“People attend ED because they choose to”

Emergency Department (ED) attendances over the past decade have been rising both in western countries as well as in the developing world. One school of thought attributes this to an increase in patients who would be better managed in primary care. Various initiatives have been put in place in the UK in recent years which include hospital based unscheduled care services staffed by GP's and other primary care clinicians aimed at diverting patients away from the ED. You could be forgiven for questioning the success of these initiatives if your ED is crowded most of the time.

On this note you might then be interested to read both the editorial by Derek Burke as well as a review of the literature by Ramlackhan and colleagues from Sheffield relating to the impact of GP delivered hospital based unscheduled care services. Their study focused particularly on process outcomes, cost effectiveness, and patient satisfaction. They found a paradoxical increase in attendance and the evidence for improved output to be poor, moreover there was no evidence of improved patient satisfaction. In one study patients actually expressed a preference for care in an ED as opposed to a new co located walk in centre. The authors concluded that there is little evidence to date to support the implementation of co–located urgent care models of care. In the absence of more robust evidence it is worrying to see the on-going proliferation of such alternative models of care. In his editorial, Derek Burke suggests that unscheduled care is a now a consumer item and seen by users as no different to 24 hour shopping. If this is the case then perhaps we should just ask patients where they would prefer to be treated and listen to what they say, now there's a novel idea!

Doctor Triage?

This can be a contentious issue in the ED, some clinicians abhor the notion citing “not the best use of doctor time” while others enjoy the opportunity. The introduction of multidisciplinary rapid assessment teams (RAT) has in some cases further muddied the waters, so it was interesting to read a systematic review by Abdulwahid and colleagues from the UK to determine if placing a senior doctor at triage (SDT) versus standard single nurse in an emergency department improves ED performance. They reviewed the evidence from 25 comparative design studies using several quality indicators.

They concluded that SDT can enhance performance. This in itself is not entirely surprising as doctors, more than nurses can see, treat and discharge patients at triage thereby reducing the overall load. I would suggest nurse practitioners at triage may have a similar impact. The findings that were perhaps more interesting and warrant further investigation were that STD did not demonstrate benefit in terms of patient satisfaction or cost effectiveness or for that matter change the occurrence of adverse events. So perhaps SDT may be a pyrrhic victory for performance if outcomes elsewhere are unchanged or more expensive. Clearly more research is needed.

Quantity, Quality or both

Quantitative methodology is traditionally the mode of scientific enquiry in medicine. More recently, mixed methods, that is coordinating qualitative and quantitative research is slowly gaining credence in emergency medicine because of its effectiveness in achieving a deeper understanding of complex issues such as medical error, communication and teamwork. In this issue, Hansen and colleagues from Oregon introduce the fundamental concepts and approaches of mixed methods research using specific examples from the Children's Safety Initiative Emergency Medical Services (CSI-EMS), a large National Institute of Health (NIH) funded project to describe the interrelation and complementary features of quantitative and qualitative methods. This is an interesting paper about the identification and prevention of errors in out of hospital paediatric care in the USA but also, a very comprehensive overview of mixed methodology and well worth reading if you are considering this approach to research.

Snakes alive

Assessing and treating snakebites is not “run of the mill” type presentation in most ED's but it accounts for 10% of all presentations in the hot summer months in a South African Hospital and this may well be the case in similar climates elsewhere in the world. So it was fascinating to read a study by Wood and Sartorious in this issue describing the use of ultrasound to determine the site and degree of cytotoxic swelling from snake bites in patients presenting to their department.

They scanned the envenomed limb of 42 patients at the point of maximum swelling comparing it with the same site of the unaffected limb. More than half of their patients were children under the age of 12 years. Tissue expansion was noted in both the subcutaneous and the muscle compartments of the envenomed limbs. Their study highlights the benefits of ultrasound as a non invasive and painless procedure which can assist the clinician assessing and monitoring the progress of the swelling. This paper is a good read, it is original and informative especially the incidence and pathology of envenomation, furthermore, the study lends a truly international feel to this issue.

Have fun

We are becoming increasingly aware of the value of simulation training as an effective learning tool in emergency care but its' use still varies from place to place. This may be due to perceived difficulties in instituting this in busy ED's or from perhaps less than enthusiastic or even sceptical responses from your colleagues. If you feel this applies to your department then read the paper in this issue a by Spurr and colleagues. It's a very useful top 10 tips +1 to setting up simulation training in your department. After reading all 10 tips you might find No 11 the “+1” the best tip of all. It recommends having fun! Now this is a great starting and finishing point and a universally recognised essential ingredient for successful team building and surviving the high's and low's of an ED career.