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For the Primary Survey this month, we present four broad themes.
Patient flow and system reform
At first glance, if you do not know otherwise, you may think that DGP is an acronym connected to the financial crisis affecting the Eurozone or an atmospheric pollutant affecting the climate. If you read the paper by Hardern, you will learn what it stands for. He also introduces us to another unfamiliar term ‘goalodicy’. Although his paper has a serious message you may end up chuckling or weeping to yourself, or both (see page 219).
Addenbrookes Hospital in Cambridge reconfigured their emergency care system when the medical admissions unit and emergency department (ED) were combined into one emergency assessment unit. What does a retrospective ‘before and after’ study tell us? The simple conclusion is that it reduced hospital admissions and inhospital mortality and gave a better quality of care to the patients. They also found that formal complaints, incident reports and the number of patients leaving before treatment fell (see page 208).
The concept of placing a general practitioner in an ED is not a new one; it has been around for many years. A Dutch study describes the impact of doing this in a university hospital in Amsterdam. The authors conclude that it is a cost-effective innovation for all outcome parameters measured (see page 192).
What can we do to increase organ donor referrals? A paper from Norwich reports that a specialist organ donation nurse in ED with collaborative care pathways has a significant impact; in Norwich they had an eightfold increase in organ donation referrals (see page 228).
Another paper from Addenbrookes Hospital reports the findings from a retrospective case note review. Does adherence to National Institute for Health and Clinical Excellence guidelines for CT scanning of head-injured children have a quantifiable effect? Yes it does—but not in the way you may think (see page 197).
We have three papers this month on this subject, one about the UK, one about Australia and one about both.
The first reports that the transportation of patients from a remote and rural area of the UK to a major trauma centre remains a problem, and more efficient systems are needed for both retrieval and transfer (see page 182). The second is a prospective observational study of endotracheal intubation performed by the Queensland Royal Flying Doctor Service (see page 251), and the third compares the performance of British and Australian helicopter and air medical services (see page 243). An interesting statement from the last paper is that the two systems do not have universal outcome measures. Where they are both similar is that neither follow up patients beyond 24 h post-transfer, outcome data are not presented externally and there are no peer review comparisons.
Is childhood abuse more common in paramedics than in other healthcare workers? The answer is unknown but a study from the Department of Psychiatry at Mount Sinai Hospital in Toronto asks the question (see page 222). The premise for the study is that previous trauma is a risk factor for psychological symptoms after exposure to critical incidents, and as such, the prevalence of childhood experiences with abuse and neglect may be important for paramedics to adapt to critical incidents.
A UK study confirms something that most of us knew anecdotally, namely there is wide geographical and diurnal variation in the availability and use of physician-based prehospital critical care support across the UK (see page 177).
Some clinical topics
Here are some brief messages.
Routine coagulation testing in adults presenting with chest pain to an ED should be replaced by a coagulation testing policy based on clinical criteria (see page 184). Nitroglycerine is not a reliable test of treatment for use in the diagnosis or coronary artery disease (see page 173). The RATPAC trial (see page 233) to find out what it means) reports that the use of point-of-care panel testing for cardiac markers varies markedly between participating hospitals. A study from the USA reports that patients with psychiatric disease are less likely to receive opiate analgesia if they present with pain to an ED (see page 201). Cardioversion is more effective than pharmacological conversion of acute atrial fibrillation of less than 48 h duration and also leads to shorter length of stay in an Italian ED (see page 188). Finally, a Brazilian study reports the prevalence of substance abuse in motorcycle drivers involved in road accidents in that country (see page 205).
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