Crowding kills

As journal Editors we keep a keen eye on Altmetric scores, the weighted count of online attention that the articles we publish gain across mainstream news, social networks and blogs. This month two articles have received unprecedented attention with Altmetric score above 1000, breaking records for the Emergency Medicine Journal. It is easy to see why. The message is clear, Emergency Department crowding kills. In a retrospective analysis of Hospital Episode Statistics and using logistic regression, Moulton and colleagues paint a stark statistical picture: delays to admission greater than 5 hours are associated with a significant increase in 30 day mortality. Delays to admission between 8–12 hours have a number needed to harm of 72. How many patients in the last month have waited this long for a bed in your emergency departments? It is a privilege to publish a lay perspective on these findings and thank Derek Prentice for his emotive commentary, this month’s Editor’s Choice.

It seems pertinent to highlight the last (senior) author, Cliff Mann, on Moulton’s work. Sadly, he did not live to see the impact of this work. A truly exceptional and wise leader, this is just one important legacy for our specialty that he leaves behind. Thank you Cliff, for your tireless dedication to delivering outstanding patient care.

We continue the broader theme of ED admissions and the currently inevitable associated crowding in our next four articles covering varying methodology and conditions. The first of these articles, by Wyatt and colleagues explores the association between admission and discharge decisions when ED and inpatient occupancy reaches extreme levels. Unsurprisingly perhaps, they find a modest association between higher admission thresholds and high bed occupancy, and conclude that riskier decisions are made when beds are full. However, to counter this, admission thresholds are also high when occupancy is particularly low. We need to think more carefully about avoidable hospital admissions.

One of the traditional system-wide reflex responses to ED and hospital crowding has been to outlie patients with medical conditions to surgical wards. Patry et al, explore the impact of this strategy on our older, more vulnerable patients, within a matched case control study from France. Importantly, they use a primary outcome that goes beyond traditional metrics such as length of stay and explore function at 6 months (living at home). They find that outlier status is associated with a lower probability of living at home. A simple reflex system response may have a huge impact at an individual patient level for our patients living with frailty.

Patient perceptions of crowding are underexplored. It is therefore great to see a more formal evaluation of this important topic from Ian Kronish and his team from New York. This single centre analysis of patients with suspected acute coronary syndrome, cross correlates crowding metrics with patient perceptions of interpersonal care. While only 11% of patients experienced crowding (you can bet that is higher now), there was a strong correlation between reduced patient satisfaction with care and crowding. And finally, a systematic review form Anniek Brink and colleagues in the Netherlands, highlights the desperate need for implementation studies to evaluate tools to predict need for admission in an emergency setting.

We have highlighted the problem of ED crowding, the obvious impacts on patients and our decision making, together with a lack of robust solutions. What better way to sum this issue up than the following excerpt from Derek Prentice in his commentary:

“Yet…this trust and indeed the dedicated service of the clinicians is being undermined by a killer and one that for far too long the government, NHS leadership, Trust Boards and their Chief Executives have chosen to ignore or simply blame the patients for having the temerity to turn up.”

Traumatic brain injuries

Away from politics, we include a number of papers exploring advances in brain injury care. In an exploratory case-control analysis of some potential brain injury biomarkers, Pia Koivikko et al may have put the kybosh on the potential clinical value of assessing clinical severity using a number of biomarkers. Carl Marcowitz and colleagues’ original research article does offer some promise that the Hull Salford Cambridge Clinical Decision Rule may facilitate early discharge of a small number of patients (3.5%) with traumatic brain injury who are at very low risk of deterioration. We also include a clinician survey that explores equipoise in the use of platelet infusion in traumatic brain injury patients taking antiplatelets. One senses a grant application is in the offing for a trial in this area, although the applicants should be mindful of using routinely collected data to inform their power calculation, an issue highlighted by Ben Bloom et al in our In Perspective article.

Ultrasound

With the continuing development of ED ultrasound practice it is great to see the next instalment of our Sono Case Series and also an original research article evaluating lung ultrasound in COVID-19 that shows promising diagnostic accuracy.

Quality improvement

The EMJ continues to offer publication of robust, well conducted Quality Improvement initiatives and it is great to see the work of Bodnar et al, which uses the Lean Six Sigma approach to test a number of discrete interventions to improve ED boarding time. Perhaps there is something emergency departments can do about crowding after all?

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