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Screening older patients in the ED
Having screening tools that are accurate in terms of specificity and sensitivity is essential to improving care for this vulnerable group. This issue includes two papers from different parts of the world that will be of interest to ED clinicians' intent on improving screening and outcomes for older patients attending their departments.
The ISAR tool: how useful is it?
The Identifying Seniors at Risk (ISAR) tool has mixed predictive ability. Suffoletto and colleagues in Pittsburg undertook a prospective study of 202 adults over the age of 65 presenting to the ED to evaluate the ability of the ISAR tool to differentiate between older patients having a poor outcome within 30 days of ED care and those that did not. They also sought to establish whether self-reported ISAR risk factors correlated with objective measures and whether objective measures altered predictive ability. Their findings suggest that the ISAR tool does not differentiate well between older adults with or without 30 day hospital revisit or death. Furthermore, they found that related objective risk factors did not improve the performance so, clearly, we need to develop more effective tools and in the meantime use ISAR judiciously and with caution.
In Thailand, Sri-on and colleagues conducted a prospective cross sectional study to determine the prevalence of delirium in patients over the age of 65 in their urban tertiary care emergency department. A secondary objective of this study was to identify risk factors and short term outcomes in elderly patients with delirium. In their sample of 232 patients, 27 (12%) were delirious in the ED of which 16 (59%) were not recognized as being delirious by ED clinicians. Unsurprisingly, patients with delirium had a higher mortality rate than those without delirium (15% versus 2% P=0.004). These findings from a middle income country are consistent with research findings from high income countries where the detection of delirium by ED physicians is also low. Clearly raising the profile of delirium as a medical emergency as well as further training for clinicians in recognizing this reversible condition is urgently needed.
Traumatic brain injury (TBI) in young people is a common presentation to the ED and many of these children, approximately 50% undergo computed tomography (CT) even though the majority with a mild TBI GCS 13–15 have no intracranial injury. Concerns have been raised over the possible overuse of CTs because ionizing radiation can lead to malignancies, so it was interesting to read of a prospective cohort study in three paediatric emergency departments in Switzerland by Manzano and colleagues which sought to assess the accuracy of S100B serum level to detect intracranial injury in children with mild traumatic brain injury. They found S100B has an excellent sensitivity but poor specificity. So, it may be an accurate tool to help rule out an intracranial injury but it cannot be used as a sole marker due to its specificity. Used with clinical decision rules, S100B may contribute to decrease the number of unnecessary CTs and this itself is worthy of further consideration.
Why is it so difficult to recruit patients to research studies in the ED?
It's long been recognized that medical research studies frequently struggle to meet patient recruitment targets. Many of the barriers and impediments to recruiting patients will be familiar to those of us who have undertaken research in the ED. Johnson et al in the UK have attempted to explore this problem further using the large multicenter AHEAD study which recruited patients at 33 Type-1 emergency departments in England and Scotland. They found overall recruitment varied greatly between sites with an eightfold variation in recruitment rates. In addition to the usual problems already documented in the literature, detailed interviews with three research nurses from the study identified other barriers and facilitators to recruiting patients. Interestingly, key to the success of the AHEAD study was a protocol that minimized the involvement of clinicians who are invariably too busy to engage. Retrospective recruitment and anopt out consent strategy also helped. So if you are in the process of planning research do read this paper, it may well change your recruitment strategy and help you reach your target.
Attending the ED: an automatic choice
Patients attending the ED with non-urgent medical problems is a growing problem in many parts of the world and St Vincents and the Grenadines in the West Indies is no exception.In this issue, Keizer-Beache and Gueli describe a qualitative study they undertook to understand why Vincentian patients with non urgent medical problems seek care in the emergency department rather than primary care facilities. Many of the reasons cited by participants have previously been documented and will be familiar to ED clinicians everywhere, such as convenience, dissatisfaction with primary care facilities etc. Perhaps more interestingly in this study, participants revealed that attending ED is automatic, describing this as a locally shared custom. They also suggested that this habitual use of the ED is reinforced by health professionals who routinely refer non urgent cases to the ED. The authors suggest that further health services research should reconsider rational choice behavior models. Is there a salient message in this paper for us all? Are we as ED clinicians inadvertently encouraging attendances in our own departments? I‘ll leave you to read this paper and ponder this question yourself.