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Health inequalities
EDs are increasingly a good barometer of pressure across the NHS and the health of the nation. Austerity measures introduced in the UK in 2010 following the 2008 recession resulted in major changes and, in some cases, significant cuts to healthcare funding. It comes as little surprise that these measures have hit the poorest hardest with cuts in the most deprived boroughs resulting in higher rates of all and avoidable emergency admissions. What is perhaps less obvious but just as concerning for society as a whole is the impact wider austerity measures have had on less deprived areas, so it was interesting but also quite disheartening to read the paper by Castro and colleagues from York. They conducted a longitudinal analysis of the average level of all cause and avoidable admissions and funding reductions between 2012 and 2017. They found that the most deprived areas had larger cuts in spending with corresponding higher rates of all and avoidable emergency admissions as well as greater within area inequality in admissions. What is perhaps more telling is that reductions in funding and expenditure were also associated with increases in inequality in the less deprived areas as well as increases in all and avoidable emergency admissions. This study has its limitations but is well worth a read, the oft-cited concept and rhetoric of ‘levelling up’ rings hollow as the failure of austerity measures on health and well-being is increasingly obvious in our EDs. Do read also the accompanying commentary by Adrian Boyle where he appropriately refers to the findings of this study as an ironical ‘levelling down’.
Trauma, mortality and morbidity
Trauma constitutes a large burden of disease globally and few would doubt that the introduction of integrated trauma systems in many countries has resulted in better care and falls in mortality. However, much less is known about the costs of these systems and, more importantly, the long-term impact on morbidity in terms of disability and economic cost. In this issue, Bath and colleagues from Cambridge undertook a systematic review to explore the impact of trauma systems on morbidity, quality of life and economic outcomes. They identified seven papers but acknowledged that the overall quality was poor with a high risk of bias. They concluded that there is limited and poor-quality evidence to assess the impact that trauma systems have on morbidity, quality of life and morbidity. They endorse the positive role trauma systems play in delivering high-quality trauma care but caution that, in setting up trauma systems, care needs to be taken to understand the sociocultural and political context of the surrounding healthcare infrastructure. This important point is particularly relevant to low and middle income countries where health systems are fragile and rudimentary and follow-up rehabilitation may be non-existent or too expensive. This situation and the moral dilemma it presents is sensitively articulated and brought to life in an accompanying commentary by Hendry Sawe who describes the challenges of trauma care in Tanzania where the reality of saving more lives may be more disability. Do read this as it is an eye opener to other world trauma care.
Pharmacists in the trauma team
Still on the topic of trauma, I was curious to read the paper by Roman and colleagues from Australia about improving analgesia in trauma. They conducted an unblinded randomised trial to assess the effects of integrating pharmacists into trauma response teams. They compared EM pharmacist involvement in trauma calls versus standard care at one level 1 trauma centre. The primary outcome was the proportion of patients who had a first dose of analgesia within 30 min. Time to analgesia in the control arm was 28 (22–35) min and 20 (15–26) with pharmacist involvement. The pharmacist prescribed the initial dose of analgesia for 88.4% of patients. There were 27 other medications prescribed by the pharmacist for these patients. This paper just confirms what most ED clinicians already know that pharmacists can contribute very effectively to ensuring efficient, safe and effective medication use in the ED not just for trauma patients but for all patients. Some EDs have a dedicated pharmacist but many do not. Having a dedicated ED pharmacist seems like an obvious step to improving medication safety in the ED. The cost of a pharmacist will be offset continuously by reductions in prescribing errors.
Re-direction stroke pathways: a qualitative study
With constant changes taking place in emergency care often with little notice or explanation, it is reassuring when staff are asked for their views on proposed changes before they happen. So you might be interested to read the paper by Day and colleagues in the UK who undertook a three-phase multiregional qualitative study to obtain health professionals views on the acceptability and feasibility of a new re-direction pathway for patients who had stroke. The issue being explored was more direct access to emergency thrombectomy. Emergency mechanical thrombectomy in patients with large artery occlusion is known to result in better outcomes reducing disability in the long term in comparison to drug treatments alone, but access to such services in the UK is limited as only regional stroke centres have the facilities and specialist workforce to deliver this treatment. Transferring patients to these centres is often fraught with delays. A new re-direction pathway may improve this situation but before pursuing this concept further, the study team sought the views of staff on the ground. They purposively sampled NHS staff in four regions in England using focus groups and semistructured interviews. Anonymised interview transcripts were analysed guided by NASSS implementation framework. The participants were positive in their responses to the proposed new prehospital re-direction pathway but also highlighted key content and implementation challenges. The authors found that the NASSS framework helped identify important and useful ‘real world’ issues that need consideration. Getting staff involved in the planning stage of initiatives they have to implement is not just common sense, it is a respect for their knowledge and skill.
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Footnotes
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 Commissioned; internally peer reviewed.