Dear Editor

The articles on the problems of Emergency Department (ED) overcrowding make interesting reading, as the problems outlined are familiar to us in the UK, and I am sure that we would all identify similar causes and both short and long term solutions.[1]

The list of stopgap measures, in the article by Fatovich and Hirsch [1] is also familiar to us all. Ambulance diversion is difficult outside large cities with multiple EDs. Chief Executives are under pressure to avoid it. Similar problems arise with regard to postponing elective surgery. Reopening inpatient beds will take time, and the same applies to increasing the size and staffing of our EDs.

Much work nationally has been put into improving discharge processes, with notable successes. However bed management itself remains a big issue that is not really discussed by Fatovich and Hirsch. In my experience the number of times that there are genuinely no empty beds are rare, the beds are usually "the wrong type of bed". It cannot be denied that placing patients on outlying wards belonging to other specialties, even in their recovery phase, carries some clinical risk, and adds to the time need to complete ward work; this has led to resistance amongst our colleagues. Overcrowding of EDs, however must be a greater clinical risk.

This is an area that has not been discussed publicly. I would suggest the time has now come that we should stimulate this as a national issue. Resolution of ED overcrowding, in both the short and long term is a Trust-wide, and NHS-wide problem. Most of the solutions are beyond our individual control, and can only be achieved by working with our colleagues for the corporate good of our patients. By working together to utilise scarce beds even more efficiently I believe we can reduce the overflow problem, without impacting on elective activity.

This is yet another stopgap, but one that has not been openly discussed. Is it time we started this debate?

Reference

(1) Fatovich DM, Hirsch RL. Entry overload, emergency department overcrowding, and ambulance bypass. Emerg Med J 2003;20:406-409.

Dear Editor

Nigam and Cutter totally fail to present evidence to justify the claim that “Welsh emergency vehicles examined exhibited an unacceptable level of bacterial contamination”.[1] What is more, a press release from the editorial team to local newspapers led Madeline Brindley of The Western Mail to write, “Dirty ambulances infested with huge amounts of harmful bacteria are carrying seriously ill patients to hospital in Wales, according to a report published today. The new research discovered that even after they have been cleaned, ambulances are still home to "unacceptable" levels of bacteria.”[2]

The authors make no attempt to quantify levels of bacteria for organisms that are expected to be present in an environment occupied by people. Inevitably, steering wheels will be home to Staphylococcus epidermidis and viridans group streptococci, as they represent normal skin commensals. Bacillus sp. are ubiquitous environmental organisms. Similar comments can be levied for all areas sampled throughout the ambulances.

The method used by Nigam and Cutter is suitable for a qualitative assessment and is normally used to identify specific pathogens. The only potential pathogen identified by the study is Staphylococcus aureus. A quantitative method should have been used for this type of study, if the conclusions were to be supported. Quantitative methods, such as those discussed by Roberts et al,[3] take a measured area of a given surface and allow the number of bacteria to be counted and expressed per square centimetre. Such a technique allows for the assessment of reduction of bacterial load after a cleaning process.

Quite reasonably, the press will pick up on stories such as these when prompted by the editorial team. However, there is a responsibility on the editorial board of journals, their reviewers and the researchers to ensure that study methods and the review process are rigorous. Only then can proper conclusions be drawn. Without that, fear can be instilled in the patient population and the NHS challenged inappropriately.

References

(1) Nigam Y, Cutter J. A preliminary investigation into bacterial contamination of Welsh emergency ambulances. Emerg Med J 2003;20:479-482.

(2) Brindley M. Dirty ambulances endanger health. The Western Mail Sept 4th 2003 available at http://icwales.icnetwork.co.uk/0100news/0200wales/page.cfm?objectid=13367275&method=full&siteid=50082 (Accessed 8th September 2003).

(3) Enumeration of micro-organisms. In Practical food microbiology: methods for the examination of foods for micro-organisms of public health significance 2nd Edition, Robers D, Hooper W, Greenwood M, (Eds). London: Public Health Laboratory Service, 1995:95-120.

Dear Editor

I welcome the paper by Frampton et al.[1] describing their experiences of nurse-administered nitrous oxide, which adds further evidence to the literature [2] supporting this technique as a useful and safe method of easing the suffering of children during their attendance at an Emergency Department.

I feel that the use of the term “relative analgesia” is somewhat confusing; this is not a term previously encountered in the literature describing sedative/analgesic techniques. The United States guidance [3, their reference 2] does not use this term when defining sedation levels nor do the current UK [4,5] and Australasian [6] guidance and definitions. To introduce a new term may prevent accurate comparisons of techniques in the literature. Nitrous oxide is known to produce both analgesia and sedation: in the context of this study it would have been better to describe the level of sedation according to established definitions so readers can assess effects, and compare them to other studies.

I would also welcome description of two other outcomes measures which readers would find important when considering a sedative/analgesic technique: adequacy of sedation and parent/operator satisfaction. The authors do describe 10 cases (4.4%) requiring additional sedation but not whether the remaining children were adequately sedated, or inadequately sedated but the procedure was completed anyway.

References

(1) Frampton A, Browne GJ, Lam LT, et al. Nurse administered relative analgesia using high concentration nitrous oxide to facilitate minor procedures in children in an emergency department.Emerg Med J 2003;20:410-413.

(2) O’Sullivan Í, Benger J. Nitrous Oxide in emergency medicine. Emerg Med J 2003;20:214-217.

(3) American College of Emergency Physicians. Clinical policy for procedural sedation and analgesia in the emergency department. Ann Emerg Med 1998;31:663–77.

(4) UK Academy of Medical Royal Colleges and their Faculties. Implementing and ensuring Safe Sedation Practice for healthcare procedures in adults. Report of an Intercollegiate Working Party chaired by the Royal College of Anaesthetists; The Academy, 2001.

(5) Scottish Intercollegiate Guidelines Network. 2002; guideline 58. http://www.sign.ac.uk/ (Accessed Mar 2003 – now under revision)

(6) Australasian College of Emergency Medicine. Policy Document – Use of intravenous sedation for procedures in the emergency department. http://www.acem.org.au/open/documents/sedation.htm (Accessed September 2003).

Dear Editor

We read with interest the comments on our best evidence topic review on Vasopressin or adrenaline in cardiac resuscitation and are happy to explain the process involved in producing the BET.

This literature search was first conducted in March 2002. Our initial and specific question was:
Is vasopressin more effective than adrenaline in achieving return of circulation and longterm survival, in human cardiac arrest?

A full and sensitive search strategy was compiled. The search strategy was checked by two additional independent doctors who cross checked their own strategies in order to maximse the sensitivity. All titles and abstracts were appraised initially by the two authors and prior to publication by the third independent author. The relevant original studies and review articles were sourced in full text (18 in total). All review articles were cross referenced.

These 18 papers were reduced to four potentially relevant papers. This included the two published studies. The search strategy and all four papers were reviewed by the Manchester Royal Infirmary Emergency Medicine journal club. A consensus decision was taken to exclude from the analysis one study reporting the effects of intravenous vasopressin on coronary perfusion pressures in 10 patients[1] and a second which reported the effects of intravenous vasopressin administered in refactory cardiac arrest, in 8 patients.[2] The first study did not use return of ciculation as an outcome, and the second did not compare the effects of vasopressin and adrenaline. The decision to publish this review was taken four months prior to publication. At that point it was reviewed by Professor Mackway-Jones, the first author repeated the search and a third independent author checked the relevant articles and search strategy.

To directly respond to your points

1. The BET addresses a specific question. We did not aim to present a vague representation of all literature on vasopressin but asked the question - is vasopressin better than adrenaline in a human cardiac arrest.

2. Dr Locker wonders why we did not include two recent reviews addressing this question. A less superficial appraisal of these papers would have revealed they found the same 4 studies. We have cross referenced all the review articles published on this subject and can find no further studies.

3. We do not pretend that these reviews are systematic reviews, (we used Medline only and do not search for unpublished data), but we do openly lay out our methodology. It would be possible for another doctor, anywhere in the world, to repeat this search exactly if they so required.

4. At present, a meta-analysis would appear wholly inappropriate to answer this question. There are only two small studies, the results of which are clearly laid out in the table. The reader is capable of drawing their own conclusions from this table. When more relevant data is available (there are at least two ongoing studies), a meta-analysis may be of use.

In conclusion, this BET is an accurate and reproducible formal review. It addresses the question posed by the authors and clearly summarises the relevant published literature.

References

(1) Morris DC. Dereczyk BE. Grzybowski M. Martin GB. Rivers EP. Wortsman J. Amico JA. Vasopressin can increase coronary perfusion pressure during human cardiopulmonary resuscitation Academic Emergency Medicine. 4(9):878-83, 1997 Sep.

(2) Lindner KH. Prengel AW. Brinkmann A. Strohmenger HU. Lindner IM. Lurie KG. Vasopressin administration in refractory cardiac arrest. Annals of Internal Medicine. 124(12):1061-4, 1996 Jun 15.