Editor's special paper

This valuable paper turns our attention away from the developed world and the problems faced by ambulances services to countries in which there is no such entity (see page 794). These authors have addressed this by a highly innovative and effective means in Madagascar, by training taxi drivers. This strikingly simple yet effective system was to provide 26 local taxi drivers with 1 day of training, delivered by clinicians from the Division of Emergency Medicine of the University of Cape Town, from the Emergency Medicine Society of South Africa (EMSSA) and local doctors from University Hospital Mahajanga, Madagascar. The training comprised workshops on prehospital scene management, dealing with bleeding and broken bones, on immobilisation and patient movement, and labour and delivery.

It was deemed successful by faculty and candidates alike. Hopefully, formal evaluation of knowledge and skill retention among the candidates will be presented at the 3rd EMSSA conference in November in Cape Town this year.

Experts from Australia, Canada and UK have combined to put forward considered ways of measuring what should be assessed in an ED so to be able to say how well it and, more generally, ED systems work whilst questioning what has been already undertaken in some countries—‘In emergency medicine, many countries have developed specific indicators to help drive improvements in patient care (see page 783). Most of these are time based and there is a lack of consensus regarding which indicators are high priority and what an appropriate framework for measuring quality should look like.’

The authors go on to develop a reasoned and well judged framework for a quality measurement programme, with the aim of making improvements in EDs. This quality measurement programme means that various performance levels can be measured that take into account the perspectives of not only practising ED physicians, but also those in emergency medicine administration and research. This international panel state important (but often unspoken) affirmations that need to be said, for example, ‘Indicators are just that, their purpose is to ‘indicate’, and taken in isolation often may not represent a patient outcome!’

They described different methods of data collections, comment on the types of indicators to use (eg, those that look at structure, at process and at outcome), outline the measures of the domains of quality (Safety culture, Effective care, Patient centred care, Timeliness of delivery of healthcare, Efficient and Equitable treatment), and touch on the factors that are required for the sustainability of an ED. This article provides practical guidance as to how to make sure that EDs are running as well as they can.

So who learns more from their stint in PICU on their training rotation—paediatric residents or emergency residents? They were studied by means of an online test, developed by the subcommittee of the paediatric section of the Society of Critical Care Medicine (n.b.-this was based in a single centre in US). The answer is …. (see page 758).

This patient took a fatal dose of antifreeze and presented to an ED with an Advance Decision against any treatment (see page 741). She died 3 days later. This review details the legal position on Advance Decisions and at the role of the Mental Health Act in such situations, drawing on the Mental Capacity Act and considers her position and that of other patients from legal and ethical standpoints.