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This month we publish a few papers that report the results from some audits; patient processes, use of resources and clinical knowledge are all under the microscope. Traditional research papers, epitomised by the gold standard of the double blinded randomised control trial, will continue to grab academic headlines, but good quality audits are arguably more important in day-to-day practice and are more relevant to most health workers and systems.
IT’S VITAL TO DO VITAL SIGNS
Armstrong and his colleagues completed a retrospective audit of how well a district general hospital emergency department recorded vital signs in adult patients. The results are fascinating and should make us all reflect on how well we do the “basics”. As the work of emergency departments gets more complex in numbers, case mix and therapeutic intervention, our whole house may come tumbling down if we fail to complete the essential basics properly. The parable of the emperor and his clothes comes to mind. We also publish a commentary on the paper (see pages 790 and 799).
FAST TRACKING WORKS
As this journal has both reported and debated from time to time, changes to patient flow processes are not always as successful as predicted in the pre-implementation phase of a project to change them, and can produce unexpected outcomes. The use of pilot studies before permanent implementation of a new process in such projects is inconsistent. A team from Melbourne, Australia retrospectively studied the effect that a fast track system had on patient (admitted and non-admitted) length of stay in their department. Their results lead to an encouraging conclusion (see page 815).
If patients are overinvestigated—a consistently recurring problem that concerns senior doctors, managers and patients—the consequences can be far-reaching. Patients may receive inappropriate additional investigations and treatment because of false positive results from the first investigation or the bell curve effect, and they may be harmed from the investigation itself (from benign bruising after venepuncture through to radiation exposure through to life-threatening complications of invasive investigations). Other consequences include overcrowding and delays in emergency departments and wards and the waste of time, resources and money in performing such inappropriate investigations. The core reasons why patients may be over-investigated are many and are well documented. A paper, also from Melbourne, reports on the use of a plain chest x ray in patients with suspected acute coronary syndrome (see page 807).
Our audit focus finishes with a clinical subject—how good is the knowledge of how to use antidotes in the management of recreational drug toxicity? I am not sure what the collective noun for a group of toxicologists is (suggestions on a postcard please), but a group of them from London and Australia tell us that the answer to the above question is that knowledge can be improved and needs to be known more consistently, especially with the newer antidotes available (see page 820).
THE TWELVE COMMANDMENTS
Many emergency departments and senior staff will have their own institutional pearls of clinical and professional wisdom, pearls that offer advice and counselling to less experienced staff, especially those working in emergency medicine for the first time. These pearls are nuggets of wise counsel that are passed on from one generation to the next or have been learned the hard way through personal experience. Derriford Hospital offers no less than twelve commandments and they will be similar to many used elsewhere. We publish them in the belief that they will be useful to some readers and to encourage other departments to send us their own personal ones. We cannot guarantee to publish all that we receive, as there will be some repetition, but we will aim to publish as many as we can that we consider of suitable interest (see page 824).
Being a tourist is not always a pleasant experience; the old saying (a tourist commandment perhaps?) that it is better to travel hopefully than to arrive, will be believed by many who have not enjoyed their holiday and wished they had stayed at home. The London air ambulance service (HEMS), in a retrospective analysis of their database, conclude that they carry a significant higher number of tourists than UK residents, when looking at the cohort of those who have been struck by a vehicle as a pedestrian. On reflection, it is not too hard to think of reasons why this might be the case (see page 843).
In recent months we have published a few toxinological papers and have also pointed out that this is a topic which is not at the top of the clinical agenda in Northern Europe, for obvious reasons. 45 000 people a year in the USA are victims of snakebite envenomation. Today we have a North American paper which reviews antivenom usage in children (see page 793).