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We have read with great interest the review of Ramlakhan et al.
(2016)1 on the effectiveness of co-locating emergency departments (ED) and
primary care centres and the findings of the authors that the evidence is
inconclusive. Yet, we are confident that there are more hints and clues in
the available evidence for policy guidance than was done in the paper by
Ramlakhan et al. (2016). We will illustrate this with a recent po...
We have read with great interest the review of Ramlakhan et al.
(2016)1 on the effectiveness of co-locating emergency departments (ED) and
primary care centres and the findings of the authors that the evidence is
inconclusive. Yet, we are confident that there are more hints and clues in
the available evidence for policy guidance than was done in the paper by
Ramlakhan et al. (2016). We will illustrate this with a recent policy
analysis carried out in Belgium.2 As Burke (2016)3 states in his editorial
it is key to determine the goals of your policy intervention (e.g.
improved access; improved flow; reduced costs; improved patient
satisfaction) and to monitor the implementation of new models. That is
exactly what we have proposed by recommending a 'proof of concept
evaluation' for 24/7 GP posts that are co-located with the ED (with one
entrance and a joint triage area) in order to substitute ED care by
primary care. Indeed, substituting more expensive ED resources by primary
care resources seems a legitimate policy goal.
Belgium has a very high self-referral rate (71%) and a large share of ED
contacts are ambulatory contacts (77%). Furthermore, estimates of
inappropriate ED contacts (40-56%) are higher than the internationally
reported figures of 20-40%.4 As in other countries there is an ever
increasing use of EDs which is in Belgium mainly observed for ambulatory
and self-referred ED contacts. In addition, previous policy measures such
as large investments in out-of-hours GP posts were unsuccessful in
stopping this increasing trend. Most of these out-of-hours GP posts were
not located at hospital sites. In the rare occasions where a GP post was
co-located with an ED they had separate entrances and triage zones not
resulting in substitution.5
Why did our policy recommendation to install GP posts on ED-sites deviate
from the inconclusive findings in the Ramlakhan et al. (2016) review? Our
review of the literature showed that 'design elements' are essential for
successful substitution of ED care by primary care. We believe that these
design elements are insufficiently analysed in the Ramlakhan et al. (2016)
study. In their review several divergent models of co-location were
assessed simultaneously (e.g. nurse-led walk-in clinics instead of GP-lead
urgent care centres; models with separate entrances and triage areas for
the primary care centre and the ED instead of one central entrance and
joint triage area; or even models without a triage function). When
analysing these studies more in-depth, it is clear that these design
elements are making the difference in substituting ED by primary care.
Indeed, 'the devil is in the details'. A difference in prescriptions of
medical imaging and laboratory tests can, for instance, be observed when
the initial triage process was carried out by trained nurses while this
was not the case when triage was done by a receptionist. Moreover, three
recent studies which were not included (van Gils-van Rooij (2015)6 for the
Netherlands; Cowling et al. (2016)7 for England; Eichler et al. (2014)8
for Switzerland) showed that: a co-location of GP posts with one entrance
and joint triage area is effective in reducing the number of self-referred
ED contacts; the largest portion of contacts triaged towards the GP does
only require care from the GP; and that GPs prescribe less medical imaging
and lab tests compared to emergency physicians.
We also acknowledge that the literature is not straightforward. Indeed,
several reviews9 10 illustrated that an expansion of the available
services might unmask latent demand and will increase the overall burden
on the emergency care system even more. However, it cannot be concluded
from the available studies that this increase in activity is caused by
overuse (e.g. shift from regular GP contacts towards urgent care centres)
nor by underuse. To account for these and other potential unintended
effects we recommend a 'proof of concept' evaluation where these (un-
)intended are carefully monitored.
Reference List
1. Ramlakhan S, Mason S, O'Keeffe C, et al. Primary care services
located with EDs: a review of effectiveness. Emerg Med J 2016.
2. Van den Heede K, Dubois C, Devriese S, et al. Organisation and
payment of emergency care services in Belgium: current situation and
options for reform. Health Services Research (HSR). Brussels: Belgian
Health Care Knowledge Centre (KCE), 2016.
3. Burke D. Primary care services located with EDs: a review of
effectiveness. Emerg Med J 2016.
4. Carret ML, Fassa AC, Domingues MR. Inappropriate use of emergency
services: a systematic review of prevalence and associated factors. Cad
Saude Publica 2009;25(1):7-28.
5. Philips H, Remmen R, Van Royen P, et al. What's the effect of the
implementation of general practitioner cooperatives on caseload?
Prospective intervention study on primary and secondary care. BMC health
services research 2010;10:222.
6. van Gils-van Rooij ES, Yzermans CJ, Broekman SM, et al. Out-of-
Hours Care Collaboration between General Practitioners and Hospital
Emergency Departments in the Netherlands. J Am Board Fam Med
2015;28(6):807-15.
7. Cowling TE, Ramzan F, Ladbrooke T, et al. Referral outcomes of
attendances at general practitioner led urgent care centres in London,
England: retrospective analysis of hospital administrative data. Emerg Med
J 2016;33(3):200-7.
8. Eichler K, Hess S, Chmiel C, et al. Sustained health-economic
effects after reorganisation of a Swiss hospital emergency centre: a cost
comparison study. Emerg Med J 2014;31(10):818-23.
9. Ismail SA, Gibbons DC, Gnani S. Reducing inappropriate accident
and emergency department attendances: A systematic review of primary care
service interventions. British Journal of General Practice
2013;63(617):e813-e20.
10. Morgan SR, Chang AM, Alqatari M, et al. Non-emergency department
interventions to reduce ED utilization: a systematic review. Academic
Emergency Medicine 2013;20(10):969-85.
We read with interest the paper by Ramlakhan et al (10.1136/emermed-
2015-204900) on the effectiveness of primary care services located in EDs.
We have just completed a test cycle week of a GP led model for managing
lower acuity patients who present to the Clinical Decisions Unit (CDU) at
the Glenfield Hospital, Leicester; however, we reached different
conclusions. The CDU is a cardiorespiratory unit that receives mixed...
We read with interest the paper by Ramlakhan et al (10.1136/emermed-
2015-204900) on the effectiveness of primary care services located in EDs.
We have just completed a test cycle week of a GP led model for managing
lower acuity patients who present to the Clinical Decisions Unit (CDU) at
the Glenfield Hospital, Leicester; however, we reached different
conclusions. The CDU is a cardiorespiratory unit that receives mixed
acuity urgent patients 24 hours a day from a range of sources (999
ambulance, GP referrals and transfers from both the local ED department
and Urgent Care Centre located on the same site two miles away), but not
self-referrals. The specialist teams are unable to rapidly manage and
discharge low acuity patients because the hospital processes and IT
systems were not designed for this purpose, resulting in overcrowding and
inefficiency. A GP/specialist nurse 'fast track' area was created to
rapidly diagnose (with access to chest x-ray and bloods), and discharge
safely, all patients triaged by experienced nurses at the 'front door' as
potentially fit for same day discharge using the primary care IT system
(SystmOne). 67 patients comprising approximately 30-40% of total
attendances were seen and 88% were discharged (mean of 116 minutes
compared with up to 6 hours at peak periods of activity). No adverse
events or seven day readmissions have been reported. Both patient and
staff satisfaction was high. The overall proportion of patients who left
the department in less than 6 hours (throughput/flow) increased by around
10% easing pressure on specialists who could then focus on the sicker
cohort of patients. GPs handle low acuity problems faster because that
fits in with their training and skill set (they appraise rapidly and
decide). It is a matter of 'right patient in front of the right
clinician'. We are planning a further eight week pilot to consider the
cost effectiveness of our model, greater integration with the local urgent
care system and the best clinician to triage on arrival.
This comparison of non-invasive haemodynamic devices, although
valuable, demonstrates some methodological aspects of the Bland-Altman
method that should be considered to ensure the accuracy of any proposed
conclusions.
The statistical minimum for comparison of two medical device
measurement methods includes reporting mean ?SD values for both methods,
correlation, and Bland-Altman bias and precision, mean % diff...
This comparison of non-invasive haemodynamic devices, although
valuable, demonstrates some methodological aspects of the Bland-Altman
method that should be considered to ensure the accuracy of any proposed
conclusions.
The statistical minimum for comparison of two medical device
measurement methods includes reporting mean ?SD values for both methods,
correlation, and Bland-Altman bias and precision, mean % differences
between methods, and concordance analysis using four quandrant plots if
haemodynamic changes were measured in the same subjects during the
repeated observations.(1) Of critical importance for application of Bland-
Altman statistics is the range of outputs over which the comparison was
made. Repeated measures comparing CO values within a narrow "normal range"
provide little useful information,(2) as the mean differences between
measures will be small and discrimination will be weak. Additionally it is
at high and low outputs that accuracy is the most critical and clinically
consequential.
The authors observed USCOM measures were "considerably" lower than
NICCOMO measures, which were similar to the values they expected. However
the clinical characteristics of the patients are not described, the mean
CO and SVR values or SD were not reported, and no quantitative Bland-
Altman values nor CO ranges presented. Further upon proposing disagreement
between the two methods, no reference was made to normal USCOM reference
values.(3) If any differences existed between the USCOM reference normal
values and the USCOM Green study normal values, then operator error may
have affected the results, and the disagreement is explained, and the
conclusion prefaced with an "in our hands" caveat. Conversely, if the
USCOM values by Green et al. agreed with the previously published normal
USCOM values, and the patient cohorts were substantially clinically
matched, then the conclusion is an error in the measurements by NICCOMO, a
possibility not raised by the authors.
Regardless, this comparison of repeated measures in a single series
of subjects is only designed to demonstrate agreement between two methods,
and not determine which technology is the most reliable, particularly if
the endpoint is attainment of arbitrary and undefined expected values.
Clinical accuracy is related to a more extensive and rigorous series of
comparisons and proofs involving multiple animal and human studies and
comparisons across a range of age groups and clinical applications, and
across wide ranges of cardiac outputs against multiple technologies.
Doppler ultrasound has a long history of reliability and clinical
utility for flow measurements.(4) The USCOM 1A, a transcutaneous Doppler
monitoring technology has been validated against flow probes in animals
across a 6 fold range of outputs during application of inotropes and
vasopressors,(5) and from 0.12L/min to 18.7L/min in humans.(6,7) It has
been validated against invasive standards and non-invasive standards in
approximately 100 studies, and found to provide reliable measures across a
range of outputs and ages.(8,9,10) It has been demonstrated to reliably
measure CI and SVI and detect fluid responsiveness with approximately 90%
sensitivity in patients with AF, free breathing and ventilated patients,
patients on vasoactive and particularly those with dynamic circulation
such as those with sepsis and septic shock where the autonomic nervous
system is active.(11) Further the device is recommended in the paediatric
sepsis guidelines as a means of monitoring disease progress and titration
of therapy,(12) improves outcomes in paediatric septic shock,(13) and has
been recommended as a pregnancy monitoring method for early detection of
pre-eclampsia.(14)
Hodgson et al.,(15) compared inter-rater reliability of stroke volume
measurements at baseline and following passive leg raising measurements,
by emergency physicians and found a 6% error (r=0.96) between measures by
different operators and concluded that "following a training period of
less than 5 h, USCOM stroke volume measurements demonstrated excellent
inter-rater reliability". This confirmed the feasibility of the USCOM
technology in the emergency setting, an assessment not completed in the
current study despite the title.
So the USCOM is comprehensively validated, while NICCOMO is a test
technology, and its disagreement with USCOM suggests further evaluation in
animals and humans, across a wide range of outputs and diseases is
required before its utilisation could be countenanced in emergency
medicine.
Comparison of method studies are technically difficult, and involve
establishing a reference standard, USCOM, and then comparing paired
measures from a proposed test technique, NICCOMO, acquired under identical
conditions. Bland-Altman comparison can only determine if the two methods
agree or disagree.(2) If the comparison demonstrates disagreement, as the
authors propose, then the appropriate scientific conclusion is that, as
the reference method has superior validation and clinical proof, the test
method doesn't agree with the reference method "in our hands", and is
therefore not valid. However additional studies of any new technology may
be worthwhile if a suspicion of occult potential clinical utility
persists.
References:
1. J. Zhang J, Critchley LAH, Huang L. Five algorithms that calculate
cardiac output from the arterial waveform: a comparison with Doppler
ultrasound. Brit J Anaesth 2015;1-11: doi: 10.1093/bja/aev254
2. Olofsen E, Dahan A, Borsboom G. Improvements in the application and
reporting of advanced Bland-Altman method of comparison. J Clin Monit
Comput 2015;29:127-139.
3. Phillips RA, Smith BE, West MJ, Rainer T, Brierley J, Harris T, He S,
Burstow DJ, Fraser JF. New noninvasive haemodynamic nomograms to simplify
hypertensive management in neonates, children and adults. J Hypertension
2012;30(suppl 1):538
4. Sotamura S. Ultrasonic Doppler method for the inspection of cardiac
functions. J Acoust Soc Am 1957;29:1181-1185.
5. Phillips RA, Hood SG, Jacobson BM, West MJ, Wan L, May CN. Pulmonary
artery catheter (PAC) accuracy and efficacy compared with flow probe and
transcutaneous Doppler (USCOM): An ovine validation. Crit Care Res Prac
2012; doi:10.1155/2012/621496
6. Phillips RA, Paradisis M, Evans NJ, Southwell DL, Burstow DJ, West MJ.
Validation of USCOM CO Measurements in Preterm Neonates by Comparison with
Echocardiography. 26th ISICEM 2006, Critical Care 2006;10(Suppl1):144.
7. Su BC, Yu HP, Yang MW, Lin CC, Kao MC, Chang CH, Lee WC. Reliability of
A New Ultrasonic Cardiac Output Monitor in Recipients of Living Donor
Liver Transplantation. Liver Transpl 2008;14:1029-1037
8. Chong SW, Peyton PJ. A meta-analysis of the accuracy and precision of
the ultrasonic cardiac output monitor (USCOM). Anaesthesia 2012;
doi:10.1111/j.1365-2044.2012.07311.x
9. Beltramo F, Menteer J, Razavi A, Khemani RG, Szmuszkovic J, Newth CJL,
Ross PA. Validation of an ultrasound cardiac output monitor as a bedside
tool for pediatric patients. Ped Cardiol 2015, DO I 10.1007/s00246-015-
1261-y
10. Wong LS, Yong BH, Young KK, Lau LS, Cheng KL, Man JS, Irwin MG.
Comparison of the USCOM Ultrasound Cardiac Output Monitor with Pulmonary
Artery Catheter Thermodilution in Patients Undergoing Liver
Transplantation. Liver Transpl 2008;14:1038-1043
11. Thiel SW, Kollef MH, Isakow W. Non-invasive stroke volume measurement
and passive leg raising predict volume responsiveness in medical ICU
patients: an observational cohort study. Critical Care 2009;39:666-688
12. Brierley J, Carcillo J, Choong K, et al. 2007 American College of
Critical Care Medicine clinical practice parameters for hemodynamic
support of pediatric and neonatal septic shock* Crit Care Med. 2009;
37(2):666-688
13. Deep A, Goonasekera CDA, Wang Y, Brierley J. Evolution of
haemodynamics and outcome of fluid refractory septic shock in children.
Int Care Med 2013 DOI 10.1007/s00134-013-3003-z.
14. Gagliardo G, Lo Presto D, Tiralongo GM, Pisanai I, Scala RL, Novelli
GP, Vasopollo B, Velensise H. Cardiac output and systemic vascular
resistance as a target for the intrauterine treatment of fetal growth
restriction. J Preg Hypertension 2015 5:133(267-POS).
doi:10.1016/j.preghy.2014.10.273
15. Hodgson LE, Venn R, Forni LG, Samuels TL, Wakeling HG. Measuring the
cardiac output in acute emergency admissions: use of the non-invasive
ultrasonic cardiac output monitor (USCOM) with determination of the
learning curve and inter-rater reliability. J Int Care Soc 2015, DOI:
10.1177/1751143715619186
Paediatric Early Warning Scores: Acute Paediatrics' Cinderella's
Slipper
Lillitos et al are to be congratulated on a most helpful paper
clarifying whether disease severity and the need for hospital admission
can be predicted using two similar PEWS systems (Brighton PEWS and COAST -
the Children's Observation And Severity Tool).
There has been a proliferation in the uptake and usage of Paediatric
Earl...
Paediatric Early Warning Scores: Acute Paediatrics' Cinderella's
Slipper
Lillitos et al are to be congratulated on a most helpful paper
clarifying whether disease severity and the need for hospital admission
can be predicted using two similar PEWS systems (Brighton PEWS and COAST -
the Children's Observation And Severity Tool).
There has been a proliferation in the uptake and usage of Paediatric
Early Warning Scores (PEWS) in recent years, as part of the patient safety
agenda. Their original (dare I say, intended) purpose was to detect early
deterioration in hospitalised children, prompting timely interventions and
predicting the need for possible Paediatric Intensive Care admission
whereas increasingly, PEWS are being employed generically in paediatric
practice in the UK. Like Cinderella's slipper (following the spirit of
this season), Early Warning systems are attractive, colourful and
everybody wants to claim them for their own, with Ambulance Call
Response/Prioritisations, Hospital Admissions, ED Triage Systems,
Telephone Triage and Decision Making algorithms, Minor Injury/Walk-in
centres (to name but a few potential suitors) all seeking to shoe-horn
their patient's demographics into one of the currently available scoring
systems, in some situations avoiding the need for proper face-to-face
clinical assessment.
Of particular importance was the author's subdivision of presenting
complaints into both minor and significant "Medical" and "Surgical"
conditions which highlights some of the limitations of Early Warning
Scores.
It is reassuring to find that both the Brighton and COAST scores were
good at detecting significant respiratory illnesses, (Brighton and COAST
ROC scores yielding AUCs of 0.9 and 0.87, respectively). Whilst intended
to be universally applicable, both these scores have an inherent
respiratory design-bias, measuring multiple respiratory parameters
(respiratory rate, moderate-severe respiratory distress, supplemental
oxygen (Brighton), hypoxia (saturations ?92% in air (COAST))), both
expected and desirable qualities given the prevalence of respiratory
illness encountered in acute "paediatric practice" (asthma/wheeze,
bronchiolitis, croup, URTI, LRTI etc.)
Importantly, both local and regional experience and reviews of
adverse incidents, morbidity and mortality have anecdotally found PEWS
scores to be less reliable in the early detection of neurological
conditions, surgical conditions and blunt and penetrating trauma (where
compensatory mechanisms delay physiological abnormalities until disease
progression has advanced) and again the authors should be thanked for
quantifying these reported observations (they describe AUC's of i)
0.48AVERAGED for significant neurology, 0.56 for general surgical
conditions, 0.65 for significant trauma and 0.7 for head injury; Table 3).
(I suspect that in major trauma, simple descriptors such as "fall from
height", "ejected through windscreen" might well outperform medical
COAST/PEWS systems).
The study also validates what has been termed the "currency of COAST"
- that a high COAST score (a score ?3) must be taken seriously. (Due to
the score's poor specificity, the converse is not true - a low score does
not exclude significant illness/the need for admission). By choosing to
use the PEWS/COAST score at Triage, the authors were reliant solely on
abnormal physiological findings at one isolated point in time (influenced
by external factors such as crying and fever etc.) whereas tracking scores
over a period of observation or on an admissions/inpatient wards may have
revealed the trends of deterioration described in the early papers that
supported the introduction of PEWS systems (1). Even so, like other
clinical descriptors (e.g. haemorrhagic rash, shock, unresponsive,
fitting) the chosen individual trigger parameters would be expected to
prompt an appropriate nursing/medical response e.g. this child's heart
rate is abnormally high, their respiratory rate is depressed, their
conscious level diminished etc. (Previous authors have discussed the
possible merits of using aggregate weighted scores rather than single
clinical parameters but neither approach has been found to be superior to
the other (2); aggregate scores are certainly more complex, less user-
friendly and suggest a knowledge and appreciation of disease processes
that - if universal- is at best, currently poorly understood i.e. what
happens to "normal" heart rates in an unwell/injured 5-year old as their
condition progresses).
One of the study's shortcomings was to "wrongly" assign each child
with a universal score of "1" for parental concern, "on the basis that
parents/carers, by bringing their child to the ED, were by default
concerned". Parents do sometimes make uninformed choices when presenting
to ED; 60% of parents whose children had ATS (Australasian Triage System)
category 4 and 5 scores described the severity of their child's illness as
the primary (or secondary) reason for ED attendance (3). The intension
behind the "Doctor/Nurse/Family concern" trigger was to appreciate the
importance of gut feelings - something subjective, often unquantifiable
and unmeasurable - to prompt an appropriate clinical response. (Van den
Bruel, A et al's paper helpfully supports this approach (4)). [Within the
confines of a retrospective study, the authors can legitimately claim that
they unfortunately had no alternative].
As an advocate of PEWS scores (I adapted and designed the COAST chart,
with permission, from the original NHS Institute for Innovation &
Improvement's PEWS chart, in 2010), I do question how often these scoring
systems have identified a child that would not otherwise have been
identified and am concerned that, in the headlong rush to employ a PEWS
system in any and every clinical setting, their value has been overstated
at the expense of comprehensive nursing observations and medical
assessments. They do most certainly i) have an important role to play in
ensuring deteriorating trends are appreciated, communicated and acted upon
by nursing and medical teams and ii) can be useful when used as a safety
netting tool but, paraphrasing social media, might I suggest that we....
"Don't confuse my early warning score for years of clinical training and
experience!"
Dr Julian Sandell, Consultant in Paediatric Emergency Medicine, Poole
Hospital NHS Foundation Trust, and author of the Children's Observation
And Severity Tool (COAST), 2010
REFERENCES:
(1) Detecting and managing deterioration in children. Monaghan A.
Paediatric Nursing. 2005 Feb;17(1):32-35
(2) "Systematic review of paediatric alert criteria for identifying
hospitalised children at risk of critical deterioration". Chapman SM et
al. Intensive Care Med. 2010 Apr;36(4):600-11. Epub 2009 Nov 26.
(3)Why parents present to ED for non-urgent care. Williams A et al. ADC
2009;94:817-820
(4)Clinicians' gut feeling about serious infections in children:
observational study. Van den Bruel, A et al. BMJ 2012;345:e6144
Conflict of Interest:
I adapted and designed the COAST chart, with permission, from the original NHS Institute for Innovation & Improvement's PEWS chart, in 2010
We wish to thank Wilmer et al for their recent article "Air ambulance
tasking: mechanism of injury, telephone interrogation or ambulance crew
assessment", which we read with interest. As researchers in the field of
triage we feel it raises a number of interesting questions. We believe
that there are considerable similarities between triaging for enhanced
trauma team despatch (eg LAA) and effective triage for direct trans...
We wish to thank Wilmer et al for their recent article "Air ambulance
tasking: mechanism of injury, telephone interrogation or ambulance crew
assessment", which we read with interest. As researchers in the field of
triage we feel it raises a number of interesting questions. We believe
that there are considerable similarities between triaging for enhanced
trauma team despatch (eg LAA) and effective triage for direct transfer to
a Major Trauma Centre (MTC). It could be reasonably suggested that those
requiring treatment at a MTC would benefit from a LAA response and indeed
be the target population.
We would welcome some further clarification which we feel would
strengthen this work and assist with further research in the field.
Although MOI has historically been used as a dispatch criterion due
to "a high rate of serious injury", the authors conclude that it is the
least accurate method of tasking. We wonder if it is possible to clarify
the injury patterns amongst patients identified via MOI, particularly
injury severity and life-saving interventions performed by LAA.Are the
authors able to identify whether any of the six MOI criteria are more
accurately predictive than others? We are not aware of any such study in
the literature and this could greatly benefit the MOI criteria for MTC
triage.
We note that the authors' findings of 31% overtriage and 19%
undertriage are amongst the closest described to the US field triage
guidelines tolerance for over and under triage (up to 35% and 5%
respectively)1. . Clearly a decision must always be made as to the trade-
off between minimising either over or under triage. The authors describe
a number of risks of over triage and this is indeed correct, a linear
relationship between over triage and critical mortality has indeed been
shown2. This is often over looked, with the harmful effects of under
triage being the most obvious. With that in mind, we would be interested
to see more information on those patients who were under triaged in this
study, particularly their MOI. Can the automatic despatch criteria be
further refined by looking at these under triaged patients?
We welcome the authors' response and their views on using this work
as a foundation to optimise MTC triage decisions.
1American College of Surgeons. Resources for the optimal care of the
injured patient: 2014. Chicago, IL: American College of Surgeons; 2014.
2Frykberg ER. Medical Management of Disasters and Mass Casualties From
Terrorist Bombings: How Can We Cope? J Trauma 2002; 53(2):201-12
Conflict of Interest:
A PICO research suggestion on MTC triage has been submitted by the author (JV) for the James Lind/RCEM Research priorities
We read with interest the article by Seligman and colleagues (1)
which evaluated a novel first responder scheme for medical students as a
collaborative venture between a medical school and the local ambulance
service. Previous authors have advocated the early introduction of
Emergency Medical Technician teaching in an undergraduate medical
curriculum in the United States.(2) We would like to report...
We read with interest the article by Seligman and colleagues (1)
which evaluated a novel first responder scheme for medical students as a
collaborative venture between a medical school and the local ambulance
service. Previous authors have advocated the early introduction of
Emergency Medical Technician teaching in an undergraduate medical
curriculum in the United States.(2) We would like to report our
experiences in delivering an innovative special study module (SSM) in pre-
hospital emergency care (PHEC), which has consistently been one of the
most popular elective modules offered to the preclinical medical students
at our institution.
The PHEC SSM was designed by senior medical educators in partnership
with paramedics and advanced paramedics at our local hospital. Our
university has conferred honorary clinical fellowships on the paramedic
supervisors involved. Second year students complete the SSM over a 10-week
period in small groups of 12 students as part of their core medical
professionalism module. Participants actively shadow ambulance crews on
emergency calls and assist in patient assessment, monitoring and hand-over
in the emergency department, under the supervision of experienced
paramedics. Students have the opportunity to consolidate their theoretical
knowledge and practise procedural skills such as blood pressure
measurement, capillary blood glucometry, electrocardiography and oxygen
administration in an authentic clinical environment. They also become
familiar with standardised emergency management, first aid, and patient
safety protocols. Students maintain a reflective log of their emergency
calls and are debriefed in the case of traumatic incidents. Assessment
involves a combination of supervisor-led student evaluation, and
submission of a written assignment based on a contemporary emergency
medicine topic. Students also deliver a group presentation in which they
are required to critically analyse the efficiency of the ambulance service
and compare it to international best practice.
The PHEC SSM provides a formative early introduction to immediate
care and emergency medicine and it focuses students' attention on the
realities of clinical practice outside of a hospital setting. SSMs such as
this are a useful vehicle for fostering greater inter-professional
learning opportunities and improving communication between members of a
multidisciplinary clinical team, as well as promoting a deeper
appreciation for team-working and the ethical dilemmas of patient care.
Some medical students will also benefit from being motivated towards a
future career in emergency medicine. This educational intervention has
greatly facilitated collaboration between the ambulance service, emergency
department and the medical school, and we propose that it may serve as a
model of good practice for other higher educational institutions.
Consideration should be given to ultimately integrating this clinical
placement into the core undergraduate medical curriculum.
Ben Murphy, Craig Joyce, Barry Hannagen, Michael Smith, Gerard
Flaherty
School of Medicine, National University of Ireland, Galway, Ireland
Correspondence to Dr. Gerard Flaherty, School of Medicine, National
University of Ireland, Galway, Ireland; gerard.flaherty@nuigalway.ie
REFERENCES
1 Seligman WH, Ganatra S, England D, et al. Initial experience in
setting up a medical student first responder scheme in South Central
England. Emerg Med J 2015;0:1-4. Doi:10.1136/emermed-2015-204638.
2 Kwiatkowski T, Rennie W, Fornari A, et al. Medical students as
EMTs: skill building, confidence and professional formation. Med Educ
Online 2014;19:24829. Doi: 10.3402/meo.v19.24829.
This article by Howlett et al. makes for interesting reading as a
junior doctor at the start of Emergency Medicine training.
This study suggests that in order for trainees (and Consultants) to
maintain successful, long, enjoyable and fruitful careers, and avoid
'burnout', we should develop 'task-orientated coping' mechanisms.
Currently one may argue that this is encouraged via personal ref...
This article by Howlett et al. makes for interesting reading as a
junior doctor at the start of Emergency Medicine training.
This study suggests that in order for trainees (and Consultants) to
maintain successful, long, enjoyable and fruitful careers, and avoid
'burnout', we should develop 'task-orientated coping' mechanisms.
Currently one may argue that this is encouraged via personal reflection in
the e-portfolio, may I suggest that a more collective approach is called
for.
The Emergency Medicine training programme dictates that one must
learn to reflect regularly and use this reflection to direct self-learning
and 'learn from our experiences'. The e-portfolio is relatively rigid in
how one must reflect: 'What you did', 'What would you do differently and
why', 'what have you learnt', and does not necessarily encourage timely
discussion with a senior colleague.
Trainees should be encouraged to discuss learning points from an
experience with their Clinical/Educational Supervisor or another senior
colleague. In the busy Emergency Department environment this cannot happen
as frequently as it may be required and one way to combat this may be
achieved through changing staff members' attitudes to the importance of
reflection.
Whilst our main focus is patient care, we must acknowledge that in
order to continue to provide excellent care for our patients, we need to
care for ourselves and ensure that we do address issues that arise in a
timely matter. All doctors will make mistakes over their career with
differing impacts on patient outcome. Open discussions regarding mistakes
made by clinicians at different levels will encourage all doctors to
reflect and discuss issues they have been involved with and improve
learning from these experiences.
Furthermore perhaps 'task-orientated coping' mechanisms should be
included in the Undergraduate medical curriculum to encourage this
practice from the outset for newly qualified doctors.
We read this article with interest, given the high prevalence of
penetrating chest trauma in South Africa and the fact that we and others
(1,2) have published on the challenges faced in high-volume systems with
errant tube placement. While we also advocate the "safe-triangle"
approach, we aim to place the tube rather in the 4th ICS to avoid the risk
of trans-diaphragmatic injury. We are also adamant that the "finger-sweep...
We read this article with interest, given the high prevalence of
penetrating chest trauma in South Africa and the fact that we and others
(1,2) have published on the challenges faced in high-volume systems with
errant tube placement. While we also advocate the "safe-triangle"
approach, we aim to place the tube rather in the 4th ICS to avoid the risk
of trans-diaphragmatic injury. We are also adamant that the "finger-sweep"
be performed to gently displace any organ (lung or herniated viscus) away
from the chest tube during placement and to ensure placement within the
thoracic cavity. Directing all tubes apico-posteriorly is also advocated
strongly.
What has been clearly shown in previous studies is that senior
clinicians have much lower complication rates and that technical "errors
of execution", especially the continued use of trochars (3), are to blame
for many complications. The range of complication rates are listed between
10 and 30% across most of the studies. Indeed, it may be time for a "check
-list approach" for trauma chest tubes! (4)
Better training, under the watchful supervision of senior experienced
clinicians, could probably reduce the complication and misplacement rates
where often junior staff place these tubes initially1,2,3. In addition, a
return to the counting of the intercostal spaces and the use of the 4th
ICS rather than the 5th ICS may further reduce these misplacements.
Regards,
Dr TC Hardcastle, MMed(Chir), PhD, FCS(SA), Trauma Surgeon
Deputy Director: Trauma Services, and Trauma ICU, IALCH, and Head: Trauma
Training Unit, UKZN, Durban ZA
Dr MS Morris, MBBS, FCEM(UK), Emergency Medicine Specialist (ret)
Honorary Senior Lecturer, Emergency Medicine, Groote Schuur, UCT, Cape
Town, ZA
References
1) Maritz D, Wallis L, Hardcastle T. Complications of tube thoracostomy
for chest trauma. S Afr Med J, 2009;99:114-117.
2) Kong V, Oosthuizen GV, Sartorius B, Keene C, Clarke DL. An audit of the
complications of intercostal chest drain insertion in a high volume trauma
service in South Africa. Ann R Coll Surg Engl, 2014;96:609-613
3) Kong V, Clarke DL. The spectrum of visceral injuries secondary to
misplaced intercostal chest drains: experience from a high volume trauma
service in South Africa. Injury, 2014;45:1435-1439
4) Civil IDS. Tube thoracostomy in trauma: Is it time for a checklist for
chest tubes? Injury, 2013; 44:1143-1144
We were surprised by the EMJ decision to publish the study by Scotter
et al (1) A number of previous studies including those studied by Scotter
and colleagues have concluded that bilateral, fixed, dilated pupils in the
context of severe head injury are not universally predictive of poor
outcome. Performing a meta-analysis of five, retrospective, cohort
studies, one of which was conducted before 1988 does not change this
m...
We were surprised by the EMJ decision to publish the study by Scotter
et al (1) A number of previous studies including those studied by Scotter
and colleagues have concluded that bilateral, fixed, dilated pupils in the
context of severe head injury are not universally predictive of poor
outcome. Performing a meta-analysis of five, retrospective, cohort
studies, one of which was conducted before 1988 does not change this
message. The results provided in the abstract are potentially misleading;
the overall mortality for patients with extradural haematomas should not
be reported as 29.7%, but rather that 25 of 82 patients died. Similarly,
for patients with subdural haematomas, the mortality was not 66.4% but
that 38 of 57 patients died. A favourable outcome was seen for 13 patients
with extradural haemorrhages and bilateral fixed pupils and 3 of those
with subdural haematomas.
The authors are correct regarding the limitations of their study -
there is considerable potential for selection bias in the published
reports, the age ranges of the study patients are unclear, the delays to
surgery are largely unreported and none reported the presence or absence
of co-morbidities. Whether a pupil of 4mm should be considered fixed and
dilated is also open to question. None of the studies addressed whether
there was any direct injury to the face that might have produced traumatic
mydriasis. There is also no mention in either Scotter's paper or those
reviewed, about the value of aggressive pre-hospital care including
intubation, ventilation and administration of hypertonic fluids. A young
patient with an extradural haematoma who is rapidly resuscitated, arrives
in a neurosurgical centre within minutes of the pupils becoming fixed and
dilated might have reasonable expectations of survival. Equally, a patient
with a subdural haematoma who has fixed and dilated pupils on arrival of
the paramedics, who is transported to a district general hospital for
intubation and who is on anticoagulation has no need to be referred for
consideration of neurosurgery but rather should be allowed to die with
comfort and dignity.
We would also take issue with the statement that patients should be
able to undergo surgery within an hour of arrival following the
introduction of major trauma networks in the U.K. Outside of London, many
patients with major trauma are initially managed in district general
hospitals. In Wessex, nearly 50% of patients with an injury severity score
of >15 (major trauma) were admitted to trauma units (Trauma Audit
Research Network, personal communication). For many patients with severe
head injuries, the initial admitting hospital remains distant from the
regional neurosurgical service. Only by altering the referral pathways
have we any hope of reducing the time to surgery for these patients (2,
3).
The motives for Scotter's paper are laudable but the messages should
be taken with a drop of (hypertonic) saline solution.
References:
1. Scotter J, Hendrickson S, Marcus HJ, Wilson MH. Prognosis of
patients with bilateral fixed dilated pupils secondary to traumatic
extradural or subdural haematoma who undego surgery: a systematic review
and meta-analysis. Emerg Med J 2015; 32: 654-659
2. Trebilcock H. The impact of increasing the running time to the
major trauma centre (MTC) to 60 minutes in the south west. Emerg Med J
2015; 32: e17-e18 doi:10.1136/emermed-2015-204980.18
3. Dickinson P, Eynon CA. Improving the timeliness of time-critical
transfers: removing 'referral and acceptance' from the transfer pathway.
Journal of the Intensive Care Society 2014; 15: 104-108
Just to clarify, they can be cut off using the same tool for cutting
off precious metal rings found in most high street jewellers. Probably the
only stipulation is that the blade is in new/really good condition and
lubrication is used e.g. Aquagel,(although a lubrication oil on the blade
such as WD40 would be better for prolonging the blade life)
It can heat up quite rapidly as well so keeping it cool with
irrig...
Just to clarify, they can be cut off using the same tool for cutting
off precious metal rings found in most high street jewellers. Probably the
only stipulation is that the blade is in new/really good condition and
lubrication is used e.g. Aquagel,(although a lubrication oil on the blade
such as WD40 would be better for prolonging the blade life)
It can heat up quite rapidly as well so keeping it cool with
irrigation is advisable. Ampoules or tap water dripped on whilst cutting
can aid here.
For ease, it is advisable to cut the ring twice from both sides so
that the ring falls off making it a 'one man job'. Failing that, if the
ring is cut only once, a method will be needed to force the ring open
enough to be removed from the finger which could involve more staff, tools
and brute force.
As shown in the article, a method of forcing the ring open when it
has only been cut once would be to feed a couple of straightened
paperclips through each side of the cut and grip with pliers. It may be
only necessary to spring the ring open a short distance to remove it.
A single unused blade will cut off one or two titanium rings with
ease. New blades are available from specialist jewellery tool companies.
We have read with great interest the review of Ramlakhan et al. (2016)1 on the effectiveness of co-locating emergency departments (ED) and primary care centres and the findings of the authors that the evidence is inconclusive. Yet, we are confident that there are more hints and clues in the available evidence for policy guidance than was done in the paper by Ramlakhan et al. (2016). We will illustrate this with a recent po...
We read with interest the paper by Ramlakhan et al (10.1136/emermed- 2015-204900) on the effectiveness of primary care services located in EDs. We have just completed a test cycle week of a GP led model for managing lower acuity patients who present to the Clinical Decisions Unit (CDU) at the Glenfield Hospital, Leicester; however, we reached different conclusions. The CDU is a cardiorespiratory unit that receives mixed...
This comparison of non-invasive haemodynamic devices, although valuable, demonstrates some methodological aspects of the Bland-Altman method that should be considered to ensure the accuracy of any proposed conclusions.
The statistical minimum for comparison of two medical device measurement methods includes reporting mean ?SD values for both methods, correlation, and Bland-Altman bias and precision, mean % diff...
Paediatric Early Warning Scores: Acute Paediatrics' Cinderella's Slipper
Lillitos et al are to be congratulated on a most helpful paper clarifying whether disease severity and the need for hospital admission can be predicted using two similar PEWS systems (Brighton PEWS and COAST - the Children's Observation And Severity Tool).
There has been a proliferation in the uptake and usage of Paediatric Earl...
We wish to thank Wilmer et al for their recent article "Air ambulance tasking: mechanism of injury, telephone interrogation or ambulance crew assessment", which we read with interest. As researchers in the field of triage we feel it raises a number of interesting questions. We believe that there are considerable similarities between triaging for enhanced trauma team despatch (eg LAA) and effective triage for direct trans...
Dear Editor,
We read with interest the article by Seligman and colleagues (1) which evaluated a novel first responder scheme for medical students as a collaborative venture between a medical school and the local ambulance service. Previous authors have advocated the early introduction of Emergency Medical Technician teaching in an undergraduate medical curriculum in the United States.(2) We would like to report...
Dear Editor,
This article by Howlett et al. makes for interesting reading as a junior doctor at the start of Emergency Medicine training.
This study suggests that in order for trainees (and Consultants) to maintain successful, long, enjoyable and fruitful careers, and avoid 'burnout', we should develop 'task-orientated coping' mechanisms. Currently one may argue that this is encouraged via personal ref...
We read this article with interest, given the high prevalence of penetrating chest trauma in South Africa and the fact that we and others (1,2) have published on the challenges faced in high-volume systems with errant tube placement. While we also advocate the "safe-triangle" approach, we aim to place the tube rather in the 4th ICS to avoid the risk of trans-diaphragmatic injury. We are also adamant that the "finger-sweep...
We were surprised by the EMJ decision to publish the study by Scotter et al (1) A number of previous studies including those studied by Scotter and colleagues have concluded that bilateral, fixed, dilated pupils in the context of severe head injury are not universally predictive of poor outcome. Performing a meta-analysis of five, retrospective, cohort studies, one of which was conducted before 1988 does not change this m...
Just to clarify, they can be cut off using the same tool for cutting off precious metal rings found in most high street jewellers. Probably the only stipulation is that the blade is in new/really good condition and lubrication is used e.g. Aquagel,(although a lubrication oil on the blade such as WD40 would be better for prolonging the blade life)
It can heat up quite rapidly as well so keeping it cool with irrig...
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