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Welcome to the December edition of the EMJ. I would like to wish you ‘Season’s Greetings’ and to suggest some highlights in this edition.
Readers of Victorian literature will be familiar with the portrayal of drug use and the use of opium, especially laudanum, by many authors. Possibly the most famous and controversial was Thomas de Quincey, who in 1821 described his experience of opiate use, initially to relieve pain, in his ‘Confessions of an English opium-eater’. He also described his addiction to, and recovery from opium abuse;
“…opium had long ceased to found its empire on spells of pleasure; it was solely by the tortures connected with the attempt to abjure it that it kept its hold.”
Ease of access to opiates was the main cause of this widespread use, especially prior to the 1868 Pharmacy Act in Britain. In the modern era, despite restrictions on legal use of these drugs, there is now much published concern over the ‘opioid epidemic’ . The historical similarities, including introduction of legislation to reduce use, are clear and stark.
Prescription of opioids within emergency departments
The iatrogenic harm of prescribed opioids is a growing international concern, both for medical professionals, but also for the public, and therefore regularly features in the news media. There are two papers in this EMJ edition that relate to this concern.
First, in North Carolina, a Government Act has been brought into law to effect a reduction of prescription of opioids for acute pain (in particular a reduction in length of prescription to under 5 days). Perry et al have looked at the effect of this legislation on prescribing practice. While this law appears to have been effective in reducing prescription of opioids for acute pain, the same is not true of opioid prescription for ‘non-pain indications’ (specifically anti-tussive use). The authors suggest this gap in the legislation could, and should, be addressed, within local organisations policies.
The second paper is a Quality Improvement report in which Raman and Fleming report a project to reduce codeine prescription within an Emergency Department in Scotland. They neatly describe both the methodologies used and the challenges that can be faced when attempting a Quality Improvement Project. One interesting challenge was that cost and legal restrictions meant reducing the number of tablets given out to patients proved unachievable. One wonders if legislation like that in North Carolina would change this.
Both papers provide sobering statistics on the ‘opioid epidemic’ and should challenge prescribers in Emergency Departments to consider their prescription practice.
Looking to the future: new technologies in emergency departments
Two short reports look at the use of EEG in the Emergency Department. Given the difficulties of identifying Non-Convulsive Status Epilepticus (NCSE), and the poor outcomes associated with this, this is a hopeful new technology. In the paper by Simma, the feasibility and clinical utility of ‘Point-of-Care EEG’ is studied in a paediatric population. Wright et allook at the effect of bedside EEG in the Emergency Department on the clinical management of NCSE. Emergency physicians interested in future practice may want to add bedside EEG to their ‘watch list’.
Looking to the future: prediction using risk scores
The Editors’ choice this month is a study by Veldhuis et al examining the effectiveness of Early Warning Scores in predicting deterioration in patients with COVID-19. No spoilers for this study; I will let you read and digest this paper. Two other studies in this EMJ also look at risk scores, which will be of interest to those who enjoy prediction. Spagnolello et al compare qSOFA and CURB-65 in patients with respiratory tract infections, and Pirneskoski et al look at prehospital NEWS scoring, and how the predictive accuracy, for mortality, changes with the age of the patient.
Care of the older patient in the emergency department: a few surprises?
Given the trend of increasing use of emergency services by older patients, these papers will hopefully be of interest to all Emergency department staff. The ‘Reader’s choice’ this month is by Shrier et al. This paper compares the Rockwood Clinical Frailty Score (CFS) performed by nursing staff at triage and on admission to hospital, and the predictive ability of the triage CFS. The results will be surprising to many readers.
The findings of the study by Takahashi et al might be less surprising. This study looked at association between increasing age and intubation complication rates. Increasing age of patient was associated with an increased risk of complications, primarily post-intubation hypotension. While this is unsurprising, the paper does alert clinicians to consider this risk and be vigilant for post-intubation complications.
The third paper in this section is a ‘review of reviews’; a meta-summary of the evidence for interventions to improve outcomes for older patients in Emergency Departments. The study notes there are inconsistencies in the description and assessment of healthcare interventions. No single intervention was identified as superior. However, improved outcomes were noted when interventions were begun within the Emergency Department, and continued when the patient leaves the department. What is striking is that the metrics for determining improvement in care were usually service metrics rather than patient-centred outcomes. The reader may well have an opinion on whether these are the correct metrics to choose.
The last paper I would recommend is the is the paper by Robson et al, which looks at staff attitudes to health promotion within the Emergency Department. The paper includes staff perceptions of both practicality of health promotion, and delivery of health promotion activities, within the ED. Screening and brief interventions within the Emergency Department are areas where controversy exists. Hopefully, this paper will stimulate readers thoughts on their practice in this area.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.