• guidelines

As ED clinicians, I think it is fair to say that we all want to do our best for anyone who presents to us for care. To paraphrase an interviewee in the Editor’s choice article ‘if you come (to ED) for help, you get help.’

Recently, in the UK and Europe in particular, the narrative around asylum seekers and refugees has become even more emotionally and politically charged. Despite clear evidence that this group does not disproportionately use emergency services, this is part of the rhetoric which may influence the publics, and by extension, healthcare workers’ opinion and interactions. In this month’s Editor’s choice (and linked commentary by Dawood), Docherty and colleagues have explored the views of staff regarding asylum seekers and refugees attending a Scottish ED. They provide some insight into what EDs can do to improve the care provided to this vulnerable group. Reassuringly, there was no moral dilemma regarding eligibility for treatment - clinicians were dismissive of the idea that individuals’ immigration circumstances could impact on the emergency care they received.

Asylum seekers and refugees are not a homogeneous group. They have varying experiences, needs and expectations of emergency care. Given that 85% of refugees and asylum seekers live in developing countries, and mostly in countries neighbouring their country of origin, this is an important international issue. This article will therefore be relevant to readers across the world as it illustrates how global EM truly becomes local.

Provision of pain relief is a core skill for ED clinicians, and we should all strive to do this in the best way possible. This may involve adopting methods and agents used from other settings or and evaluating whether they can improve on our current strategies. van der Have and colleagues detail their experience with remimazolam for ED procedural sedation. Although used in daycase settings, there is little experience of ED use up to now. Given that it aims to combine the properties of two familiar agents (remifentanil and midazolam) and a suggestion that it may be particularly useful in higher risk patients, it is worth watching this space for more robust evidence of safety and comparative efficacy. The linked commentary by Ong is also worth a read.

Perhaps more familiar is the use of ultrasound guided erector spinae plane block (ESPB), which was primarily used for surgical anaesthesia, before being adopted for use by EPs (I think it’s great for managing posterior rib fractures!). In the open-label ‘EASIER’ RCT, David and colleagues have used ESPB for ED patients with hepatobiliary pain (mainly pancreatitis). Compared with intravenous morphine, ESPB provided better pain relief (measured by a 10-point numerical rating scale), and required less rescue analgesia up to 10 hours post-administration. Although there were limitations (unblinded, less than a third of eligible patients recruited due to only two operators performing blocks), which may preclude immediate adoption, ESPB certainly shows promise, particularly in resource limited EDs and those with high numbers of boarded patients requiring ongoing analgesia.

The more familiar modalities (haematoma block, Bier’s block and sedation) compared in the retrospective Australian study by Pitman and colleagues of 226 forearm fracture reductions makes for interesting reading. They suggest that the 84 patients who had haematoma blocks (HB) had lower ED LOS. However, this was offset by 4.6 times higher odds of successful first attempt at reduction with sedation than HB. Although more complications were recorded in the sedation group, this may have been due to more systematic recording as is standard in ED sedation practice. There was also a suggestion of lower cost and resource utilisation using HB, but this was not subject to formal cost-effectiveness analysis. Even with the recognised bias inherent in retrospective data, this is certainly worth a look and reflection on your EDs current practice.

Although we are still some way off integrating artificial intelligence (AI) in our routine workstreams, this study from Novak and colleagues on AI-assisted identification of pneumothoraces is promising. Overall, reader sensitivity increased by 11% when aided by the AI, with larger improvement in more junior readers. As with any reader study, we would want to see how the software performs in vivo with real ED patients (and clinicians) before adoption.

Of course, deciding whether to request a particular imaging test is important and based on pre-test probability, diagnostic performance, outcomes and safety considerations. Radiology guidelines on requesting plain abdominal x-rays (AXR) are conflicting, despite evidence suggesting that they are mostly of limited utility. In the QIP by Love and colleagues, simple interventions (education, radiographer vetting, changes to e-requesting) led to almost one-third reduction in AXR requests. Interestingly, most patients had further imaging regardless of whether their AXR showed an abnormality or not. Recognising that specific interventions are not the sole determinants of sustained QI change, the engagement strategy and methodology described will be useful for any ED looking at a similar initiative.

There are over 20 000 ambulances dispatched per month in England for suspected acute coronary syndrome (ACS) patients, of which the majority are transported to an ED. While a clear direct pre-hospital pathway for ST elevation MI is commonplace, such pathways are uncommon for the other, much larger cohort of possible non-ST elevation ACS. Decision tools such as HEART, T-MACS and EDACS are established in the ED assessment of this cohort, but prehospital risk-stratification using clinical risk scores (with point-of-care troponin) have not yet been validated. Demandt and colleagues have presented their external validation of the pre(hospital)-HEART score in a planned analysis of a prospective cohort of patients from a Dutch TRIAGE-ACS study. They demonstrated good overall diagnostic performance of preHEART and HEART in the determination of NSTE-ACS in transported patients. This is promising, although arguably, the main benefit will be in safely identifying a low-risk cohort who do not require ED conveyance. We are not quite there yet, but as a start, this paper is a step in the right direction.

There’s a lot more in this issue that is worth a look, and we hope that you enjoy reading it!