Managing acute behavioural disturbance: expert insights

Acute behavioural disturbance (ABD) has gained a lot of attention in recent years, following a number of high profile cases covered by the media. This is a challenging presentation riddled with pitfalls in the emergency department (ED), where clinicians must manage patients to maintain their safety and the safety of the care team, while also ensuring that potentially life-threatening causes have been appropriately investigated.

Humphries et al report the results of a Delphi study to gain consensus on the appropriate terminology and approach to care for patients with ABD. This makes for important reading, highlighting the key features of this presentation, which terminology to use and which to avoid, and how to safely manage patients. The authors emphasise the dangers of restraint, the importance of de-escalation and the indications that emergency intervention is required.

What would happen if all low acuity presentations were diverted from the emergency department?

When we’re planning an innovative new service, it might be reasonable to ask what the expected impact will be. But if we’ve never delivered the service that way, how could we know? We could run a clinical trial, but that would take several years to complete. Another way might be to simulate the impact. That’s exactly what Squires et al did to anticipate the impact of diverting all low acuity attendances away from the ED to co-located primary care services between 9am and 5pm. The authors used a discrete event simulation to do this. While this has some limitations when simulating a complex ED environment with irregular and to some extent unpredictable patterns of attendance, it can give a very useful indication of the likely impact of an intervention. The authors’ findings suggest that successfully diverting low acuity patients would lead to an average reduction in waiting time of 29 min for the higher acuity patients: a benefit that could save lives.

Case prediction and prevention to reduce mortality

Speaking of saving lives, we also present results from a fascinating randomised controlled trial that included 1688 consenting participants. Bull et al used a clinical prediction model to identify ED attendees who were at high risk of re-attendance within the next 6 months. They then approached the patients for consent and randomised those providing consent to either receive standard care (which involved no further follow-up) or a health coaching intervention over the next 4–6 months.

The authors have experienced some important setbacks in obtaining data for their primary analyses. However, they have reported early an analysis describing the impact of the health coaching intervention on mortality at 24 months. While this was only a safety endpoint of the trial (meaning that the authors did not expect to find that health coaching would improve mortality), one of the key bottom lines reported in this trial was the observation that men aged >75 years in the intervention group had a lower mortality rate than those in the standard care group. So could health coaching really save lives, or is this a chance finding? Read the full article and put your critical appraisal skills to the test before making up your mind.

Online NHS 111 to reduce demand for a telephone service

In 2023 we published the results of a qualitative evaluation reporting experiences of NHS 111 staff with the service they provide. In the UK, NHS 111 provides both an online platform and a telephone service to direct patients to the most appropriate method of receiving urgent and emergency care. Sampson et al report the findings of another qualitative evaluation, this time exploring drivers of the use of the online NHS 111 platform, and whether its use could reduce demand on the telephone service. The questions asked of users of the online platform are the same as those asked by telephone, though the online platform lacks the supervision of a call handler.

The findings suggest that patients are likely to place emphasis on the importance of human interaction, feeling that the telephone interactions are most likely to be trustworthy and that the online platform may be accessed more speculatively by users. Could the online platform replace the telephone service? Judging from these insightful findings, it seems unlikely.

Decision rules for blood cultures and pneumonia in infants

We also report the findings of two studies focusing on the diagnosis of infectious disease. The first derived and validated a clinical prediction model that used a combination of 12 clinical factors to ‘rule out’ bacteraemia without a blood culture, achieving high sensitivity and negative predictive value. The other described the clinical features associated with radiographic pneumonia in infants presenting to the ED, which will be of interest to those practising in paediatric emergency medicine.

There are also some additional gems including a highly educational short answer question about narrow complex tachycardia in pregnancy. We hope that you enjoy reading!