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Welcome to the December issue of EMJ, it is a good time to reflect on and celebrate the research progress in emergency medicine in 2024, which is so inspiring. It is also a good time to consider the areas of emergency medicine such as mental health where more research is much needed. We continue to see a worrying rise in mental health presentations globally so it is timely to have number of papers in this issue pertaining to mental health and psychosocial issues. The first paper by Giannouchos and colleagues from America investigates the association of self-injury-related ED attendance with homelessness. They conducted a retrospective, secondary data analysis using a nationally representative sample of ED visits by adults aged 25–64 years in the USA from the 2016 to 2021 National Hospital Ambulatory Medical Care Survey. The incidence rate ratio for self-injury-related ED visits was 3.14 (95% CIs 2.05 to 4.83) for individuals experiencing homelessness compared with housed individuals. They found homelessness was significantly associated with self-injury-related ED visits, individuals experiencing homelessness accounted for 12.0% and 11.7% of self-injury-related ED visits in 2020 and 2021, respectively, compared with about 8.4% in previous years. Clearly, the pandemic and associated lockdowns exacerbated the already dire psychosocial situation for the most vulnerable in our societies, but unlike the pandemic, this situation has not faded into the background but remains steadfast and forefront in the complex tapestry of ED challenges. As the homeless population continues to grow in most countries, future studies need to address the health interventions and outcomes for these marginalised individuals. This paper adds to the knowledge of this sad human dilemma and is well worth a read.
Staying on the topic of mental health, the ED is often the only point of contact in a system that is failing patients in a mental health crisis. Olanzapine is a long-acting injection commonly used in the treatment of schizophrenia but we may not all be aware of post-injection delirium/sedation syndrome (PDSS) as a potential side effect. Kochen and colleagues from the Netherlands give an overview of the current literature outlining the key aspects of managing this syndrome in a critical care setting, illustrated by a typical fictional clinical case. They discuss useful and practical aspects of PDSS for emergency physicians and critical care physicians, including pharmacological background, common symptoms, diagnostic criteria and the therapeutic options. I highly recommend this paper, it is full of practical advice, which will help the ED physician on the shop floor.
Such a headache
Headache accounts for between 1% and 2% of all ED attendances, serious pathology is found in only 10% of this number. Subarachnoid haemorrhage (SAH) is the most frequently identified serious pathology, for ED physicians, SAH is high on the list of a ‘must not can not miss’ diagnosis. Nonetheless, diagnosing SAH is not a simple process; traditionally, it was deemed that SAH cannot be excluded by non-contrast CT and so patients should have a lumbar puncture if the initial CT is normal. International guidelines propose brain imaging within 6 hours of headache onset can exclude SAH in isolation. However, there are differing views around the safety of this approach. In this issue, Roberts et al report on the SHED study (Subarachnoid Haemorrhage in the Emergency Department) which was a multicentre prospective cohort study led by The Trainee Emergency Research Network (TERN) UK. They questioned whether a normal CT brain within 6 hours is sufficient to exclude SAH in patients attending an ED with acute headache. This study between 2020 and 2023 enrolled 3663 patients from 88 EDs. Their findings suggest a very low likelihood of SAH following a negative CT-brain scan performed early after headache onset. This study was a commendable achievement on the part of TERN and is worthy of your reading time, but do also read the excellent commentary accompanying this paper by Metcalf whose recognition of the complexity is balanced with the need for clarity of the evidence. This paper will help inform both physicians and indeed patients’ decision-making on the risks and benefits of further investigation for SAH after a negative CT brain scan.
Patient safety
Patient safety in healthcare is an intrinsic component of quality care. The WHO recognises patient safety as a serious public health problem and ED professionals recognise the ED as having unique safety challenges, primarily due to rising patient attendances, staff shortages and crowding. Therefore, it is good to see a paper in this issue by Pardo and colleagues from Spain that explores safety in the ED. They compared the culture of safety in the Adult Emergency Department (AED) and Paediatric Emergency Department (PED) before and after the COVID-19 pandemic. They conducted a quasi-experimental study in 2019 using the Spanish-adapted Hospital Survey on Patient Safety Culture, which they sent to all staff (doctors, nurses and paediatric residents) in AED and PED.
This survey provides scores for 12 separate domains and a global assessment of safety (scale 0–10). They repeated the survey in 2021 after the first wave of the COVID-19 pandemic. After the second survey, the researchers constructed a Pareto chart (based on the responses from the surveys), highlighting the most pressing issues on which to develop improvement proposals. The 2019 questionnaire was completed by 125 AED workers and 65 PED workers. The 2021 questionnaire was completed by 79 AED workers and by 50 PED workers. The global assessment of safety in the AED was 6.13 points at baseline and increased to 7.58 points. The baseline perception of the culture of safety was higher in the PED but improved in both services during the COVID-19 pandemic. The authors concluded that adverse situations can provide an opportunity to improve patient safety culture. So, a silver lining of COVID? Maybe. What is indisputable is that patient safety must stay top of the agenda.
And, on that note, I would like to take this opportunity to wish all our readers a safe and joyful festive season and thank you for your ongoing support of the journal.
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X @maryeleanordawood
Funding The author has 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.