The Intergovernmental Panel on Climate Change's(IPCC) fourth
assessment report unequivocally describes the high risk we face with
unmitigated climate change of adverse impacts on human health.1
Gudjondottir et al's2 observational study on the surge in cardiac
presentations amongst Icelandic females following the catastrophic 2008
financial collapse adds another compounding element to the assessment of
health impacts l...
The Intergovernmental Panel on Climate Change's(IPCC) fourth
assessment report unequivocally describes the high risk we face with
unmitigated climate change of adverse impacts on human health.1
Gudjondottir et al's2 observational study on the surge in cardiac
presentations amongst Icelandic females following the catastrophic 2008
financial collapse adds another compounding element to the assessment of
health impacts likely to be seen in coming decades. The surge in
attendance to the cardiac Emergency Department(ED) for ischaemic heart
disease(IHD) in the week following the economic meltdown was 80% above
normal for females. This trend could have serious consequences if extended
from this study to the broader public health implications of climate
change.
We know that climate change health impacts will exacerbate and
magnify existing inequities and create large surges on existing healthcare
resources as a result of extreme weather events and changes in weather
patterns. 3 The specificity of increased female presentations for
cardiac issues hints at an underlying vulnerability, and it is the health
of vulnerable groups who will be most severely impacted by climate change.
The economic impacts of a warming world are potentially catastrophic: with
drought, floods and fires wreaking havoc on food production.
Gudjonsdottir et al have shown a potential for flow on effects from
economic collapse that further influence societal levels of good health.
Economic growth and development are tied to good health and using the
Hyogo Framework for Action's(HFA)4 principles of disaster risk
reduction(DRR), this information gives further imperative for mitigation
action on climate change to reduce the public health disaster of a
'business as usual' scenario. Adaptation strategies will need to build
resilience and find innovative ways of resource allocation, to allow for
unforeseen vulnerabilities such as those demonstrated by Gudjonsdottir et
al.
1. Parry, ML, Canziani OF, Palutikof JP, van der Linden PJ &
Hanson CE, Contribution of Working Group II to the Fourth Assessment
Report of the Intergovernmental Panel on Climate Change 2007, Available
at: http://www.ipcc.ch/publications_and_data/ar4/wg2/en/contents.html
2. Gudjonsdottir GR, Kristjinsson M, Olafsson O et al, Immediate
surge in female visits to the cardiac emergency department following the
economic collapse in Iceland: an observational study, Emerg Med J 2012 29:
694-698
3. Parry et al
4. UNISDR, 2005, Hyogo framework for Action 2005-2015: Building the
resilience of the nations and communities to disasters, Available at:
www.unisdr.org/wcdr/intergover/official-docs/Hyogo- framework- action-
english .pdf
syr/en/spm.html
am happy to have gone through this study report.
i am a clinical officer working in a public hospital and when i was
reading through the report, i found a lot of true reflections of the
situation at the ground. its true that ED services in our country are not
well established.
though their is positive developments towards this direction. the
government in conjunction with a donor have put up emergency (casualty)
units in...
am happy to have gone through this study report.
i am a clinical officer working in a public hospital and when i was
reading through the report, i found a lot of true reflections of the
situation at the ground. its true that ED services in our country are not
well established.
though their is positive developments towards this direction. the
government in conjunction with a donor have put up emergency (casualty)
units in several district hospitals and others are still in progress.
as we celebrate this positive development as health workers, we are a were
of the skill gap in ED care. personally i visited Torbay hospital in
Britain May 2012 to have a view of ED services in the UK and i guttered
lots of differences between UK and Kenyan ED management systems.The trip
preceded a training on Primary Trauma Care by a team of trainers from
South African the model of the training was appropriate and i wish that
its adopted nationally.
the report is commendable.
thanks a lot.
George.
I applaud "It's good to talk--but the talk must be good"
by Geoffrey Hughes
I have been an emergency physician for over twenty years and have the
pleasure of working at the VA Healthcare Center in Manhattan. The patients
that come to our Emergency Department are brave men and women who served
in the military with much sacrifice. There is no doubt they truly
appreciate quality healthcare. I feel, however, they are even more...
I applaud "It's good to talk--but the talk must be good"
by Geoffrey Hughes
I have been an emergency physician for over twenty years and have the
pleasure of working at the VA Healthcare Center in Manhattan. The patients
that come to our Emergency Department are brave men and women who served
in the military with much sacrifice. There is no doubt they truly
appreciate quality healthcare. I feel, however, they are even more
gratified when the physicians delivering that quality healthcare speak
respectfully with clarity and candor. When patients and family members are
addressed with dignity, compassion and clarity in a respectful fashion,
they are very appreciative. Physicians who deliver excellent healthcare
are great, but if they can communicate clearly and respectfully with
patients and family members they are rare and truly outstanding.
We read with interest the systematic review by Stippler et al. which
assesses efficacy of routine follow-up computed tomography (CT) for the
management of mild traumatic brain injury (mTBI). The authors should be
commended for undertaking this exhaustive review; however, the findings
are limited due to failure to adhere to the contemporary systematic
review methodology (Higgins 2011). Specifically, the findings of the...
We read with interest the systematic review by Stippler et al. which
assesses efficacy of routine follow-up computed tomography (CT) for the
management of mild traumatic brain injury (mTBI). The authors should be
commended for undertaking this exhaustive review; however, the findings
are limited due to failure to adhere to the contemporary systematic
review methodology (Higgins 2011). Specifically, the findings of the
systematic review are weakened by the limited search strategy, vague
inclusion criteria, and incorrect methods for pooling of data (Higgins
2011).
Stippler et al. limited their search strategy to English only
abstracts from the last decade and relied on references from a previous
systematic review conducted on a broader TBI population (Wang 2006).
Cochrane guidelines recommend against setting time and language limits on
the search strategy, as this may hinder the primary aim of a systematic
review which is to identify all studies on a given topic. In terms of
unclear inclusion and exclusion criteria, the reviewers did not specify a
priori which study designs (e.g. cohort versus case series etc.) were
eligible for inclusion in the review. Very often cohort studies were
incorrectly labeled as case-series and pooled jointly (Dekkers 2012). This
goes against the precept of pooling studies with similar design,
population, intervention, control (if applicable) and outcomes in analysis
(Higgins 2011). Lastly, a significant error relates to incorrect method of
pooling of all observations (see table 1 and results). The results are
pooled in a way that it wrongly gives the impression of one large study
where all events and total number of subjects from each individual study
are treated as participants in a single mega study. This violates another
key principle of not mixing patients across studies when undertaking a
meta-analysis. Only aggregate data from each study should be pooled
according to a weighted method whereby patients on one study are not mixed
with patients from another study.1 The issue of routine follow-up head CT
after mTBI is an extremely important topic as it not only affects patient
health and safety, but is also a factor in ever increasing health care
costs. Again we applaud Stippler et al. for undertaking a review on such a
relevant area; however, the limitations discussed here emphasize the
importance of conducting a systematic review using appropriate methods.
REFERENCES:
Higgins JPT GS, ed. Cochrane Handbook for Systematic Reviews of
Interventions. Version 5.1.0 ed: The Cochrane Collaboration; 2011.
Wang MC, Linnau KF, Tirschwell DL, Hollingworth W. Utility of repeat
head computed tomography after blunt head trauma: a systematic review. J
Trauma. Jul 2006;61(1):226-233.
Dekkers OM, Egger M, Altman DG, Vandenbroucke JP. Distinguishing case
series from cohort studies. Ann Intern Med. Jan 3 2012;156(1 Pt 1):37-40.
We congratulate Dr Newstead and co-workers with the results they
achieved introducing the pain passport in the emergency department. After
introduction of the pain passport 69% of the children in pain in the
emergency department received analgesia within 20 minutes and in 96% of
children a pain score was recorded.
However, the original concept of the pain passport was perhaps
misunderstood.
The pain passport i...
We congratulate Dr Newstead and co-workers with the results they
achieved introducing the pain passport in the emergency department. After
introduction of the pain passport 69% of the children in pain in the
emergency department received analgesia within 20 minutes and in 96% of
children a pain score was recorded.
However, the original concept of the pain passport was perhaps
misunderstood.
The pain passport is originally based on the idea that children,
especially children with serious long-term or recurrent diseases, develop
their own coping strategies, helping them to cope with pain and distress,
during medical treatment.
In daily practice, due to stress and hectic circumstances, the child
often does not get the opportunity to express their coping strategy. To
ensure that all staff is well informed of the child's coping strategy,
children are encouraged by the hospital play specialist (or child life
specialist) to write important issues down in their passport.(1)
Caregivers are encouraged to read the pain passport before they perform
any distressing medical interventions.
Lisa, a 14-year-old girl, has a fear of injections. During her long
stay in the hospital she has learned that diversion helps her most. In her
pain passport the caregivers can read that she wants to search for animals
in a special book, at the moment of her injection.
We agree with the authors that raising the awareness of pain in
children is an important step in improving pain management and we are
delighted that the pain passport developed in the Wilhelmina Children's
Hospital played a roll in this.
Reference:
1. Pain passport, providing patient directed care by respecting the
personal coping strategy of a child.
Aline Kalisvaart, oral presentation during the European Working Group on
Psychosocial Aspects of children with chronic renal failure (EWOPA), june
2009, Belgium.
I read with interest the recent articles discussing the use of early
warning scores (EWS) in the Emergency Department (ED).[1, 2] Whilst I
agree with the observation that their current use in the ED is flawed, I
would suggest there is perhaps a dangerous overdesire to seek out a
'system to recognise the sick patient'. Arguably this 'system' should be
already in place - that is the nursing and medical t...
I read with interest the recent articles discussing the use of early
warning scores (EWS) in the Emergency Department (ED).[1, 2] Whilst I
agree with the observation that their current use in the ED is flawed, I
would suggest there is perhaps a dangerous overdesire to seek out a
'system to recognise the sick patient'. Arguably this 'system' should be
already in place - that is the nursing and medical team.
Roland and Coats are right to point out that patients who deteriorate
in hospital often have 'measurable physiological changes hours before
recognition by nursing and medical staff'.[3] Observations were therefore
either not done, or done but not recognised as potentially signifying
serious deterioration. The root cause of this problem is therefore either
a workload or training issue.
Whilst I agree EWS offer a partial solution, I would suggest they
obscure a much wider, sinister and deeply fundamental issue permeating
through the NHS, namely deficient training and an overburdened workforce
preventing basic patient needs from being accomplished adequately.
I would go further and suggest this 'nursing by numbers' approach we
have been witness to over the past decade reinforces this 'knowledge gap',
making it almost acceptable for team members to maintain an over
dependence on yet to be validated systems, without recourse to addressing
the real training issues - the ability to recognise a sick patient based
on a clinical interpretation of regularly measured
physiological parameters.
Call me a traditionalist but I would rather my nursing colleagues
were able to perform observations when required and had the knowledge of
how to interpret them, rather than the current attitude of workforce
deskilling and resultant natural progression to "the patient must be ill
as 'their EWS' says so".
James Moore
Emergency Nurse Practitioner
Emergency Department
Royal Devon and Exeter NHS (Foundation) Trust
Exeter
References
1) Roland D, Coats T. An early warning? Universal risk scoring in
emergency medicine. EMJ 2011;28:263
2) Griffiths J, Kidney E. Current use of early warning scores in UK
emergency departments. EMJ Published online 1 October 2011.
doi:10.1136/emermed-2011-200508
3) Schein R. Hazday N, Pena N, et al. Clinical antecedents to in-
hospital cardiopulmonary arrest. Chest 1990; 98:1388-92.
Woodcock et al highlight that changing the four hour standard from
98% to 95% resulted in processes adjusting accordingly. But they fail to
address the key issue of whether it benefits patients. Their conclusion
that this shows that more patients are waiting for care is imprecise and
possibly wrong. The four hour standard relates to the total time spent in
the emergency department until discharge or admission to a ward....
Woodcock et al highlight that changing the four hour standard from
98% to 95% resulted in processes adjusting accordingly. But they fail to
address the key issue of whether it benefits patients. Their conclusion
that this shows that more patients are waiting for care is imprecise and
possibly wrong. The four hour standard relates to the total time spent in
the emergency department until discharge or admission to a ward. Care
starts much earlier, figures for January 2012 show that the median wait
for ambulance cases to be assessed by a health care professional (triage)
was 3 minutes (95% seen in 47 minutes) and the median time for all cases
to be seen by a decision making clinician is 49 minutes (95% in 85
minutes) [1]. This has only been collected nationally since April 2011 and
so we cannot assess change over the last few years.
The 240 minute total time in England stills compares favourably to
other countries. The four hour rule in Western Australia requires 90 per
cent of patients leave the ED within four hours [2]. New Zealand has a 95%
admitted, discharges or transferred within six hours target[3]. In Alberta
it is 75% of discharge patients in four hours and 60 per cent of admitted
patients leaving in eight hours[4].
The change to 95% was introduced following requests from professional
bodies and was openly welcomed by the RCN [5] . It was reduced because
clinicians believed that the change in clinical emergency medicine
practice meant more people would benefit clinically from spending longer
in the emergency department. Over the last ten years more investigation
and more treatment has been undertaken in the emergency department before
admission. More patients are now discharged home after more complex
investigations. This takes longer but benefits patients.
This study looks at the total time standard in isolation. Use of the
single target was subject to much criticism and so it is unfortunate that
this article persists in analysing one measure in isolation. The reason
for establishing the clinical quality indicators was to "provide a broader
picture" [6] and encourage a "more sophisticated debate". To achieve this
requires the whole set of indicators to be viewed together. Using three
measures of time allows the flow of patients through the emergency
department to be seen. Measuring experience as well as re-attendance rate
and left without being seen rate helps to ensure that care is of high
quality as well as timely. Later this year I will be publishing the first
annual report of the clinical quality indicators for Accident and
Emergency Departments in England and will illustrate why we need the
balance approach of analysing all the indicators as one set.
Professor Matthew Cooke
National Clinical Director Urgent and Emergency Care, Dept of Health
1. Accident and Emergency Hospital Episode Statistics (HES). NHS
Information Centre. London (accessed 6 June 2012)
http://www.ic.nhs.uk/statistics-and-data-collections/hospital-
care/accident-and-emergency-hospital-episode-statistics-hes
2. Emergency Access Reform. Government of Western Australia. Perth
(accessed 6 June 2012)
http://www.health.wa.gov.au/emergencyaccessreform/home/
3. Shorter Stays in Emergency Departments health target. Minsitry of
Health. Aukland. (accessed 6 June 2012) http://www.health.govt.nz/our-
work/hospitals-and-specialist-care/emergency-departments/shorter-stays-
emergency-departments-health-target
4. Action on Emergency Department Lengths of Stay. Alberta Health
Services. Alberta . (accessed 6 June 2012)
http://www.albertahealthservices.ca/3166.asp
5. Reducing four-hour target a welcome move. Royal College of Nuring.
London. (accessed 6 June 2012)
http://www.rcn.org.uk/newsevents/press_releases/uk/reducing_four-
hour_target_a_welcome_move,_rcn_says
6. A&E Clinical Quality Indicators. Department of Health. London
2010.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_123055.pdf
I was absolutely transfixed by this paper and felt my jaw gently
descending in a southerly direction as I read ever onward. So, in
conclusion, EM Consultants are better than junior doctors at making
decisions in a timely manner and admitting patients unnecessarily. That
conclusion is hardly earth shattering.
I note that at the time of the study, SHO's were working the weekends
without sen...
I was absolutely transfixed by this paper and felt my jaw gently
descending in a southerly direction as I read ever onward. So, in
conclusion, EM Consultants are better than junior doctors at making
decisions in a timely manner and admitting patients unnecessarily. That
conclusion is hardly earth shattering.
I note that at the time of the study, SHO's were working the weekends
without senior cover, whilst the senior tier took up the Monday, Tuesday
and Wednesday slots. GMC and Deanery guidelines have made it abundantly
clear to Trusts what they feel about a lack of senior cover at night, and
I am guessing that Wrexham can no longer use a system where SHO's are
alone on any night of the week!
The authors make a case for Consultant expansion in order to
facilitate 24/7 working and this, in and of itself, seems not too
unreasonable. I would suggest that in the current climate where we cannot
attract sufficient numbers to fill training posts (never mind SAS grades)
that this could be counter-productive. How can we attract people to our
speciality when all we can offer is 20+ years of night time working,
evening working, high stress and low pay? What do today's Medical Students
and Foundation Doctors feel about a career in Emergency Medicine? We take
60 F2/GPVTS trainees a year through our department and feel fortunate if
even 1 young doctor is attracted to our speciality. Haven spoken to
colleagues throughout our region, this is not an unusual statistic.
Trusts find it very difficult to fill existing EM Consultant
vacancies. 2 of my fellow EM trainees left for General Practice very late
on in their training as they felt that their quality of life would be far
superior outside the ED. (They're not wrong!)
I feel that we need to attract large numbers of quality EM trainees
to our speciality before even beginning to think about Consultant
expansion. Who wants the hard slog of night time service provision, with
the prospect of little reward? Many of my colleagues are either well over
50 or young part time mothers and will not work at night. Future EM
Consultants will consists of a high proportion of part time working
mothers who may not be in a position to work at night on a regular basis.
I really think that we as a speciality need to think this though from the
bottom up.
The recently published manuscript, Suicide attempts and completions
in the emergency department in Veterans Affairs Hospitals, makes several
recommendations to improve quality of care concerning emergency department
patients with suicidal ideation. These recommendations are excellent and
certainly will guard against untoward outcomes among VA patients who might
attempt suicide while in the emergency department.
The recently published manuscript, Suicide attempts and completions
in the emergency department in Veterans Affairs Hospitals, makes several
recommendations to improve quality of care concerning emergency department
patients with suicidal ideation. These recommendations are excellent and
certainly will guard against untoward outcomes among VA patients who might
attempt suicide while in the emergency department.
At the VA Emergency Department New York Harbor Healthcare System we
have also implemented a team approach to safeguard patients' safety. This
approach consists of making "rounds" during the day when the emergency
department is busy with a team consisting of Charge Nurse, all staff
nurses, all physicians (in-training and attending physicians), nurse
technicians and social workers. During this time, the entire team reviews
each emergency department patient regarding presenting complaint, work-up
in progress, most likely disposition and safety concerns.
Thus, all patients are "introduced" to the entire team and issues
such as concerns for fall, suicide risks or possiblity of future social
service needs are reviewed. This team approach, I believe, will improve
outcomes for medical as well as psychiatric patients. If there are
emergency department patients with suicidal ideation, for example, not
only do they have "one to one" observation, but the entire team is aware
of this risk so that all healthcare providers cooperate to ensure the
safety of such patients.
I believe our innovative team approach for emergency department
patients will reduce the risk to patients with suicidal ideation. This
approach should be considered along with those recommended in "Suicide
attempts and completions in the emergency department in Veterans Affairs
Hospitals", to improve patient safety.
Nancy Lutwak, M.D.
Dept. of Emergency Medicine
VA New York Harbor Healthcare System,
NYU School of Medicine
I enjoyed reading the paper by Markus S?ren Roessler and colleagues,
but wondered how a claim for superiority could be made on the basis of a
pilot study?
The Intergovernmental Panel on Climate Change's(IPCC) fourth assessment report unequivocally describes the high risk we face with unmitigated climate change of adverse impacts on human health.1 Gudjondottir et al's2 observational study on the surge in cardiac presentations amongst Icelandic females following the catastrophic 2008 financial collapse adds another compounding element to the assessment of health impacts l...
am happy to have gone through this study report. i am a clinical officer working in a public hospital and when i was reading through the report, i found a lot of true reflections of the situation at the ground. its true that ED services in our country are not well established. though their is positive developments towards this direction. the government in conjunction with a donor have put up emergency (casualty) units in...
I applaud "It's good to talk--but the talk must be good" by Geoffrey Hughes I have been an emergency physician for over twenty years and have the pleasure of working at the VA Healthcare Center in Manhattan. The patients that come to our Emergency Department are brave men and women who served in the military with much sacrifice. There is no doubt they truly appreciate quality healthcare. I feel, however, they are even more...
We read with interest the systematic review by Stippler et al. which assesses efficacy of routine follow-up computed tomography (CT) for the management of mild traumatic brain injury (mTBI). The authors should be commended for undertaking this exhaustive review; however, the findings are limited due to failure to adhere to the contemporary systematic review methodology (Higgins 2011). Specifically, the findings of the...
We congratulate Dr Newstead and co-workers with the results they achieved introducing the pain passport in the emergency department. After introduction of the pain passport 69% of the children in pain in the emergency department received analgesia within 20 minutes and in 96% of children a pain score was recorded.
However, the original concept of the pain passport was perhaps misunderstood. The pain passport i...
Dear Sir
I read with interest the recent articles discussing the use of early warning scores (EWS) in the Emergency Department (ED).[1, 2] Whilst I agree with the observation that their current use in the ED is flawed, I would suggest there is perhaps a dangerous overdesire to seek out a 'system to recognise the sick patient'. Arguably this 'system' should be already in place - that is the nursing and medical t...
Woodcock et al highlight that changing the four hour standard from 98% to 95% resulted in processes adjusting accordingly. But they fail to address the key issue of whether it benefits patients. Their conclusion that this shows that more patients are waiting for care is imprecise and possibly wrong. The four hour standard relates to the total time spent in the emergency department until discharge or admission to a ward....
Dear Editor,
I was absolutely transfixed by this paper and felt my jaw gently descending in a southerly direction as I read ever onward. So, in conclusion, EM Consultants are better than junior doctors at making decisions in a timely manner and admitting patients unnecessarily. That conclusion is hardly earth shattering.
I note that at the time of the study, SHO's were working the weekends without sen...
The recently published manuscript, Suicide attempts and completions in the emergency department in Veterans Affairs Hospitals, makes several recommendations to improve quality of care concerning emergency department patients with suicidal ideation. These recommendations are excellent and certainly will guard against untoward outcomes among VA patients who might attempt suicide while in the emergency department.
A...
I enjoyed reading the paper by Markus S?ren Roessler and colleagues, but wondered how a claim for superiority could be made on the basis of a pilot study?
Conflict of Interest:
None declared
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