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Achieving the right care
The Right Care Alliance (RCA) is a US based coalition of clinicians, patients and community members who aim to achieve the best healthcare outcomes at the fairest price without any over diagnosis, investigation or treatment. In this month’s Reader’s Choice article, the RCA Emergency Medicine council members have used a modified Delphi process to identify the top ten recommendations on how we might have a more balanced approach to healthcare for our ED patients. Four are around ‘the quixotic search for certainty’ where clinicians do not accept any element of risk and believe that tests are more objective than clinical judgement. Examples include requesting a whole body CT scan for a trauma patient or a ‘just-in-case’ Troponin T for very low risk chest pain. The remaining six remind us that social determinants (eg, homelessness, substance addiction, deprivation) may be more important to health than medical care and we should focus on spending more time with our patients discussing and sharing objectives. Definitely worth a read and some reflection.
Centralisation of emergency departments: does it reduce mortality?
There is good evidence that centralization of major trauma, cancer, myocardial infarction and stroke services can achieve better outcomes, but the evidence for the benefits of centralization for Emergency Medicine patients is less clear. This month’s commentary by previous RCEM President Cliff Mann critically appraises the article from Price and colleagues: assessing the impact of a merger of three district general hospitals in Newcastle (UK) in 2015. The ‘Editor’s choice’ paper evaluated the mortality of patients who passed through the ED’s, before and after the merger, so it is hard to establish whether the improvements were due to service change or representative of a national trend. Thinking of The Right Care principles (see above paragraph) this study also isn’t able to identify whether there were any disproportionate effects on the poorer socioeconomic groups who now would have difficulty accessing their local ED due to transport or the critically unwell patients who have longer journey times to hospital.
Weeding out the impact of a Festival event
Our Emergency Departments are often located near the venues of large sporting or festival-type events with a potential impact on the normal pattern of patient attendances. 4/20 events originated in the United States but are held worldwide on the 20th April in celebration of marijuana and to protest against the existing laws around the drug’s use and possession. At 4.20pm large numbers of attendees simultaneously consume marijuana which may be expected to lead to an increase in the need for medical services. Staples and colleagues from Vancouver report on their figures of ED attendance from ten consecutive years, comparing data for 20th April to the same time period a week before and a week after, in six regional hospitals. While there was no significant increase in overall ED attendances on the day of the 4/20 event, there was a notable increase in young male patient numbers, a five-fold increase in visits for substance misuse, a ten-fold increase in visits for intoxication and a significantly increase in overall attendances for the nearest hospital. While the results of this study may not be directly generalizable, it raises valuable concepts around preparedness of Emergency Departments for these events, the importance of on-site festival medical cover, and the planning for diversion of ambulances to more distant ED’s.
Barriers to alcohol screening in the ED: are we capturing the right patients?
In 2013, the SIREN study in the Netherlands attempted to perform screening for hazardous alcohol use on consecutive adult patients at ED triage. Over the 1 year period, 35% of the 28 019 patients were not screened: of which three quarters were due to staff (forgetting or omitting) and the remainder were because the patient was unable or unwilling to undertake the screening. Examining characteristics of the unscreened cohort revealed that these patients were more likely to have risk factors for hazardous drinking and therefore the patients most likely to benefit may have been missed. The study also describes the staff factors (which should be considered when implementing such a programme) and rightfully considers whether triage is the right point in the patient’s attendance to perform effective screening.
MEDS score in the ED
Disease severity scoring systems have been developed to assess the severity of illness and stratify patients based on mortality risk, but most contain parameters not readily available in the ED. This month’s systematic review examines the accuracy of the ‘Mortality in the Emergency Department Sepsis’ score in predicting 28 day mortality in patients with infection. The score ranges from 0 to 27 and includes nine variables including some novel parameters such as terminal illness, nursing home resident, bandemia, and thrombocytopenia. The authors concluded that the score carried a sensitivity of 79% (95%CI 72% to 84%) and a specificity of 74% (95%CI 68% to 80%). However results are limited by heterogeneity, particularly in the timing of when the assessment was carried out or the cut-off values used.
How would you remove wound glue from the eyelid?
I am sure many ED doctors have had a ‘near miss’ using tissue adhesive to close a wound. Following an incident in their hospital where a glove was glued to a patient’s eyelid, Liu and colleagues tested 24 different products to remove Histoacryl adhesive within 90 s of application to a cadaveric porcine skin incision. Of the products appropriate to use near the eye, the winner was Polydexa eye/ear drops after 2 hours of soaking. Sadly this is not something commonly kept in ED stock and I wonder if commercial eye make-up remover products might be just as effective, although they might take longer to work? Go to @EmergencyMedBMJ on twitter and let us hear your top tips!
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
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