• emergency care systems
• COVID-19

COVID-19 continues to dominate the news as well as our practice but the focus has moved on from adapting our departments and ways of working to enhancing our knowledge of the disease as well as evaluating some of the possible collateral damage of the pandemic including the impact on doctors. This issue includes three papers on COVID-19 which are important and of interest. The decrease in ED attendances over the lock down periods has been noticeable and this has been a cause of concern that patients who might have really needed ED were deterred by lock down restrictions as well as a fear of contracting the virus. Sless and colleagues in Ireland undertook a retrospective study comparing ED attendances of 2020 to 2017–2019. Triage presentations of abdominal pain, shortness of breath, chest pain, headache and trauma were examined. They found a significant decrease in daily attendances of these presentations in 2020 compared with 2017–2019.

Similarly, Charlton and colleagues in the UK explored the incidence of emergency calls as well as out of hospital cardiac arrests in the north east of England during two periods of lockdown in 2020. They found a reduction in incidence of calls as compared with 2019 but a rise in incidence of OHCA and OHCA deaths during the same period, however, these changes appear transient. The findings of both of these studies highlight the importance of reassuring the public that safety measures are in place to ensure that those needing emergency medical attention should not be afraid to attend so we can, as far as possible, minimise any further adverse impact of the pandemic.

There is little doubt that the unprecedented nature, intensity and duration of the pandemic has been distressing for healthcare staff. Many of our readers will identify with the findings of a study by Roberts and colleagues in the UK who conducted an initial cross-sectional electronic survey, within a three-part longitudinal study to quantify psychological distress experienced by emergency, anaesthetic and intensive care doctors during the acceleration phase of the first pandemic wave of COVID-19 in the UK and Ireland. 5440 responses were obtained and all levels of doctor seniority were represented. The authors found that during the acceleration phase of the pandemic almost half of front-line doctors working in acute care reported case level psychological distress as measured by the general health questionnaire (GHQ-12) as well as some additional questions. It is hoped that findings from this study will be taken seriously and used to inform strategies for future preparedness including doctors’ health and well- being in the short and long-term.

News on Sepsis

Sepsis mortality is an ongoing concern. Hyperchloraemia is associated with poor clinical outcomes in patients with sepsis but less is known about the clinical implications of hypochloraemia, so, you might be interested to read in this issue a study by Lee and colleagues from South Korea. They conducted a retrospective analysis using a multicentre prospective cohort of 11 emergency departments to evaluate the prevalence of chloride imbalance defined by sodium chloride difference adjusted criteria and the independent association between hypochloraemia and 28 day mortality in ED patients. They found hypochloraemia was more frequently observed than hyperchloraemia in ED patients with septic shock and it was independently associated with 28 day mortality. This is an interesting finding which shines a new light on an enduring medical concern, well worth a read.

Usability of EHR

The move to electronic health records (EHR) has undoubtedly transformed healthcare delivery but relies heavily on staff to navigate the system to enter data. We have probably all faced the challenge of adapting to different electronic health records when working in different settings. Clunky and difficult to use systems with poor interfaces cause delays which can adversely impact safety as well as being frustrating for staff who want to be efficient in their working lives. On the other hand, a system that is intuitive and easy to use can increase efficiency, safety and staff satisfaction. Bloom and colleagues in London sought to measure the usability of common EHR systems in the UK using a validated assessment tool. This tool, the International Organisation for Standardisation (ISO) has defined standards for usability which allow manufacturers and customers to identify systems that have been appropriately tested and which support good clinical care through good usability. Possibly not surprising to those of us using these systems, this study found that no UK ED EHR system met the internationally validated standard of acceptable usability for information technology. The findings of this study may confirm many of our misgivings about our current EHR but nonetheless this paper is a ‘must read’ for clinical leads in the process of instituting or changing their ED EHR.

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Analgesia equality

Men and women may experience and express pain differently but does this difference influence treatment? You might think not, but the findings of a study by Lau and colleagues in Canada suggest otherwise. They undertook a multicentre population based observational study to evaluate the effect of sex on ED opioid administration. They found that males and females had similar likelihood of receiving opioids but males with trauma, flank pain, headache and abdominal pain were much more likely to receive opioids. Is this an unconscious sex bias? I’ll leave you to read the paper and decide. The authors suggest that we should self-examine our analgesic practices and departments should have evidence based, indication-specific analgesic protocols to reduce practice variability and optimise opioid analgesia. So, food for thought, another challenge for equality in healthcare and perhaps a worthwhile quality improvement project.