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I'm rather hoping that in the Northern Hemisphere at least, our May edition will feel as though summer has arrived with perhaps slightly more time for personal and organisational development. Winter was tough here in the UK, so let's hope the better weather brings a bit of relief. Even now crowding looms large in our collective memory with an interesting paper and accompanying editorial focusing on its effect on our emergency departments (EDs).
The complexities of measuring crowding in the ED
Adrian Boyle and colleagues examined two scoring systems, NEDOCS and sICMED together with staff perceptions to look at ways of measuring crowding in the ED. Clearly crowding is a multifactorial perception including aspects such as patient load, flow and severity. They collected real time data using these measures demonstrating that some of this data can be collected in real time but that they cannot reflect hour by hour variation. Further work is needed to give us a score that could be used to track and compare ED crowding and it's inherent dangers to patients and staff.
Parents, paediatrics and perceptions
As a consultant who works in a paediatric ED I can understand why Astha Singal and colleagues decided to examine avoidable paediatric ED visits. Although this study is from the US, with alternative funding and insurance mechanisms the implication here about increasing numbers of primary care visits to the ED for children will be familiar to many of us, regardless of where we work. They found that the families socio-economic position, notably food security, was a strong predictor of attendance. Many parents agreed that alternative health providers could have cared for their children, but difficulties in accessing alternative services led to children being brought to the ED. This is another useful study demonstrating that public health and economic factors have significant impact on our workload and patient mix.
Paediatric early warning score scores and predictions
More paediatrics from the UK this month with an analysis of the ability of paediatric early warning score (PEWS) to predict admission and significant illness. PEWS has certainly been popular in recent years, with several papers published in the EMJ on the subject, but the score was designed to be used in the in patient setting, In this single centre study PEWS performance was assessed in the ED population. Interestingly they found a high specificity, but low specificity which is typically the opposite of what we require of an ED screening tool. The reported sensitivity, as low as 30%, means that it's ability to screen for significant illness or admission is too low. Perhaps we need something better derived from the ED population.
Tanzanian Gestalt for anaemia
In this study clinicians were challenged to predict the outcomes of a blood count using clinical judgment (described as Gestalt in this paper). In this clinical setting anaemia is common and an important diagnostic finding. Clinically the physicians did well as measured by concordance, but that is to be expected. However, their ability to pick up severe anaemia only had a sensitivity of 64%, and for moderate anaemia only 56%. This may be on the low side for clinical practice and thus laboratory testing will still be needed. The specificity for moderate and severe anaemia was better and may be high enough to guide resuscitation whilst waiting for the lab results.
Tailored training improves CPR performance
Govender and colleagues examined the impact of a tailored teaching programme to teach CPR to paramedics. The addition of tailored pre and post interventions improved performance. The bottom line is that if you teach people more often and with a range of materials they learn more and can do better.
Transcutaneous carbon dioxide
We frequently measure CO2 levels in the ED, with the use of arterial blood gases acting as the gold standard. However, these can be difficult to obtain, painful for the patient and are not without potential complications. A non-invasive method would surely be better and such devices do exist. This month Nicolas Peschanski and colleagues compare transcutaneous readings with arterial samples amongst patients with respiratory problems in the ED (the group we would be interested). Sadly only about a third of readings were within 5 mm Hg between the non invasive method and the blood gas. Clearly we can't abandon the blood gas yet.
Prehospital referrals for falls
Elderly fallers are a high risk population for all in emergency medicine and in prehospital care. A simple fall may be a harbinger of significant pathology that may be eminently treatable. In this systematic review by Zozula et al the evidence for prehospital teams assessing and referring patients for referral to falls services shows that the evidence base is pretty weak. In this incredibly important area we clearly need better work linked to patient outcomes before we can assess the impact of prehospital referral.
Stress tests after Troponin
There has been a huge amount of work regarding the exclusion of myocardial damage using troponin testing in the ED. However, thee have been concerns that simply troponin testing will miss patients with significant coronary disease, but who have yet not manifest myocardial damage as shown by a troponin leak. In this study by Aldous and colleagues they looked at patients who were negative for troponin tests, but who then had a stress test. Interestingly they identified 34 patients from 709 who subsequently went on to revascularization. It's tricky to know what this means for clinical practice, and of course we must remember that the new generation of high sensitivity troponins might yield a different result.
Acute Kidney Injury in the ED
Finally, we have a review article from Patrick Nee and colleagues on the recognition of Acute Kidney Injury in the ED. This is a common problem in the ED and one where emergency physicians should have some expertise in. It's also quite a common question in exams, so there is something for everyone on this important topic.
Provenance and peer review Commissioned; Not peer reviewed.