A timely and interesting read if for no other reason colleagues and I were discussing / bemoaning recurrent abdominal pain presentations only last week. Many of the features that act as obstacles were well recognised and omnipresent.
The solutions are an excellent mixture of skills and I can see much utility, I can also foresee the care pathways being highly personalised in our healthcare institutions (Daniels et al allude to this by describing one the ED consultants with an interest in HIU) and once that person moves job the pathway crumbles.
To an extent excluding medical emergency (the 1st E in ERROR) does require medicalisation whether it be vitals being taken or the initial bloods including lactate. I can see the purpose and benefit of not repeating unnecessary blood tests and I suspect not doing tests will be a feat more easily achieved with seniority, There is benefit in letting HIUs be seen exclusively by such.
I was surprised that Daniels and the other authors claim that "pain is not a central consideration in RCEM guidelines...". The college guidelines page (https://www.rcem.ac.uk/RCEM/Quality_Policy/Clinical_Standards_Guidance/R...) lists at east 3 where pain is most certainly the central consideration, or was this in relation to abdominal pain only?
A timely and interesting read if for no other reason colleagues and I were discussing / bemoaning recurrent abdominal pain presentations only last week. Many of the features that act as obstacles were well recognised and omnipresent.
The solutions are an excellent mixture of skills and I can see much utility, I can also foresee the care pathways being highly personalised in our healthcare institutions (Daniels et al allude to this by describing one the ED consultants with an interest in HIU) and once that person moves job the pathway crumbles.
To an extent excluding medical emergency (the 1st E in ERROR) does require medicalisation whether it be vitals being taken or the initial bloods including lactate. I can see the purpose and benefit of not repeating unnecessary blood tests and I suspect not doing tests will be a feat more easily achieved with seniority, There is benefit in letting HIUs be seen exclusively by such.
I was surprised that Daniels and the other authors claim that "pain is not a central consideration in RCEM guidelines...". The college guidelines page (https://www.rcem.ac.uk/RCEM/Quality_Policy/Clinical_Standards_Guidance/R...) lists at east 3 where pain is most certainly the central consideration, or was this in relation to abdominal pain only?
Overall good article. Timely and worthwhile for us all working in EDs.
I enjoyed reading this article, however, the reference to a cytokine storm warrants clarification. An editorial in JAMA Internal Medicine doi:10.1001/jamainternmed.2020.3313 suggested little evidence for such a storm and this has been supported by more recent studies by Remy et al in JCI Insight (10.1172/jci.insight.140329) who demonstrated severe immunosuppression and Kox et al in JAMA (doi:10.1001/jama.2020.17052) who found multiple cytokines were reduced in severe COVID-19.
The use of Angiotensin II for cardiogenic shock(1) might be counterproductive in patients who have cardiogenic shock attributable to Takotsubo cardiomyopathy(TTC) characterised by left ventricular outflow tract(LVOT) obstruction. The following are the reasons justifying non-use of that treatment modality:-
Angiotensin II induces catecholamine release(2), thereby potentially exacerbating the catecholamine surge which characterises TTC. This catecholamine surge is mimicked by exogenous administration of epinephrine, the latter well documented as a trigger for de novo TTC in 22 patients reviewed in the literature search by Madisa et al(2). In another literature review, dobutamine(also a catecholamine ) triggered the onset of TTC in 22 patients(3). A typical example of the latter was a 61 year old woman who developed chest pain at 70% of her age-predicted heart rate, when she was on a 40 mcg/min infusion of dobutamine. Her electrocardiogram(ECG) then showed inferolateral ST segment elevation. Transthoracic echocardiography showed severe akinesia of the apical, anteroseptal, and apicolateral segments at peak dobutamine infusion. Coronary angiography disclosed normal epicardial vasculature(5).
When LVOT obstruction occurs in TTC it can give rise to severe hypotension, exemplified by a 60 year old woman with a nadir systolic blood pressure(SBP) of 80 mm Hg in association with a gradient of 58 mm Hg across the LVOT. After landiolol( a beta blocker) inf...
The use of Angiotensin II for cardiogenic shock(1) might be counterproductive in patients who have cardiogenic shock attributable to Takotsubo cardiomyopathy(TTC) characterised by left ventricular outflow tract(LVOT) obstruction. The following are the reasons justifying non-use of that treatment modality:-
Angiotensin II induces catecholamine release(2), thereby potentially exacerbating the catecholamine surge which characterises TTC. This catecholamine surge is mimicked by exogenous administration of epinephrine, the latter well documented as a trigger for de novo TTC in 22 patients reviewed in the literature search by Madisa et al(2). In another literature review, dobutamine(also a catecholamine ) triggered the onset of TTC in 22 patients(3). A typical example of the latter was a 61 year old woman who developed chest pain at 70% of her age-predicted heart rate, when she was on a 40 mcg/min infusion of dobutamine. Her electrocardiogram(ECG) then showed inferolateral ST segment elevation. Transthoracic echocardiography showed severe akinesia of the apical, anteroseptal, and apicolateral segments at peak dobutamine infusion. Coronary angiography disclosed normal epicardial vasculature(5).
When LVOT obstruction occurs in TTC it can give rise to severe hypotension, exemplified by a 60 year old woman with a nadir systolic blood pressure(SBP) of 80 mm Hg in association with a gradient of 58 mm Hg across the LVOT. After landiolol( a beta blocker) infusion her SBP recoverd to 120 mm Hg, and her LVOT resolved(6). In another study propranolol infusion also generated an improvement in SBP and an amelioration of LVOT obstruction(7). Conversely, Ansarin et al showed that rates of in-hospital events and short- as well as long-term mortality were significantly higher in TTC patients receiving catecholamine support as compared to other study patients(8). In one other report a 78 year old hypotensive woman with TTC, ST segment elevation , SBP 68 mm Hg and intraventricular pressure gradient(IVPG) 104 mm Hg was initially treated with a dopamine(20 mcg/kg/min) infusion. When the clinicians began to suspect that her prolonged hypotension was contributing to her prolonged hypotension they gradually decreased the dose of dopamine. Immediately after cessation of dopamine her SBP increased to 96 mm Hg and the IVPG fell to 54 mm Hg . She was subsequently treated with carvedilol. Five days later the IVPG had completely resolved (9)
TTC-related LVOT obstruction is often characterised by the presence of a systolic murmur even in the presence of severe hypotension. Accordingly, when cardiogenic shock is accompanied by a systolic murmur in a patient with ST segment elevation the differential diagnosis should include TTC-related LVOT obstruction . In that context beta adrenergic blocked should be prioritised over the use of noradrenaline, dopamine, or, even, Angiotensin II
I have no funding and no conflict of interest
References
(1) Wallis M., Chow JH., Winters M., McCurdy MT
Angiotensin II for the emergency physician
Emerg J Med 2019;doi.10.1136/emermed-2019-209062 Epub ahead of print
(2)Dendorfer A., Thornagel A., Raasch W., Grisk O., Tempel K., Dominiak P
Angiotensin II induces catecholamine release by direct ganglionic excitation
Hypertension 2002;40:348-354
(3) Madias JE
Epinephrine administration and Takotsubo syndrome : Lessons from past experience
Int J Cardiol 2016;doi.org/10.1016/j.ijcard 2016.01.145
(4) Hajsadeghi S., Rahbar MH., Iranpour A., Salehi A., Asadi O., Jafarian SR et al
Dobutamine induced takotsubo cardiomyopathy: A systematic review of the literature and case report
Abatol J Cardiol 2018;19:412-421
(5) Margey R., Diamond P., MvCann H., Surgue D
Dobutamine stress echo-induced apical ballooning(Takotsubo) syndrome
Eur J Echocardiogr 2009;10:395-399
(6) Takada T., Jujo K., Ishida I., Hagiwara N
Recurrent takotsubo syndrome with worsening of left ventricular outflow obstruction during hemodialysis: case report
Eur Heart J Case Reports 2020;4:1-4
(7) Yoshioka T., Hashimoto A., Tschihashi K., Nagao K., Kyuma M., Ooiwa H et al
Clinical implications of midventricular apical ballooning(Takotsubo cardiomyopathy)
Am Heart J 20018;155:526.e1-525.e7
(8) Ansari U., El-Battrawy I., Fastner C., Behnes M., Sattler K., Huseynov A et al
Clinical outcomes associated with catecholamine use in patients diagnosed with Takotsubo cardiomyopathy
BMC Cardiovascular Disorders doi.otg/10.1186/s12872-018-0784-6
(9)Abe Y., Tamura A., Kadora J
Prolonged cardiogenic shock caused by high-dose intravenous administration of dopamine in a patient with takotsubo cardiomyopathy
Int J Cardiol 2010;141:e1-e3
The enforcement of lockdown in the UK in March 2020 saw businesses shut up shop and most of the general population barricade themselves in the safety of their homes. NHS and community facilities had to implement downgraded versions of their services to comply with social distancing with a reduced workforce available to deliver these services. One such cohort affected by these measures is those who take recreational drugs, either socially or habitually.
The number of people who use recreational drugs regularly is unknown. NHS Digital data states that there were 14,053 patients admitted to hospital with ‘poisoning by illicit drugs’ in England in 2018. 53% of these patients were male and two-thirds fell into the 16-44yrs age bracket. Men were more than twice as likely to use cannabis or cocaine compared to women and older age groups were more likely to use opiates alone (1).
One in 12 adults were found to have taken an illicit drug between 2016 and 2017 (1). Whilst lockdown may have caused many inconveniences to the everyday lives of most of us, many habitual drug users have found themselves with additional stressors extending beyond contracting COVID-19 itself. This may not be someone’s chosen path in life but it is the reality that many are living with. This lifestyle is intertwined with medical and psychological difficulties which may necessitate NHS support.
If your first thought upon waking is how you are going to obtain your next fix, then how are...
The enforcement of lockdown in the UK in March 2020 saw businesses shut up shop and most of the general population barricade themselves in the safety of their homes. NHS and community facilities had to implement downgraded versions of their services to comply with social distancing with a reduced workforce available to deliver these services. One such cohort affected by these measures is those who take recreational drugs, either socially or habitually.
The number of people who use recreational drugs regularly is unknown. NHS Digital data states that there were 14,053 patients admitted to hospital with ‘poisoning by illicit drugs’ in England in 2018. 53% of these patients were male and two-thirds fell into the 16-44yrs age bracket. Men were more than twice as likely to use cannabis or cocaine compared to women and older age groups were more likely to use opiates alone (1).
One in 12 adults were found to have taken an illicit drug between 2016 and 2017 (1). Whilst lockdown may have caused many inconveniences to the everyday lives of most of us, many habitual drug users have found themselves with additional stressors extending beyond contracting COVID-19 itself. This may not be someone’s chosen path in life but it is the reality that many are living with. This lifestyle is intertwined with medical and psychological difficulties which may necessitate NHS support.
If your first thought upon waking is how you are going to obtain your next fix, then how are you going to orchestrate daily life during lockdown? Although drug dealers are not exempt from social isolation, they are unlikely to have their usual presence on the street and drug-seeking may be more difficult. With international travel currently limited there is likely to have been adaptations to the mechanisms via which drugs are acquired and sold. Smaller drug packages are likely to be on offer to maintain transactions, especially to those who have lost usual sources of income. To address shortages of supply there may be more ‘cutting’ of active substance with other substances, potentially with toxic side-effects. These factors are likely to end up being the most detrimental to a vulnerable end-user.
Perhaps the paucity of supply of the usual drug abused by an individual forces them towards different, more easily available substances to which they go on to become addicted to. For those who have become addicted to prescribed medication, the cost of obtaining such drugs is likely to have sky rocketed.
Conversely, this scenario of desperation may not be replicated in those whom partake only in occasional recreational drug use. Staying at home may cause a decrease in social drug use from lack of opportunities to see friends, bans on festivals and parties, closure of nightclubs or because an individual is at home with their family. The rising use of video-based social gatherings could, however, trigger increasing drug use.
This complete disruption to normal life, however, could prove an opportunity for periods of abstinence and detox. There is an increased presence of information upon social media platforms reaching out to patients who may be suffering with drug addiction during this time. Many habitual drug users who are previously homeless have been accommodated in hotels, paid for by local councils, to protect them during COVID-19 pandemic (2). This has given many a well-needed source of stability with the opportunity to recuperate and achieve positive lifestyle changes. Community drug project workers have had an active presence in such hotels providing socially-distanced needle-exchange programmes, opiate substitute therapy, community naloxone provision and nursing staff to monitor those symptomatic of COVID.
This change in social circumstance may also have contributed to 56.6% fewer attendances to Emergency Departments (ED) in April 2020 compared to the same month in 2019 (3). High Intensity Users (HIUs), those whom attend ED more than five times per year, make up a significant proportion of this case load (4). Drug-related HIU attendances are likely are likely to have fallen in line with other non-COVID presenting complaints.
If analysis of current statistics proves a reduction in ED attendances related to drug use, including overdose, withdrawal, changes to mental health and death from drug toxicity, then there could be more evidence to increase funding and provision of services to this cohort of the population. And if that is the case, at least there is one small positive found at the end of the NHS rainbow.
We have read with great interest the article by Vihonen et al, ‘Glucose as an additional parameter to National Early Warning Score in prehospital setting enhances identification of patients at risk of death: an observational cohort study’, recently published in your journal.(1)
Traditionally, the scores published to assess the risk of mortality in patients attended in a prehospital setting, the predictive value of which had been questioned until recent studies, did not include the quantification of glycemia among the parameters analysed in the initial assessment of the patient.(2-4)
Overlooking its systematic determination in the initial care of any critically ill patient represents an easily avoidable risk, due to its accessibility and to the ease in interpreting results in any setting. This shortcoming is especially relevant in the initial care of patients with acute poisoning, due to the limitations of the anamnesis and the need to establish a rapid and reliable differential diagnosis in patients with often complex and plural clinical symptoms.(5,6) In this regard, the prognostic value of glycemia as a biomarker in some acute, highly lethal levels of poisoning must also be taken into account.(7,8)
In Catalonia, two studies undertaken by the Prehospital Medical Emergency Service in recent years have shown that only 30.1% of those poisoned by caustic products or 15.2% of the 1,930 people poisoned by carbon monoxide or smoke released f...
We have read with great interest the article by Vihonen et al, ‘Glucose as an additional parameter to National Early Warning Score in prehospital setting enhances identification of patients at risk of death: an observational cohort study’, recently published in your journal.(1)
Traditionally, the scores published to assess the risk of mortality in patients attended in a prehospital setting, the predictive value of which had been questioned until recent studies, did not include the quantification of glycemia among the parameters analysed in the initial assessment of the patient.(2-4)
Overlooking its systematic determination in the initial care of any critically ill patient represents an easily avoidable risk, due to its accessibility and to the ease in interpreting results in any setting. This shortcoming is especially relevant in the initial care of patients with acute poisoning, due to the limitations of the anamnesis and the need to establish a rapid and reliable differential diagnosis in patients with often complex and plural clinical symptoms.(5,6) In this regard, the prognostic value of glycemia as a biomarker in some acute, highly lethal levels of poisoning must also be taken into account.(7,8)
In Catalonia, two studies undertaken by the Prehospital Medical Emergency Service in recent years have shown that only 30.1% of those poisoned by caustic products or 15.2% of the 1,930 people poisoned by carbon monoxide or smoke released from fire, had their glycemia levels determined in a prehospital setting, an issue which we consider can really be improved. For all these reasons, we have recently proposed that the determination of glycemia in poisoned patients should be routine, being included in the panel of indicators of healthcare quality of these patients(9), which reinforces the conclusion of Vihonen et al.
References
1. Vihonen H, Lääperi M, Kuisma M, Pirneskoski J, Nurmi J. Glucose as an additional parameter to National Early Warning Score in prehospital setting enhances identification of patients at risk of death: an observational cohort study. Emerg Med J. 2020; 37:286-92.
2. Kievlan DR, Martin-Gill C, Kahn JM, Callaway CW, Yealy DM, Angus DC, et al. External validation of a prehospital risk score for critical illness. Crit Care. 2016; 20:255-61.
3. Lane DJ, Wunsch H, Saskin R, et al. Assessing Severity of Illness in Patients Transported to Hospital by Paramedics: External Validation of 3 Prognostic Scores. Prehosp Emerg Care. 2020; 24:273‐81.
4. Patel R, Nugawela MD, Edwards HB, Richards A, Le Roux H, Pullyblank A, et al. Can early warning scores identify deteriorating patients in pre-hospital settings? A systematic review. Resuscitation. 2018; 132:101-11.
5. Amrein K, Kachel N, Fries H, Hovorka R, Pieber TR, Plank J, et al. Glucose control in intensive care: usability, efficacy and safety of SpaceGlucose Control in two medical European intensive care units. BMC Endocr Disord. 2014; 14: 62.
6. Erickson TB, Thompson TM, Lu JL. The approach to the patient with an unknown overdose. Emerg Med Clin N Am. 2007; 25: 249-81.
7. Moon JM, Chun BJ, Cho YS. Hyperglycemia at presentation is associated with in hospital mortality in non-diabetic patient with organophosphate poisoning. Clin Toxicol. 2016; 54:252‐8.
8. Sharma A, Balasubramanian P, Gill KD, Bhalla A. Prognostic Significance of Blood Glucose Levels and Alterations Among Patients with Aluminium Phosphide Poisoning. Sultan Qaboos Univ Med J. 2018; 18: e299‐e303.
9. Ferrés-Padró V, Amigó-Tadín M, Puiguriguer-Ferrando J, Nogué-Xarau S. Proposal for a new quality indicator for care of patients with acute poisoning. JHQR. 2020. (In press) JHQR-D-19-00203R1.
This article draws its evidence from two citations, one by Madsen et al., and the other from a systematic review, which has been mis-cited as a duplicate of the Madsen reference. The correct citation to the systematic review is not Madsen et al., but Tarnutzer et al., PubMed ID 28356464 (Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. Neurology. 2017;88(15):1468-1477. doi:10.1212/WNL.0000000000003814.).
I read with interest the recent article by Carley et al., “Evidence-based medicine and COVID-19: what to believe and when to change”1. The authors pay homage to the challenges of keeping pace with a pandemic growing at unprecedented speeds, forcing the hand of clinicians to make therapeutic decisions on the basis of weak, often unvalidated evidence. They also note the influence of political opinion, referencing Donald Trump’s infamous declaration on the efficacy of hydroxychloroquine as a treatment for COVID-192. In their concluding statements, the authors eloquently present the need to follow science rather than emotions or politics.
Having worked in a large critical care unit over the pandemic, I question how easy this is in practice. Clinicians, nurses and Allied Health Professionals do not exist in a vacuum, but rather their opinions and knowledge are inevitably shaped by social and cultural rhetoric. I use the example of Personal Protective Equipment (PPE), an acronym once reserved to select professions yet now colloquially used by the lay person. Information regarding the appropriate PPE to be worn was disseminated in multiple formats, from news broadcasts to social media platforms such as Twitter. As knowledge developed about how the SARS-COV-2 virus was transmitted, recommendations on PPE changed accordingly. As of July 23rd, it was recommended that double gloving was not necessary3, and in fact increased the risk of transmitting e-coli...
I read with interest the recent article by Carley et al., “Evidence-based medicine and COVID-19: what to believe and when to change”1. The authors pay homage to the challenges of keeping pace with a pandemic growing at unprecedented speeds, forcing the hand of clinicians to make therapeutic decisions on the basis of weak, often unvalidated evidence. They also note the influence of political opinion, referencing Donald Trump’s infamous declaration on the efficacy of hydroxychloroquine as a treatment for COVID-192. In their concluding statements, the authors eloquently present the need to follow science rather than emotions or politics.
Having worked in a large critical care unit over the pandemic, I question how easy this is in practice. Clinicians, nurses and Allied Health Professionals do not exist in a vacuum, but rather their opinions and knowledge are inevitably shaped by social and cultural rhetoric. I use the example of Personal Protective Equipment (PPE), an acronym once reserved to select professions yet now colloquially used by the lay person. Information regarding the appropriate PPE to be worn was disseminated in multiple formats, from news broadcasts to social media platforms such as Twitter. As knowledge developed about how the SARS-COV-2 virus was transmitted, recommendations on PPE changed accordingly. As of July 23rd, it was recommended that double gloving was not necessary3, and in fact increased the risk of transmitting e-coli infection. Clinical staff reacted to the change with a mixture of concern and mistrust, referencing the ever-changing advice from government sources and the differences in practices across trusts.
This pandemic has led to an unprecedented change to the dissemination of scientific information. In usual times, it is expected that evidence-based medicine (EBM) forms the pillar from which clinical practice is developed. The channels in which this information is delivered are well-established and validated through peer-review, as the authors note. The vast public interest and vested political interest in the outcomes and development of the pandemic has led to more scientific information being shared on public platforms.
With this in mind, I propose to the authors an addition to their fourth solution: “design studies for deployment in future pandemics and place them in a ‘hibernated state’ such that the future research infrastructure is in place prior to requirement”1. I suggest the implementation of internal trust structures for the dissemination of up-to-date EBM and resulting changes to clinical practices and policies. This may be in the format of daily or weekly briefings, perhaps through trust intranet services or via a specified research guardian dedicated to the communication of EBM to staff.
The authors have proposed detailed suggestions as to how EBM should be upheld during the COVID-19, and future, pandemics. I caution the need to maintain and uphold channels for communicating such evidence, particularly when social media, news outlets and politicians proliferate information at a speed greater than traditional avenues for the dissemination of research.
References
1. Carley S, Horner D, Body R, et al Evidence-based medicine and COVID-19: what to believe and when to change. Emergency Medicine Journal Published Online First: 10 July 2020. doi: 10.1136/emermed-2020-210098
2. Rome BN, Avorn J. Drug evaluation during the Covid-19 pandemic. N Engl J Med 2020;382:2282 doi:10.1056/NEJMp2009457 pmid:http://www.ncbi.nlm.nih.gov/pubmed/32289216
3. COVID-19 personal protective equipment (PPE) [Internet]. GOV.UK. 2020 [cited 6 August 2020]. Available from: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infec...
What this proposed reset does not describe is a reorganisation of 'at the door' triage based on the type of presentation.
The need for effective patient throughput (patient flow); the major problem in contemporary A&E (at least pre Covid19) has not been addressed.
.
I propose triaging 'at the door' carried out by nurse practitioners (assisted by paramedic crews bringing patients in) and admin staff to access medical information rapidly (for example via the Great North Care Record). These insights were gained from camp Bastion in Afghanistan.
There should be 4 key portals and pathways thereafter.
a) The seriously ill (Major Trauma, Sepsis, Stroke, Cardiac Infarcts, Acute Abdomens etc.)
b) Cases of frailty (mainly elderly people, including delirium / dementia, minor trauma)
c) mental Health presentations (of all ages, including learning disability)
d) overspill from General Practice
These pathways would be staffed by specialist nurse practitioners, pharmacists and speciality doctors, working on prearranged algorithms with electronic prescribing and discharge / handover templates (ideally in a SBAR format) to assist patient flow. cross referral (called scaffolding in mental health) should be possible on occasion. Overall, a duty matron should keep overall control of activity through an electronic dashboard. Paramedic / ambulance crews should have access to this matron remotely to make crucial d...
What this proposed reset does not describe is a reorganisation of 'at the door' triage based on the type of presentation.
The need for effective patient throughput (patient flow); the major problem in contemporary A&E (at least pre Covid19) has not been addressed.
.
I propose triaging 'at the door' carried out by nurse practitioners (assisted by paramedic crews bringing patients in) and admin staff to access medical information rapidly (for example via the Great North Care Record). These insights were gained from camp Bastion in Afghanistan.
There should be 4 key portals and pathways thereafter.
a) The seriously ill (Major Trauma, Sepsis, Stroke, Cardiac Infarcts, Acute Abdomens etc.)
b) Cases of frailty (mainly elderly people, including delirium / dementia, minor trauma)
c) mental Health presentations (of all ages, including learning disability)
d) overspill from General Practice
These pathways would be staffed by specialist nurse practitioners, pharmacists and speciality doctors, working on prearranged algorithms with electronic prescribing and discharge / handover templates (ideally in a SBAR format) to assist patient flow. cross referral (called scaffolding in mental health) should be possible on occasion. Overall, a duty matron should keep overall control of activity through an electronic dashboard. Paramedic / ambulance crews should have access to this matron remotely to make crucial decisions on decisions to pick up patients from homes or to leave them to be attended by 'hospital at home' services (including mental health crisis / street triage).
Finnikin and colleagues describe a large data set of retrospectively calculated National Early Warning Scores (NEWS) in a system that was not using or responding to NEWS. Understanding the relationship between NEWS and referral practices is an important area of research which could help shed some light on the impact of introducing NEWS into primary care.
The first important point is that only 31% (74,992/242,451) of patients who had face-to-face encounters had a full set of observations and the clinical characteristics of the 69% excluded from the study are unknown. In our experience, GPs tend to perform a full set of observations on patients who appear more unwell so it is possible that the population studied may not be representative.
Finnikin and colleagues found that only 6.9% of patients referred to hospital had a NEWS≥5 and 69% with a NEWS ≥5 were not referred. There is emerging evidence that NEWS calculated by GPs at referral correlates with mortality (data from West of England accepted for publication) so the fact that it did not correlate with referral is of concern. Scott et al in the West of England (1, 2) and Inada Kim et al in Wessex (unpublished data) have demonstrated that the higher the NEWS on referral or arrival, the more likely the patient is to be admitted and the more likely the patient is to die.
The lack of linkage to any outcomes is a major weakness of this work. While an increase in admissions of 16.2% is not ideal in an alr...
Finnikin and colleagues describe a large data set of retrospectively calculated National Early Warning Scores (NEWS) in a system that was not using or responding to NEWS. Understanding the relationship between NEWS and referral practices is an important area of research which could help shed some light on the impact of introducing NEWS into primary care.
The first important point is that only 31% (74,992/242,451) of patients who had face-to-face encounters had a full set of observations and the clinical characteristics of the 69% excluded from the study are unknown. In our experience, GPs tend to perform a full set of observations on patients who appear more unwell so it is possible that the population studied may not be representative.
Finnikin and colleagues found that only 6.9% of patients referred to hospital had a NEWS≥5 and 69% with a NEWS ≥5 were not referred. There is emerging evidence that NEWS calculated by GPs at referral correlates with mortality (data from West of England accepted for publication) so the fact that it did not correlate with referral is of concern. Scott et al in the West of England (1, 2) and Inada Kim et al in Wessex (unpublished data) have demonstrated that the higher the NEWS on referral or arrival, the more likely the patient is to be admitted and the more likely the patient is to die.
The lack of linkage to any outcomes is a major weakness of this work. While an increase in admissions of 16.2% is not ideal in an already extremely busy system, if those patients require acute attention it is important that they are appropriately referred. Similarly, there may be a number of patients with NEWS<5 who were unnecessarily referred to hospital; without outcomes data, conclusions about appropriateness of referrals cannot be drawn. In addition, in the West of England, where NEWS is used by GPs, admissions did not increase at any greater rate than elsewhere (3).
It is also suggested in the paper that a NEWS cut off of <5 could be used to reduce ‘low acuity admissions’; however, it is often appropriate to admit a patient irrespective of NEWS, for example someone with a stroke or crushing central chest pain. The Royal College of Physicians is clear that ‘NEWS should be used as an aid to clinical assessment- it is not a substitute for competent clinical judgement’ (4). Using NEWS promotes a full assessment of the patient and, if used at referral, is also a useful communication tool which helps the receiving hospital to recognise the patients that are deteriorating in the time frame between referral and arrival.
GPs have to make important and challenging decisions in a short time frame and formal actions should not be ascribed to NEWS in the community but instead there should be increased awareness that the higher the NEWS the more likely the patient is to be sick. Before NEWS, GPs would admit a patient and highlight the most extreme observations; perhaps the learning from this analysis could be that simply measuring observations is of limited value in identifying who needs admission and the aggregate nature of NEWS is better suited to identifying potential deterioration than high scores for a single vital sign(5).
1. Scott LJ, Redmond NM, Garrett J, et al. Distributions of the National Early Warning Score (NEWS) across a healthcare system following a large-scale roll-out. Emergency Medicine Journal 2019; 36:287-292.
2. Scott LJ, Redmond NM, Tavaré A, et al. National Early Warning Scores in primary care are associated with clinical outcomes. BJGP 2020, In press.
3. Pullyblank A, Tavaré A, Little H, et al System Wide Implementation of the National Early Warning Score Reduces Mortality in Patients with Suspicion of Sepsis. BJGP 2020, In press.
4. Royal College of Physicians. National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. London: RCP, 2017.
5. Jarvis S, Kovacs C, Briggs J, et al. Aggregate National Early Warning Score (NEWS) values are more important than high scores for a single vital signs parameter for discriminating the risk of adverse outcomes. Resuscitation 2015, Volume 87, 75 – 80.
The courage with which emergency medicine specialists are responding to COVID19 crisis is admirable. They are in a situation similar to the battlefields of first World War. It is a protracted war unlike the disasters and tsunamis that we have faced in recent times. Lord Moran in his seminal book "The Anatomy of Courage" based on his WW1 experience of treating medical emergencies had noted that battle fatigue would set in the most courageous of soldiers after 30 days of trench warfare. This led to the deployment of battalions in formations, which provided relief to those in the front lines through planned rotation. This model may be useful in developing systems of rostering which provide planned periods of relief and recuperation for medics and paramedics manning the front lines of COVID 19 crisis.
A timely and interesting read if for no other reason colleagues and I were discussing / bemoaning recurrent abdominal pain presentations only last week. Many of the features that act as obstacles were well recognised and omnipresent.
The solutions are an excellent mixture of skills and I can see much utility, I can also foresee the care pathways being highly personalised in our healthcare institutions (Daniels et al allude to this by describing one the ED consultants with an interest in HIU) and once that person moves job the pathway crumbles.
To an extent excluding medical emergency (the 1st E in ERROR) does require medicalisation whether it be vitals being taken or the initial bloods including lactate. I can see the purpose and benefit of not repeating unnecessary blood tests and I suspect not doing tests will be a feat more easily achieved with seniority, There is benefit in letting HIUs be seen exclusively by such.
I was surprised that Daniels and the other authors claim that "pain is not a central consideration in RCEM guidelines...". The college guidelines page (https://www.rcem.ac.uk/RCEM/Quality_Policy/Clinical_Standards_Guidance/R...) lists at east 3 where pain is most certainly the central consideration, or was this in relation to abdominal pain only?
Overall...
Show MoreI enjoyed reading this article, however, the reference to a cytokine storm warrants clarification. An editorial in JAMA Internal Medicine doi:10.1001/jamainternmed.2020.3313 suggested little evidence for such a storm and this has been supported by more recent studies by Remy et al in JCI Insight (10.1172/jci.insight.140329) who demonstrated severe immunosuppression and Kox et al in JAMA (doi:10.1001/jama.2020.17052) who found multiple cytokines were reduced in severe COVID-19.
The use of Angiotensin II for cardiogenic shock(1) might be counterproductive in patients who have cardiogenic shock attributable to Takotsubo cardiomyopathy(TTC) characterised by left ventricular outflow tract(LVOT) obstruction. The following are the reasons justifying non-use of that treatment modality:-
Show MoreAngiotensin II induces catecholamine release(2), thereby potentially exacerbating the catecholamine surge which characterises TTC. This catecholamine surge is mimicked by exogenous administration of epinephrine, the latter well documented as a trigger for de novo TTC in 22 patients reviewed in the literature search by Madisa et al(2). In another literature review, dobutamine(also a catecholamine ) triggered the onset of TTC in 22 patients(3). A typical example of the latter was a 61 year old woman who developed chest pain at 70% of her age-predicted heart rate, when she was on a 40 mcg/min infusion of dobutamine. Her electrocardiogram(ECG) then showed inferolateral ST segment elevation. Transthoracic echocardiography showed severe akinesia of the apical, anteroseptal, and apicolateral segments at peak dobutamine infusion. Coronary angiography disclosed normal epicardial vasculature(5).
When LVOT obstruction occurs in TTC it can give rise to severe hypotension, exemplified by a 60 year old woman with a nadir systolic blood pressure(SBP) of 80 mm Hg in association with a gradient of 58 mm Hg across the LVOT. After landiolol( a beta blocker) inf...
The enforcement of lockdown in the UK in March 2020 saw businesses shut up shop and most of the general population barricade themselves in the safety of their homes. NHS and community facilities had to implement downgraded versions of their services to comply with social distancing with a reduced workforce available to deliver these services. One such cohort affected by these measures is those who take recreational drugs, either socially or habitually.
The number of people who use recreational drugs regularly is unknown. NHS Digital data states that there were 14,053 patients admitted to hospital with ‘poisoning by illicit drugs’ in England in 2018. 53% of these patients were male and two-thirds fell into the 16-44yrs age bracket. Men were more than twice as likely to use cannabis or cocaine compared to women and older age groups were more likely to use opiates alone (1).
One in 12 adults were found to have taken an illicit drug between 2016 and 2017 (1). Whilst lockdown may have caused many inconveniences to the everyday lives of most of us, many habitual drug users have found themselves with additional stressors extending beyond contracting COVID-19 itself. This may not be someone’s chosen path in life but it is the reality that many are living with. This lifestyle is intertwined with medical and psychological difficulties which may necessitate NHS support.
If your first thought upon waking is how you are going to obtain your next fix, then how are...
Show MoreDear Editor,
We have read with great interest the article by Vihonen et al, ‘Glucose as an additional parameter to National Early Warning Score in prehospital setting enhances identification of patients at risk of death: an observational cohort study’, recently published in your journal.(1)
Show MoreTraditionally, the scores published to assess the risk of mortality in patients attended in a prehospital setting, the predictive value of which had been questioned until recent studies, did not include the quantification of glycemia among the parameters analysed in the initial assessment of the patient.(2-4)
Overlooking its systematic determination in the initial care of any critically ill patient represents an easily avoidable risk, due to its accessibility and to the ease in interpreting results in any setting. This shortcoming is especially relevant in the initial care of patients with acute poisoning, due to the limitations of the anamnesis and the need to establish a rapid and reliable differential diagnosis in patients with often complex and plural clinical symptoms.(5,6) In this regard, the prognostic value of glycemia as a biomarker in some acute, highly lethal levels of poisoning must also be taken into account.(7,8)
In Catalonia, two studies undertaken by the Prehospital Medical Emergency Service in recent years have shown that only 30.1% of those poisoned by caustic products or 15.2% of the 1,930 people poisoned by carbon monoxide or smoke released f...
This article draws its evidence from two citations, one by Madsen et al., and the other from a systematic review, which has been mis-cited as a duplicate of the Madsen reference. The correct citation to the systematic review is not Madsen et al., but Tarnutzer et al., PubMed ID 28356464 (Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. Neurology. 2017;88(15):1468-1477. doi:10.1212/WNL.0000000000003814.).
Dear Editor,
I read with interest the recent article by Carley et al., “Evidence-based medicine and COVID-19: what to believe and when to change”1. The authors pay homage to the challenges of keeping pace with a pandemic growing at unprecedented speeds, forcing the hand of clinicians to make therapeutic decisions on the basis of weak, often unvalidated evidence. They also note the influence of political opinion, referencing Donald Trump’s infamous declaration on the efficacy of hydroxychloroquine as a treatment for COVID-192. In their concluding statements, the authors eloquently present the need to follow science rather than emotions or politics.
Having worked in a large critical care unit over the pandemic, I question how easy this is in practice. Clinicians, nurses and Allied Health Professionals do not exist in a vacuum, but rather their opinions and knowledge are inevitably shaped by social and cultural rhetoric. I use the example of Personal Protective Equipment (PPE), an acronym once reserved to select professions yet now colloquially used by the lay person. Information regarding the appropriate PPE to be worn was disseminated in multiple formats, from news broadcasts to social media platforms such as Twitter. As knowledge developed about how the SARS-COV-2 virus was transmitted, recommendations on PPE changed accordingly. As of July 23rd, it was recommended that double gloving was not necessary3, and in fact increased the risk of transmitting e-coli...
Show MoreWhat this proposed reset does not describe is a reorganisation of 'at the door' triage based on the type of presentation.
The need for effective patient throughput (patient flow); the major problem in contemporary A&E (at least pre Covid19) has not been addressed.
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I propose triaging 'at the door' carried out by nurse practitioners (assisted by paramedic crews bringing patients in) and admin staff to access medical information rapidly (for example via the Great North Care Record). These insights were gained from camp Bastion in Afghanistan.
There should be 4 key portals and pathways thereafter.
a) The seriously ill (Major Trauma, Sepsis, Stroke, Cardiac Infarcts, Acute Abdomens etc.)
b) Cases of frailty (mainly elderly people, including delirium / dementia, minor trauma)
c) mental Health presentations (of all ages, including learning disability)
d) overspill from General Practice
These pathways would be staffed by specialist nurse practitioners, pharmacists and speciality doctors, working on prearranged algorithms with electronic prescribing and discharge / handover templates (ideally in a SBAR format) to assist patient flow. cross referral (called scaffolding in mental health) should be possible on occasion. Overall, a duty matron should keep overall control of activity through an electronic dashboard. Paramedic / ambulance crews should have access to this matron remotely to make crucial d...
Show MoreFinnikin and colleagues describe a large data set of retrospectively calculated National Early Warning Scores (NEWS) in a system that was not using or responding to NEWS. Understanding the relationship between NEWS and referral practices is an important area of research which could help shed some light on the impact of introducing NEWS into primary care.
The first important point is that only 31% (74,992/242,451) of patients who had face-to-face encounters had a full set of observations and the clinical characteristics of the 69% excluded from the study are unknown. In our experience, GPs tend to perform a full set of observations on patients who appear more unwell so it is possible that the population studied may not be representative.
Finnikin and colleagues found that only 6.9% of patients referred to hospital had a NEWS≥5 and 69% with a NEWS ≥5 were not referred. There is emerging evidence that NEWS calculated by GPs at referral correlates with mortality (data from West of England accepted for publication) so the fact that it did not correlate with referral is of concern. Scott et al in the West of England (1, 2) and Inada Kim et al in Wessex (unpublished data) have demonstrated that the higher the NEWS on referral or arrival, the more likely the patient is to be admitted and the more likely the patient is to die.
The lack of linkage to any outcomes is a major weakness of this work. While an increase in admissions of 16.2% is not ideal in an alr...
Show MoreThe courage with which emergency medicine specialists are responding to COVID19 crisis is admirable. They are in a situation similar to the battlefields of first World War. It is a protracted war unlike the disasters and tsunamis that we have faced in recent times. Lord Moran in his seminal book "The Anatomy of Courage" based on his WW1 experience of treating medical emergencies had noted that battle fatigue would set in the most courageous of soldiers after 30 days of trench warfare. This led to the deployment of battalions in formations, which provided relief to those in the front lines through planned rotation. This model may be useful in developing systems of rostering which provide planned periods of relief and recuperation for medics and paramedics manning the front lines of COVID 19 crisis.
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