The courage with which emergency medicine specialists are responding to COVID19 crisis is admirable. They are in a situation similar to the battlefields of first World War. It is a protracted war unlike the disasters and tsunamis that we have faced in recent times. Lord Moran in his seminal book "The Anatomy of Courage" based on his WW1 experience of treating medical emergencies had noted that battle fatigue would set in the most courageous of soldiers after 30 days of trench warfare. This led to the deployment of battalions in formations, which provided relief to those in the front lines through planned rotation. This model may be useful in developing systems of rostering which provide planned periods of relief and recuperation for medics and paramedics manning the front lines of COVID 19 crisis.
Finnikin and colleagues describe a large data set of retrospectively calculated National Early Warning Scores (NEWS) in a system that was not using or responding to NEWS. Understanding the relationship between NEWS and referral practices is an important area of research which could help shed some light on the impact of introducing NEWS into primary care.
The first important point is that only 31% (74,992/242,451) of patients who had face-to-face encounters had a full set of observations and the clinical characteristics of the 69% excluded from the study are unknown. In our experience, GPs tend to perform a full set of observations on patients who appear more unwell so it is possible that the population studied may not be representative.
Finnikin and colleagues found that only 6.9% of patients referred to hospital had a NEWS≥5 and 69% with a NEWS ≥5 were not referred. There is emerging evidence that NEWS calculated by GPs at referral correlates with mortality (data from West of England accepted for publication) so the fact that it did not correlate with referral is of concern. Scott et al in the West of England (1, 2) and Inada Kim et al in Wessex (unpublished data) have demonstrated that the higher the NEWS on referral or arrival, the more likely the patient is to be admitted and the more likely the patient is to die.
The lack of linkage to any outcomes is a major weakness of this work. While an increase in admissions of 16.2% is not ideal in an alr...
Finnikin and colleagues describe a large data set of retrospectively calculated National Early Warning Scores (NEWS) in a system that was not using or responding to NEWS. Understanding the relationship between NEWS and referral practices is an important area of research which could help shed some light on the impact of introducing NEWS into primary care.
The first important point is that only 31% (74,992/242,451) of patients who had face-to-face encounters had a full set of observations and the clinical characteristics of the 69% excluded from the study are unknown. In our experience, GPs tend to perform a full set of observations on patients who appear more unwell so it is possible that the population studied may not be representative.
Finnikin and colleagues found that only 6.9% of patients referred to hospital had a NEWS≥5 and 69% with a NEWS ≥5 were not referred. There is emerging evidence that NEWS calculated by GPs at referral correlates with mortality (data from West of England accepted for publication) so the fact that it did not correlate with referral is of concern. Scott et al in the West of England (1, 2) and Inada Kim et al in Wessex (unpublished data) have demonstrated that the higher the NEWS on referral or arrival, the more likely the patient is to be admitted and the more likely the patient is to die.
The lack of linkage to any outcomes is a major weakness of this work. While an increase in admissions of 16.2% is not ideal in an already extremely busy system, if those patients require acute attention it is important that they are appropriately referred. Similarly, there may be a number of patients with NEWS<5 who were unnecessarily referred to hospital; without outcomes data, conclusions about appropriateness of referrals cannot be drawn. In addition, in the West of England, where NEWS is used by GPs, admissions did not increase at any greater rate than elsewhere (3).
It is also suggested in the paper that a NEWS cut off of <5 could be used to reduce ‘low acuity admissions’; however, it is often appropriate to admit a patient irrespective of NEWS, for example someone with a stroke or crushing central chest pain. The Royal College of Physicians is clear that ‘NEWS should be used as an aid to clinical assessment- it is not a substitute for competent clinical judgement’ (4). Using NEWS promotes a full assessment of the patient and, if used at referral, is also a useful communication tool which helps the receiving hospital to recognise the patients that are deteriorating in the time frame between referral and arrival.
GPs have to make important and challenging decisions in a short time frame and formal actions should not be ascribed to NEWS in the community but instead there should be increased awareness that the higher the NEWS the more likely the patient is to be sick. Before NEWS, GPs would admit a patient and highlight the most extreme observations; perhaps the learning from this analysis could be that simply measuring observations is of limited value in identifying who needs admission and the aggregate nature of NEWS is better suited to identifying potential deterioration than high scores for a single vital sign(5).
1. Scott LJ, Redmond NM, Garrett J, et al. Distributions of the National Early Warning Score (NEWS) across a healthcare system following a large-scale roll-out. Emergency Medicine Journal 2019; 36:287-292.
2. Scott LJ, Redmond NM, Tavaré A, et al. National Early Warning Scores in primary care are associated with clinical outcomes. BJGP 2020, In press.
3. Pullyblank A, Tavaré A, Little H, et al System Wide Implementation of the National Early Warning Score Reduces Mortality in Patients with Suspicion of Sepsis. BJGP 2020, In press.
4. Royal College of Physicians. National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. London: RCP, 2017.
5. Jarvis S, Kovacs C, Briggs J, et al. Aggregate National Early Warning Score (NEWS) values are more important than high scores for a single vital signs parameter for discriminating the risk of adverse outcomes. Resuscitation 2015, Volume 87, 75 – 80.
Both in the context of suspected acute myocardial infarction(AMI)(1) and in the context of its close mimic, suspected pulmonary embolism(PE)(2) there is an appreciable risk of overdiagnosis even when clinicians rely on typicality of AMI symptoms(1) or typicality of PE symptoms the latter as portrayed in clinical decision rules(2). Furthermore, both AMI and PE may have, in common, some atypical features such as atypical retrosternal pain(3)(4), which may sometimes be associated with raised serum troponin(4), and ST segment elevation in the absence of coronary artery occlusion, a feature documented both in Type 2 AMI(5) and also in PE(6). The differential diagnosis of atypical retrosternal pain also includes atypical thoracic aortic dissection(TAD) where the atypical feature may be the absence of back pain in a patient presenting with retrosternal pain.(7). In view of these considerations(3)(4)(5)(6)(7) the time is long overdue for point of care transthoracic echocardiography(TTE) to be incorporated into the IMPACT protocol to facilitate the distinction between AMI, PE, and TAD. TTE would identify stigmata of PE such as right ventricular dilatation, elevated pulmonary artery systolic pressure(8), or even pulmonary emboli in transit through the cardiac chambers . Furthermore, when appropriately focused, TTE can identify "red flags" for TAD such as direct signs of TAD(for example presence of an intimal flap separating two aortic lumens), thoracic aortic d...
Both in the context of suspected acute myocardial infarction(AMI)(1) and in the context of its close mimic, suspected pulmonary embolism(PE)(2) there is an appreciable risk of overdiagnosis even when clinicians rely on typicality of AMI symptoms(1) or typicality of PE symptoms the latter as portrayed in clinical decision rules(2). Furthermore, both AMI and PE may have, in common, some atypical features such as atypical retrosternal pain(3)(4), which may sometimes be associated with raised serum troponin(4), and ST segment elevation in the absence of coronary artery occlusion, a feature documented both in Type 2 AMI(5) and also in PE(6). The differential diagnosis of atypical retrosternal pain also includes atypical thoracic aortic dissection(TAD) where the atypical feature may be the absence of back pain in a patient presenting with retrosternal pain.(7). In view of these considerations(3)(4)(5)(6)(7) the time is long overdue for point of care transthoracic echocardiography(TTE) to be incorporated into the IMPACT protocol to facilitate the distinction between AMI, PE, and TAD. TTE would identify stigmata of PE such as right ventricular dilatation, elevated pulmonary artery systolic pressure(8), or even pulmonary emboli in transit through the cardiac chambers . Furthermore, when appropriately focused, TTE can identify "red flags" for TAD such as direct signs of TAD(for example presence of an intimal flap separating two aortic lumens), thoracic aortic dilatation, pericardial effusion or tamponade, and aortic valve regurgitation, warranting urgent definitive aortic imaging or transfer to expert centres(9). In particular, in the latter study "integration of[focused TTE] with D-dimer provided an exceptionally safe and fairly efficient rule-out criterion for AAS(acute aortic syndrome"(9).
I have no funding and no conflict of interest
References
(1) Greenslade JH., Sieben N., Parsonage WA
Factors influencing physicians' estimates for acute cardiac events in emergency patients with suspected acute coronary syndrome
EMJ 2020;37:2-7
(2) Swan D., Hitchen S., Klok FA., Thachill J
The problem of underdiagnosis and overdiagnosis of pulmonary embolism
Thrombosis Research 2019;177:122-129
(3) Gimenez MR., Reiter M., Twerenbold R et al
Sex-specific chest pain characteristics in early diagnosis of acute myocardial infarction
JAMA Internal Medicine 2014;174:241-249
(4) Kukla P., Diugopolski R., Krupa E et al
How often pulmonary embolism mimics acute coronary syndrome?
Kardiologia Polska 2011;69:235-240
(5) Sandoval Y., Thgesen K
Myocardial infarction Type 2 and myocardial injury
Clinical Chemistry 2017;63:101-107
(6) Villablanca PA., Vlismas PP., Aleksandrovich T et al
Case report and systematic review of pulmonary embolism mimicking ST segment elevation myocardial infarction
Vascular 2019;27:90-97
(7) Amjad A., Ali A., Bashir A et al
Chest pain with raised troponin, ECG changes bu normal coronary arteries
BMJ case Reports 2014;doi:10.1136/bcr-2013-201975
(8) Yen K-H., Chang H-C
Massive pulmonary embolism with anterolateral ST segment elevation: electrocardiogram limitations and role of echocardiogram
Am J Emerg Med 2008;26:632.e1-632.e3
(9)Nazerian P., Mueller C., Vanni S et al
Integration of transthoracic focused cardiac ultrasound in the diagnostic algorithm for suspected acute aortic syndromes
Eur Heart J 2019;40:1952-1960
PS please ignore my previous Rapid Response. This one is the definitive version
I was happy to see the inclusion of two systematic reviews regarding the proper treatment and evaluation of drowning patients in the same issue; this one, pertaining to CT head investigation, and an additional one pertaining to cervical spine immobilization. While the information included is up to date and pertinent, unfortunately the nomenclature used is over 15 years out of date and no longer accepted by all major health organizations dealing with the prevention and treatment of drowning. In 2002, the World Conference on Drowning developed the uniform definition for drowning, which is "The process of experiencing respiratory impairment due to submersion or immersion in a liquid." With this work also came the recommendations to discontinue the use of modifiers such as "near", "wet", "dry", and "secondary" to describe a drowning, as these terms are inconsistent and do not fit within the wording of the uniform definition. Since its development, the medical and research communities as a whole have been fairly slow to adopt, but much progress has been made with the hard work of many drowning researchers and educators around the world.
We encourage authors, reviewers, and editors and educate themselves on the current, accepted drowning nomenclature so that we may all present a uniform front in our efforts to decrease this prominent cause of morbidity and mortality around the world. The most recent version of the BMJ Bes...
I was happy to see the inclusion of two systematic reviews regarding the proper treatment and evaluation of drowning patients in the same issue; this one, pertaining to CT head investigation, and an additional one pertaining to cervical spine immobilization. While the information included is up to date and pertinent, unfortunately the nomenclature used is over 15 years out of date and no longer accepted by all major health organizations dealing with the prevention and treatment of drowning. In 2002, the World Conference on Drowning developed the uniform definition for drowning, which is "The process of experiencing respiratory impairment due to submersion or immersion in a liquid." With this work also came the recommendations to discontinue the use of modifiers such as "near", "wet", "dry", and "secondary" to describe a drowning, as these terms are inconsistent and do not fit within the wording of the uniform definition. Since its development, the medical and research communities as a whole have been fairly slow to adopt, but much progress has been made with the hard work of many drowning researchers and educators around the world.
We encourage authors, reviewers, and editors and educate themselves on the current, accepted drowning nomenclature so that we may all present a uniform front in our efforts to decrease this prominent cause of morbidity and mortality around the world. The most recent version of the BMJ Best Practice on drowning was written by members of the International Drowning Researchers' Alliance, and includes a review of nomenclature. Additionally, readers are invited to visit https://bit.ly/2PgUgD2, which includes an evidence-based post regarding the frequent use of the out-dated term "dry drowning" in the media.
We were pleased to read the short report entitled: ‘Preparation for the next major incident: are we ready? A 12-year update’ by Mawhinney et al. (1). We were particularly interested to read the recommendations of the authors for improving knowledge of major incident protocol, as we have recently completed a Quality Improvement (QI) initiative at a central London hospital Emergency Department (ED), aiming to improve knowledge and awareness of major incident protocols.
We note that in your paper you assessed only doctors at registrar level. While we recognise the value of this approach, we adopted a slightly different methodology, by evaluating a single department but across staff groups; the importance of nurses, porters and security staff would be vital in transitioning to a major incident state.
We reviewed a trust Emergency Preparedness, Resilience and Response (EPRR) report that demonstrated, although the trust was broadly compliant with major incident guidelines, there was a suggestion training and awareness amongst staff could be improved.
We conducted a driver analysis to determine possible factors causing low levels of awareness of major incidents and methods of protocol access. This allowed us to optimise our understanding and target our interventions. Following this analysis we conducted baseline data collection and implemented two interventions: a poster campaign directing staff to both hard copies of the major incident...
We were pleased to read the short report entitled: ‘Preparation for the next major incident: are we ready? A 12-year update’ by Mawhinney et al. (1). We were particularly interested to read the recommendations of the authors for improving knowledge of major incident protocol, as we have recently completed a Quality Improvement (QI) initiative at a central London hospital Emergency Department (ED), aiming to improve knowledge and awareness of major incident protocols.
We note that in your paper you assessed only doctors at registrar level. While we recognise the value of this approach, we adopted a slightly different methodology, by evaluating a single department but across staff groups; the importance of nurses, porters and security staff would be vital in transitioning to a major incident state.
We reviewed a trust Emergency Preparedness, Resilience and Response (EPRR) report that demonstrated, although the trust was broadly compliant with major incident guidelines, there was a suggestion training and awareness amongst staff could be improved.
We conducted a driver analysis to determine possible factors causing low levels of awareness of major incidents and methods of protocol access. This allowed us to optimise our understanding and target our interventions. Following this analysis we conducted baseline data collection and implemented two interventions: a poster campaign directing staff to both hard copies of the major incident protocol as well as intranet based guidance; and a series of handover presentations.
From baseline to final collection, more staff in the ED were able to correctly define a major incident (58% to 94%); understand the role of major incident protocol (58% to 100%) as well as correctly locate the protocol quickly (63% to 100%). These interventions demonstrate how simple QI initiatives can significantly improve awareness, knowledge and understanding, for negligible cost.
As part of additional data we collected, we surveyed staff attitudes towards the importance of understanding major incident protocol as well as the number who had received formal training in major incidents. Only 67% had received formal training, and the format of this was variable. Some training was delivered at trust induction, some had attended simulation and disaster management courses.
We strongly endorse your recommendations to improve knowledge of major incident protocol, especially through the use of simulation and induction action cards as well as using virtual reality and other technology. Our cost effective interventions, and targeting of all stakeholders in the department would help to improve basic understanding of the need for and the role of the MIP, and would encourage staff to improve major incident protocol knowledge and event preparedness.
Reference: Mawhinney JA, Roscoe HW, Stannard GAJ, et al Preparation for the next major incident: are we ready? A 12-year update. Emergency Medicine Journal Published Online First: 12 August 2019
We thank Drs Gibson, Jones and Watkins for their interest in our paper and for pointing out that our statement that RSI is commonly used by paramedics may be incorrectly interpreted by readers. We agree that whilst RSI for traumatic and non-traumatic causes of coma are common in paramedic practice, it cannot be inferred that paramedic RSI is common in stroke. It would have been more accurate to say that paramedic RSI is not uncommon in stroke patients that are unconscious. In our dataset of 38,352 strokes 3,374 had an initial Glasgow Coma Scale of less than nine, of which 627 (18.6%) received RSI by our paramedics, but this was not reported in our paper. In our opinion, 18.6 % paramedic RSI in unconscious patients would qualify as common use of RSI.
Alternatively, we could have stated that the emergency use of intubation techniques such as RSI in the stroke patient is common. In our recent systematic review and meta-analysis it was demonstrated that emergency department and prehospital intubation via methods such as RSI is commonplace in strokes.1 This review shows that emergency endotracheal intubation was used in 79% of haemorrhagic, and 6% of ischemic strokes. In a sensitivity analysis, the removal of a large influential study raised the prevalence of intubation in ischaemic strokes to 25%. We argue that most of these intubations were RSI, and we can therefore conclude that RSI in the emergency setting for strokes is frequent.
We thank Drs Gibson, Jones and Watkins for their interest in our paper and for pointing out that our statement that RSI is commonly used by paramedics may be incorrectly interpreted by readers. We agree that whilst RSI for traumatic and non-traumatic causes of coma are common in paramedic practice, it cannot be inferred that paramedic RSI is common in stroke. It would have been more accurate to say that paramedic RSI is not uncommon in stroke patients that are unconscious. In our dataset of 38,352 strokes 3,374 had an initial Glasgow Coma Scale of less than nine, of which 627 (18.6%) received RSI by our paramedics, but this was not reported in our paper. In our opinion, 18.6 % paramedic RSI in unconscious patients would qualify as common use of RSI.
Alternatively, we could have stated that the emergency use of intubation techniques such as RSI in the stroke patient is common. In our recent systematic review and meta-analysis it was demonstrated that emergency department and prehospital intubation via methods such as RSI is commonplace in strokes.1 This review shows that emergency endotracheal intubation was used in 79% of haemorrhagic, and 6% of ischemic strokes. In a sensitivity analysis, the removal of a large influential study raised the prevalence of intubation in ischaemic strokes to 25%. We argue that most of these intubations were RSI, and we can therefore conclude that RSI in the emergency setting for strokes is frequent.
Ultimately we agree with Drs Gibson, Jones and Watkins in that our statement that RSI is commonly used by paramedics for stroke is not clear without qualification, but we hope they agree that RSI is indeed commonly used in unconscious stroke patients and in the emergency setting more broadly. If it is true that RSI is frequently used, and that there is a lack of high-quality evidence to support emergency intubation in stroke patients, then it is clear that a trial is needed.
Reference
1. Fouche PF, Stein C, Jennings PA, Boyle M, Bernard S, Smith K. Review article: Emergency endotracheal intubation in non-traumatic brain pathologies: A systematic review and meta-analysis. Emerg Med Australas 2019; 31(4): 533-41.
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...
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,
effectiveness, patient-centredness, timeliness, efficiency and equity are left profoundly wanting, however2,3, 14-16.
Although the authors were unable to link data for all level 1 emergency departments, the message to the CQC within this immense dataset should be loud and clear. Either the measures of quality utilised are invalid or the recommendations resulting from the rating derived are invalid. Given the increasing parliamentary scrutiny on this struggling behemoth, the author hopes that further analysis does not continue to demonstrate lack of efficacy of both assessment and implementation of change9-11.
Regulatory organisations such as CQC are becoming ever-more reliant on “intelligent data modelling”7,12,15. These programs utilise artificial intelligence and readily available datasets. It is reasonable to assume that status quo will remain when considering emergency department performance indicators, as these datapoints will continue to be generated at the click of a mouse at time of triage, treatment or discharge. Unfortunately, some hard truths must be considered by the CQC. These indicators may not be valid measures of quality, and neither may be inspection ratings. It is also possible that even if both performance indicators and inspections and ratings are valid forms of quality measurement, no relationship between the 2 in their current forms will ever exist. Lack of insight into this possibility is evident in that no piloting or testing occurred prior to the large-scale implementation of the CQC inspection program.
This article lays the foundation for addressing the dearth of evidence in performance indicators in the emergency department. I applaud the authors for shining a light on the lack of impact of Care Quality Commission inspections on emergency department performance and more importantly, for promoting the importance of inspecting the inspectors
1. 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. Emerg Med J 2019;36:326–332. doi:10.1136/emermed-2018-207941
2. Flodgren et al. Effectiveness of external inspection of compliance with standards in improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes. Cochrane Database Syst Rev 2011:CD008992.doi:10.1002/14651858.CD008992.pub2
3. Brubakk et al. A systematic review of hospital accreditation: the challenges of measuring complex intervention effects. BMC Health Serv Res 2015;15:280.doi:10.1186/s12913-015- 0933-x
4. NHS Digital. Provisional Accident and Emergency Quality Indicators - England. 2017 http://digital.nhs.uk/catalogue/PUB23839. Accessed July 19, 2019.
5. NHS Digital. Methodology for producing the A&E clinical quality indicator from provisional Hospital Episode Statistics (HES) data. 2016 https://files.digital.nhs.uk/publicationimport/pub23xxx/pub23839/prov-ae... january. Accessed July 19, 2019.
6. Care Quality Commission. How to get and re-use CQC information and data. 2016 http://www.cqc.org.uk/content/how-get-and-re-use-cqc-information-and-data. Accessed July 19, 2019.
7. Care Quality Commission. Inspection framework: NHS and independent acute hospitals. Core service: Urgent and emergency services. 2018 http://www.cqc.org.uk/sites/default/files/inspection-framework-acute-hos... emergency-services.pdf. Accessed July 19, 2019.
8. Care Quality Commission. Shaping the future. CQC’s strategy for 2016 to 2021. 2016 http://www.cqc.org.uk/sites/default/files/20160523_strategy_16- 21_strategy_final_web_01.pdf. Accessed July 19, 2019.
9. Iacobucci Gareth. CQC-style inspections don’t raise standards or improve patient safety, say RCGP members BMJ 2018; 363: k4216
10. Burton. What’s wrong with the CQC? Centre for Healthcare Reform. https://www.centreforwelfarereform.org/uploads/attachment/534/whats-wron... cqc.pdf. Accessed July 19, 2019.
11. Statement on BMA criticisms of CQC inspection regime. https://www.cqc.org.uk/news/stories/statement-bma-criticisms-cqc-inspect.... Accessed July 19, 2019.
12. Sorup et al. Evaluation of emergency department performance – a systematic review on recommended performance and quality-in-care measures. Scand J Trauma Resusc Emerg Med. 2013; 21: 62. Published online 2013 Aug 9. doi: 10.1186/1757-7241-21-62
13. Alberti G. Transforming emergency care in England. 2005. http://aace.org.uk/wp- content/uploads/2011/11/Transforming-Emergency-Care-in-England.pdf. Accessed July 19, 2019.
14. Alessandrini EA, Knapp J. Measuring quality in paediatric emergency care. Clin Ped Emerg Med. 2011;12(2):102–112. doi: 10.1016/j.cpem.2011.05.002.
15. Coleman P, Nicholl J. Consensus methods to identify a set of potential performance indicators for systems of emergency and urgent care. J Health Serv Res Policy. 2010; 15:12– 18. doi: 10.1258/jhsrp.2009.009096
16. The King’s Fund. Impact of the Care Quality Commission on provider performance: room for improvement? https://www.kingsfund.org.uk/publications/impact-cqc-provider- performance. Accessed July 19, 2019
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.
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 and CW are partly funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, North West Coast. The views expressed are those of the authors and not necessarily those of the NIHR, NHS, or Department of Health and Social Care.
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.
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.
The courage with which emergency medicine specialists are responding to COVID19 crisis is admirable. They are in a situation similar to the battlefields of first World War. It is a protracted war unlike the disasters and tsunamis that we have faced in recent times. Lord Moran in his seminal book "The Anatomy of Courage" based on his WW1 experience of treating medical emergencies had noted that battle fatigue would set in the most courageous of soldiers after 30 days of trench warfare. This led to the deployment of battalions in formations, which provided relief to those in the front lines through planned rotation. This model may be useful in developing systems of rostering which provide planned periods of relief and recuperation for medics and paramedics manning the front lines of COVID 19 crisis.
Finnikin and colleagues describe a large data set of retrospectively calculated National Early Warning Scores (NEWS) in a system that was not using or responding to NEWS. Understanding the relationship between NEWS and referral practices is an important area of research which could help shed some light on the impact of introducing NEWS into primary care.
The first important point is that only 31% (74,992/242,451) of patients who had face-to-face encounters had a full set of observations and the clinical characteristics of the 69% excluded from the study are unknown. In our experience, GPs tend to perform a full set of observations on patients who appear more unwell so it is possible that the population studied may not be representative.
Finnikin and colleagues found that only 6.9% of patients referred to hospital had a NEWS≥5 and 69% with a NEWS ≥5 were not referred. There is emerging evidence that NEWS calculated by GPs at referral correlates with mortality (data from West of England accepted for publication) so the fact that it did not correlate with referral is of concern. Scott et al in the West of England (1, 2) and Inada Kim et al in Wessex (unpublished data) have demonstrated that the higher the NEWS on referral or arrival, the more likely the patient is to be admitted and the more likely the patient is to die.
The lack of linkage to any outcomes is a major weakness of this work. While an increase in admissions of 16.2% is not ideal in an alr...
Show MoreBoth in the context of suspected acute myocardial infarction(AMI)(1) and in the context of its close mimic, suspected pulmonary embolism(PE)(2) there is an appreciable risk of overdiagnosis even when clinicians rely on typicality of AMI symptoms(1) or typicality of PE symptoms the latter as portrayed in clinical decision rules(2). Furthermore, both AMI and PE may have, in common, some atypical features such as atypical retrosternal pain(3)(4), which may sometimes be associated with raised serum troponin(4), and ST segment elevation in the absence of coronary artery occlusion, a feature documented both in Type 2 AMI(5) and also in PE(6). The differential diagnosis of atypical retrosternal pain also includes atypical thoracic aortic dissection(TAD) where the atypical feature may be the absence of back pain in a patient presenting with retrosternal pain.(7). In view of these considerations(3)(4)(5)(6)(7) the time is long overdue for point of care transthoracic echocardiography(TTE) to be incorporated into the IMPACT protocol to facilitate the distinction between AMI, PE, and TAD. TTE would identify stigmata of PE such as right ventricular dilatation, elevated pulmonary artery systolic pressure(8), or even pulmonary emboli in transit through the cardiac chambers . Furthermore, when appropriately focused, TTE can identify "red flags" for TAD such as direct signs of TAD(for example presence of an intimal flap separating two aortic lumens), thoracic aortic d...
Show MoreI was happy to see the inclusion of two systematic reviews regarding the proper treatment and evaluation of drowning patients in the same issue; this one, pertaining to CT head investigation, and an additional one pertaining to cervical spine immobilization. While the information included is up to date and pertinent, unfortunately the nomenclature used is over 15 years out of date and no longer accepted by all major health organizations dealing with the prevention and treatment of drowning. In 2002, the World Conference on Drowning developed the uniform definition for drowning, which is "The process of experiencing respiratory impairment due to submersion or immersion in a liquid." With this work also came the recommendations to discontinue the use of modifiers such as "near", "wet", "dry", and "secondary" to describe a drowning, as these terms are inconsistent and do not fit within the wording of the uniform definition. Since its development, the medical and research communities as a whole have been fairly slow to adopt, but much progress has been made with the hard work of many drowning researchers and educators around the world.
We encourage authors, reviewers, and editors and educate themselves on the current, accepted drowning nomenclature so that we may all present a uniform front in our efforts to decrease this prominent cause of morbidity and mortality around the world. The most recent version of the BMJ Bes...
Show MoreDear Editor,
We were pleased to read the short report entitled: ‘Preparation for the next major incident: are we ready? A 12-year update’ by Mawhinney et al. (1). We were particularly interested to read the recommendations of the authors for improving knowledge of major incident protocol, as we have recently completed a Quality Improvement (QI) initiative at a central London hospital Emergency Department (ED), aiming to improve knowledge and awareness of major incident protocols.
We note that in your paper you assessed only doctors at registrar level. While we recognise the value of this approach, we adopted a slightly different methodology, by evaluating a single department but across staff groups; the importance of nurses, porters and security staff would be vital in transitioning to a major incident state.
We reviewed a trust Emergency Preparedness, Resilience and Response (EPRR) report that demonstrated, although the trust was broadly compliant with major incident guidelines, there was a suggestion training and awareness amongst staff could be improved.
We conducted a driver analysis to determine possible factors causing low levels of awareness of major incidents and methods of protocol access. This allowed us to optimise our understanding and target our interventions. Following this analysis we conducted baseline data collection and implemented two interventions: a poster campaign directing staff to both hard copies of the major incident...
Show MoreWe thank Drs Gibson, Jones and Watkins for their interest in our paper and for pointing out that our statement that RSI is commonly used by paramedics may be incorrectly interpreted by readers. We agree that whilst RSI for traumatic and non-traumatic causes of coma are common in paramedic practice, it cannot be inferred that paramedic RSI is common in stroke. It would have been more accurate to say that paramedic RSI is not uncommon in stroke patients that are unconscious. In our dataset of 38,352 strokes 3,374 had an initial Glasgow Coma Scale of less than nine, of which 627 (18.6%) received RSI by our paramedics, but this was not reported in our paper. In our opinion, 18.6 % paramedic RSI in unconscious patients would qualify as common use of RSI.
Alternatively, we could have stated that the emergency use of intubation techniques such as RSI in the stroke patient is common. In our recent systematic review and meta-analysis it was demonstrated that emergency department and prehospital intubation via methods such as RSI is commonplace in strokes.1 This review shows that emergency endotracheal intubation was used in 79% of haemorrhagic, and 6% of ischemic strokes. In a sensitivity analysis, the removal of a large influential study raised the prevalence of intubation in ischaemic strokes to 25%. We argue that most of these intubations were RSI, and we can therefore conclude that RSI in the emergency setting for strokes is frequent.
Ultimately we agree with...
Show MoreTo the editor,
Show MoreI 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...
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...
Show MoreDear 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.
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.
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