• emergency care systems

This month’s EMJ focuses on the topic of pain. We start with the ‘Readers choice’ because I think it’s the study most likely to change our management in the ED tomorrow. Baril and colleagues present a prospective observational study of pain scores for patients aged >65 years who had common procedures carried out in two ED’s in Quebec, Canada. Not all painful procedures were studied but there were median reported pain scores of 0/10 for x-ray, CT or bedside ultrasound, 1/10 for blood sampling and 2/10 for cannulation. The second highest scores were for urinary catheterization (4.5/10) indicating that analgesia is routinely required for this procedure while the highest scores (median 5/10) were for application of a rigid cervical collar and spinal immoblisation in a mattress. These data suggest we must be aware of the pain these ‘minor’ interventions cause, consider alternative methods, and to minimise time delays by prioritising assessment, imaging and reporting for older patients with spinal immoblisation. Within the convenience sample of 318 patients, it is worth noting that 20% of participants were in severe pain at the time of the interview. Older patients may report pain less and we should be asking pain scores more routinely in ED.

Lower back pain is one of the top five reasons for ED attendances and most patients will be discharged home with advice. What advice do you give patients regarding the natural clinical course of their pain and disability if they have non-specific lower back pain? What do you say when they ask: ‘When will I get better, doctor?’. Coombs and colleagues conducted a systematic review of the literature to answer this question and found eight studies with moderate level evidence, involving 1994 patients in total. While the studies were from a variety of countries and heterogenous, there was a low risk of bias. The headline figure was that on average patients would have a reduction in pain and disability of around 35% after 1 day, 41% after 1 week and 53% at 6 weeks, but mild pain was still present at 6 months (the end of follow-up period for all studies). The authors suggest this information may help clinicians to inform patients of the timeframe for recovery in order to better manage expectations and future use of resources after discharge.

The POEM study (published in 2019) identified that in 8346 patients attending 12 UK Emergency Departments with isolated limb fracture/dislocation, staff only recorded pain scores in half, and of those only 58% received appropriate analgesia. A secondary analysis of the data now compares the results for adults vs children and found that children were statistically more likely to have an initial assessment within 20 min of arrival, to have a pain score recorded and to receive appropriate analgesia. Achieving the above standards was also more likely in a children’s only hospital compared with a children’s ED sited in a mixed hospital. The number of patients attending each department during the study period was not included in the data and may have helped to explain some of those figures for time to triage/analgesia. The take away point was that no analgesia was provided in the patient journey for 20% of children and 21.5% of adults with a confirmed fracture: we must do better.

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The issue with chest pain isn’t as much treating it as ruling out a serious cause. This month we have two studies and two related commentaries on the topic. The ‘Editor’s choice’ is a secondary analysis of prospective data from a single ED in Sweden assessing the diagnostic accuracy of the 0/1 hour high sensitivity cardiac Troponin assay combined with the HEART score or EDACS accelerated diagnostic pathway. The authors found that both scoring systems had similar diagnostic accuracy for 30-day major adverse cardiac events with negative predictive values of around 99%. The impact could be a significant increase in patients who could be safely discharged from ED. However, Edd Carlton’s commentary asks us whether in fact, in the age of HS troponin, risk scores “only muddy the waters.”

Looking at the topic from a resources perspective: GP’s, ambulance services and the UK’s 111 on-line healthcare system will frequently direct patients with chest pain to the Emergency Department. Many of these patients are low risk. So I was excited to see the study from the Netherlands which demonstrated a strong performance of the HEART score (with ECG and point of care Troponin testing) used by paramedics to accurately risk stratify adults with low-risk chest pain. This has great potential in not only reducing the number of attendances to ED but also directing patients with high scores to PCI centres. Furthermore, when the authors then removed cardiovascular risk factors and added male sex, heart rate, systolic and diastolic blood pressure, plus modified the age groups and Troponin cut offs the ‘preHEART’ score performed better.

Finally, in this months Concepts paper, Hendley et al ask us to consider the risks of over investigating patients with low risk chest pain versus missing a major adverse cardiac event using the following ethical principles: beneficence (ensuring deliver care which will most benefit patient), non-maleficence (considering pre-test probability and using risk tools appropriately), justice (considering differences in race and social deprivation) and respect for autonomy (supporting patients to make informed decision about their care when there is clinical equipoise).