicine: explanation or pragmatism? Large or small? Simple or complex.
Coats highlights the potential role of emergency medicine in conducting large pragmatic t...
RE: Coats, Timothy J.: Future research in emergency medicine: explanation or pragmatism? Large or small? Simple or complex? Emerg Med J. 2011 Dec;28(12):1004-7.
Emergency Medicine Can! Response to Coats, Timothy J.: Future research in emergency medicine: explanation or pragmatism? Large or small? Simple or complex.
Coats highlights the potential role of emergency medicine in conducting large pragmatic t...
We were intrigued to read that procedural sedation by emergency physicians is safe and effective whilst admitting that complications do occur. To us this is a contradiction in terms. Following the NAP4 project into airway complications we know that aspiration is still the commonest cause of death (1,3). Furthermore, patients undergoing airway manoeveres in the ED and ICU are generally more challenging, with a higher inci...
Dear Editor and Authors,
While studying for my upcoming FCEM critical appraisal examination I happened to use this paper, with it's table of sensitivities, specificities, PPV and NPVs, to practice some calculations. Unfortunately it would appear that some errors have made it into the final publication of this data (I am unsure whether they were simply transcribed incorrectly). In the first line of the table the...
We thank Prof. Cooke for his interest in our article [1], and are glad that our analysis has provoked debate. We would like to take this opportunity to address his response to these analyses. His major criticisms seem to be:
1. " ...they fail to address the key issue of whether it benefits patients"
2. "...their conclusion that this shows more patients are waiting for care is imprecise and possibly...
Dear Sir,
Krikscionaitiene et al. 1 reported that lightweight rescuers require special attention during CPR (cardiopulmonary resuscitation) training, with an emphasis on correct body posture and positioning of body mass to ensure CCs (chest compressions) are performed according to the European Resuscitation Council Guidelines for Resuscitation 2010. We routinely educate rescuers with regard to appropriate postu...
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