Community care?

Our Editor’s Choice this month explores a novel approach to care delivery, the Physician Response Unit (PRU), which aims to reduce ED attendances by finding a community solution to the emergency complaint. Joy and colleagues’ retrospective analysis of 12 months of data from this service, which is based in London, demonstrated that of nearly 2000 patients attended to, 67% remained in the community. The authors conclude that this model of care is a successful demonstration of integration and collaboration that also reduced ambulance conveyances and ED attendances. These results are promising, however, as the excellent commentary by Professor Sue Mason identifies, some unanswered questions remain. Whether these results can be generalised across the wider NHS, beyond the unique confines of the capital, and in light of starkly heterogenous healthcare systems and workforces remains unknown.

Moving closer to the front door

Physician in Triage (PIT) remains a controversial topic in EM. In an interesting analysis of PIT from Israel, Schwarzfuchs and colleagues present an uncontrolled before-after analysis of the impacts of this triage strategy on a single time-critical condition, STEMI. At the EMJ, we usually discourage this type of study. However, here, the authors demonstrate how, with the inclusion of an appropriate logistic regression to consider confounders, this methodology may be an appropriate way to evaluate such interventions which may be difficult to do within a randomised controlled trial. “Minutes mean myocardium” and as such the reduction in door-to-balloon time of 9 min when a senior physician was present, demonstrated here, may lend further support to the implementation of PIT. This is certainly a rich area for quality improvement work evaluating such targeted interventions for our patients.

All about the Bayes’

We welcome an observational analysis from Hautz and colleagues that seeks to explain the patient, physician and contextual factors associated with diagnostic test ordering. Baye’s theorem describes the probability of an event based on the prior knowledge conditions that may relate to that event. A key concept we should all adopt in test ordering. However, this manuscript goes further in exploring that prior knowledge by evaluating physician experience, patient and situational context. Rather surprisingly, in this single centre analysis of 473 patients and 38 physicians, these factors seem to have a limited impact on test ordering. Rather, it seems that, uncertainty around the patient’s condition (high acuity) and case difficulty seem to influence test ordering more. So, uncertain pre-test probability equates to higher degrees of diagnostic test ordering. The Reverend Bayes would be turning in his grave.

Wellness

Now, unlike ever before, it is important to establish the need for physical and psychological recuperation among our staff. The first manuscript within our Wellness section, from Graham and colleagues (this months Reader’s Choice) evaluates the Need For Recovery (NFR) Score in 168 emergency workers at a single site. The high NFR in this population provides a quantifiable insight into our high work intensity but further validation is required beyond a single site. Over to you TERN….

While knowing the extent of the problem is of great importance, what we do about it is perhaps a greater challenge. We would therefore encourage our readers to take home some of the top tips included in our expert practice review this month, Top Ten Evidence-Based Countermeasures for Night Shift Workers by Wallace and Haber.

There’s a bug going around…

We have had a record number of submissions during the COVID-19 pandemic and the extent to which the EM community has pulled together to inform clinical practice at this time has been breath taking. We are sorry we cannot accept all your excellent work. It is a pleasure to publish a number of Reports from the Front on this topic ranging from patient level interventions such as proning, to invaluable lessons from systems wide responses to the pandemic. However, the importance of evidence-based medicine has never been higher and this is discussed in our excellent Concepts paper by some very eminent EM Professors.

Introducing SONO case series

Lastly, this month sees the first in a series of SONO cases published in the EMJ. This will be a regular feature and is a case-based approach to demonstrate how ED Ultrasound can influence and improve patient care.