833 e-Letters

  • Are Care Quality Commission inspections fostering a vicious cycle of (quality) improvement?

    To the editor,
    I read with interest the recent article by Allen et al, “Measurement and improvement of emergency department performance through inspection and rating: an observational study of emergency departments in acute hospitals in England”1.
    National Health Service (NHS) performance indicators are cited throughout Care Quality Commission (CQC) reports when rating emergency departments4-8. Given use of these data as justification for achieving a specific rating, it is reasonable for the authors and the wider acute medicine and healthcare communities to assume a relationship exists between improved ratings and improved performance. Allen et al found no such relationship on any of the 6 emergency department NHS performance indicators prior to CQC inspection and on the subsequent rating score. This finding expands the void of evidence to support the suggestion of improved emergency department performance after inspection and published ratings2.
    Performance indicators such as those implemented by Allen et al and the CQC have evolved over the
    last 2 decades as we attempt to “cross the quality chasm”. Time and presentation-based data points
    such as time to assessment and treatment, time in department, unplanned re-presentations, left
    before being seen etc. are easily measurable since the advent on electronic health records and patient
    management systems. Their reflections in the tenets of the Institute of Medicine’s ideals of safety...

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  • Rapid sequence intubation (RSI) is uncommon in prehospital stroke care

    As researchers with an interest in pre-hospital stroke care, we read this paper with interest, but also with some surprise at the authors’ assertion that ‘RSI is commonly used by paramedics in stroke’. On examining the cited studies and the authors’ own findings more closely, this statement is hard to justify. Although Meyer et al did indeed report that 55% of out-of-hospital haemorrhagic strokes received RSI, this actually refers to a retrospective chart review of 20 children, all of whom with a Glasgow Coma Scale ≤ 8 following acute haemorrhagic stroke from a cerebral arteriovenous malformation rupture. This small, selective paediatric sample cannot be held to be representative of all stroke patients who are conveyed to hospital by emergency medical services. The other study cited as evidence found that people with acute stroke form a substantial proportion (36.6%) of RSIs undertaken by paramedics (Fouche et al., 2017). Whilst stroke may be a common reason for paramedic RSI, it cannot therefore be inferred that paramedic RSI is common in stroke. The authors’ own findings bear this out: of their sample of nearly 44,000 stroke patients conveyed by the emergency medical services, only 2% had received paramedic RSI.

    Whilst we congratulate the authors on their comprehensive analysis of this large dataset, it is important that readers do not gain the impression that paramedic RSI is frequently indicated and performed in pre-hospital stroke care.

    Disclaimer: JG an...

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  • Reply

    Dear Dr J Benger,

    Thank you for highlighting the need for correction in the article. The option D was meant to be spelt as Abductor pollicis longus (APL) instead of Adductor pollicis longus.  Your elaboration on the anatomy of APL muscle will help readers understand our article better.

  • Thumbs down for anatomical accuracy

    Smith and Bongale correctly emphasise the importance of anatomical accuracy when examining the hand.[1] However their article requires correction. The muscle adductor pollicis longus (answer D in their question) does not exist. The abbreviation APL usually denotes abductor pollicis longus, a muscle of the forearm which contributes to abduction and extension of the thumb, and which runs alongside extensor pollicis brevis as it crosses the anterior (radial) border of the anatomical snuffbox. Adductor pollicis (shown in Figure 2 of the article) is an intrinsic muscle of the hand, and is not involved in thumb extension.

    Hand injuries are common in Emergency Departments. Anatomical accuracy is essential when examining and describing these important presentations.

    1. Smith E, Bongale S. Thumbs down: testing anatomy in the ED. Emerg Med J 2019;36:224-238.

  • Emergency Department Setting: an opportunity to detect the patient with heart failure who may benefit from palliative care.

    Dear Editor,
    We have read the study published by Lipinski et al.(1) in which the authors observed that only a little percentage of patients with heart failure (HF) were monitored by a specific palliative care (PC) team. Also, this usually happened in the last two weeks of life. This suggests the need to identify earlier high-risk patients who can benefit from monitoring by a palliative care team (1).
    In relation to this study, we would like to share our experience in a Spanish Emergency Department (ED). Our study included 143 patients with acute HF (AHF), mean age 82.5 (range 65-99) years old, of whom 69 (48.2%) were women. None of these patients were being monitored by a PC team before their admission in ED and only 8 (5.6%) were transferred to PC after the index visit. Out of 8 patients included in CP, 3 (37.5%) died within 30 days after visiting ED. Although our cohort had a lower 1-year mortality than the Canadian study (18.2% vs 27.0%), our findings confirm that older patients with AHF are not frequently followed-up by a PC team, although HF is known to be a disease with a progressive course which is associated with a significant morbidity and mortality, and a high consumption of socio-health resources (2). This may be due to the lack of awareness, among health professionals, that HF is a chronic disease with a poor 5-year prognosis, and the need of palliative care for older patients with HF in an earlier phase than the terminal care (3).
    In conclusi...

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  • missed diagnosis of infective endocarditis-related stroke in the emergency department

    Failure to diagnose infective endocarditis(IE) as the underlying cause of embolic stroke merits recognition alongside failure to diagnose other subtypes of stroke,. The reason is that failure to recognise an infective basis for cerebral emboli precludes time-sensitive interventional strategies such as thrombectomy(1)(2) and, instead, exposes the patient to relatively contraindicated treatment options such as intravenous thrombolysis(IVT)(3)(4). One study compared outcomes from IVT in 222 patients(mean age 59) with IE-related stroke versus 134,048 subjects(mean age 69) with ischaemic stroke in the absence of IE. The rate of post-thrombolytic intracranial haemorrhage was significantly(P=0.006) higher in patients with IE-related stroke. The rate of favourable outcome was also significantly(P=0.01) lower in IE-related stroke(3). A high index of suspicion is required to diagnose IE-related stroke because both fever and heart murmurs are present in only a minority of IE patients at the time of presentation with stroke(4). For patients in whom a timely diagnosis of IE-related stroke is made thrombectomy appears to be a treatment option which generates a favourable outcome(1)(2).
    For the sake of completeness one also ought to mention the potential for meningovascular syphilis to be overlooked in a patient presenting with stroke both in HIV positive(5) and in HIV-negative subjects(6). In both instances neither IVT nor thrombectomy will suffice. Definitive treatment o...

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  • HM Coastguard inclusion

    Dear Authors,

    Thank you for your interesting article about hypothermia in the UK. I couldn't find reference in the case to the HM Coastguard cliff rescue operatives nor to HM Coastguard helicopter search and rescue service (Currently run by Bristow). Was there a reason for excluding these organisations or is there data included under the heading of another organisation? Thank you again,

  • Response to Matthew. L Khan-Dyer

    We do not disagree with the comment, hence our conclusion that, “CT is a valid first line imaging technique in suspected occult hip fracture and is easily accessible in most centres.” The intention of the BET was to present evidence on whether one modality was better than the other and so we looked for studies comparing the two imaging techniques. The study by Thomas et al. forms part of the evidence that CT scanning is a valid method of detecting occult hip fractures and so was not included in the table of evidence.
    Thomas RW, Williams HLM, Carpenter EC, Lyons K. The validity of investigating occult hip fractures using multidetector CT. Br J Radiol

  • Mr

    I read this article with interest as I am currently launching a QUIP on this exact subject.

    As a declaration of possible bias I am looking to use highly sensitive CTs to screen off negative findings to frailty services and thus avoiding orthopaedic beds.

    I am surprised that more credence was not given to the study by Thomas et al. who's sensitivity and specificity was 100% for ct. The study is one that clearly identifies MDCT as the protocol of choice when identifying occult hip fractures. I am not sure whether this is directly comparable to other studies in this way, and therefore some doubt exists as to whether current discrepancies in reporting are more attributable to the scanning protocol used.

    I feel that the current nice guidelines are out of date with modern CT scanning and is having undue influence on first line diagnostics of occult hip fractures.

    I do appreciate the move forward for CT scanning hips as first line diagnostics thus cutting bed-days/patient, expediting correct treatment and improving patient experience.

  • methodological variables involved in the measurement of blood pressure

    The conclusion that there is an association between systolic blood pressure and in-hospital mortality requires further qualification in view of the multiciplicity of variables which impact on the measurement of blood pressure in the older patient first evaluated in the emergency department. Firstly, blood pressure measurement in the Post-SPRINT era specifies that the blood pressure should be measured after 5 minutes rest in a quiet room, and that 3 readings should be taken at 1-minute intervals(1). Is that feasible at A & E?. Secondly, "It is axiomatic that ...measurement should be recorded in both arms.....the higher of the two readings should be used for diagnosis and management...."(2). Is that feasible at A & E?. Finally, allowance should be made for seasonal differences in blood pressure, given the fact that many hypertensive patients have higher blood pressure levels in winter than in summer(3). Those who "buck" this trend experience worse cardiovascular outcomes than those who conform to this trend(3).
    (1) Myers MG., Cloutier L., Gelfer M., Padwai RS., Kaczorowski J
    Blood pressure measurement in the Post-SPRINT Era
    Hypertension doi.org/10.1161/HYPERTANSIONAHA.116.07598
    (2)Giles TD., Egan P
    Inter-arm differences in blood pressure may have serious research and clinical implications
    The Journal of Clinical Hypertension 2012;14:491-492
    (2) Giles TD., Egan P
    Inter-arm dif...

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