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Editor’s Choice: Quality not quantity
As I write this on a Monday morning, I am acutely aware that Emergency Departments across the UK are facing an unrelenting pressure. Attendance records are being broken daily and departments are drowning. In the face of this pressure, ED staff are striving to provide high quality care. It is therefore apt that this month’s Editor’s Choice, provides a unique perspective on the assessment of performance versus quality. In their observational analysis of 118 acute trusts in England, Thomas Allen and colleagues explore the relationship between established ED performance indicators, including the key 4 hour target, and departmental ratings following inspection by the Care Quality Commission (CQC). They find a complete lack of association between time-based metrics and CQC ratings. While this may not come as a surprise to many ED clinicians, as Adrian Boyle points out in his excellent accompanying editorial, these data provide evidence to commissioners and hospital boards that poor performance against established time-based metrics does not necessarily mean that the quality of care delivered in our EDs is substandard.
Improving outcomes in OHCA
This month’s Reader’s Choice explores the pre-hospital determinants of successful outcomes after out of hospital cardiac arrest (OHCA). In a registry analysis of over 9000 OHCA arrest patients in the UK, Barnard and colleagues use univariate and multivariate analysis to identify predictors of survival. Where this adds to our understanding is in separating cardiac arrest into traumatic and non-traumatic aetiologies. The authors ascertain that these two aetiologies are clinically distinct with different predictors of outcome. Interestingly, an initial shockable rhythm was a predictor of favourable outcomes in both cohorts (although shockable rhythm is of course a rare entity in traumatic arrest and this finding may be due to misdiagnosis). However, this paper highlights the need for improved public access to defibrillators and engagement in bystander CPR, in order to improve OHCA outcomes.
The changing face of thoracic trauma
We have previously highlighted in the EMJ that the demographics of major trauma are changing, with an increasing healthcare burden of older person’s trauma or ‘Silver Trauma.’ This month, in a retrospective registry review from Australia, Noha Ferrah and colleagues provide novel insight into a subset of major trauma patients; those with serious thoracic injury. The same patterns emerge, with the greatest increase of thoracic injuries (14% per year) seen in older patients aged over 85 years. Given the morbidity attached to thoracic injuries in this vulnerable patient group, this work highlights the need for improved identification and an evidence-base for the subsequent management of these patients.
How much do you care?
It is a pleasure to publish the early fruits of a Royal College of Emergency Medicine PhD Studentship. Blair Graham brings us back to what really defines quality of care from a patient perspective in a qualitative meta-synthesis of patient experience in the ED, pleasingly with no mention of the 4-hour access target. Themes explored, particularly around good interpersonal communication and addressing emotional needs, allow the authors to provide us with an interesting conceptual model of patient experience. It appears patients are generally accepting of prolonged waits.
Concepts
Our Concepts paper this month explores the anatomy of resuscitative care units, a novel service that appears to be gaining traction in the United States, as a potential solution to ensure patients receive optimal care during the most critical hours of their illness.
Perspectives
In a salutary lesson to all ED clinicians our Perspectives paper discusses how pelvic examinations should perhaps not be confined to the gynaecological ward. Mary McLean and Livia Satiago-Rosado, caution the rush to judgement around this key clinical question and urge us to examine the evidence before changing our practice. We look forward to seeing similar articles in future.
Footnotes
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
Patient consent for publication Not required.