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30th May 2023
Burnout, retirement and a reliance on locum staff are among a host of concerns raised in a new report from the Royal College of Emergency Medicine (RCEM), which urges the UK Government to take action to support and maintain the emergency medicine (EM) workforce.
The report, entitled ‘Emergency Medicine Workforce in England’, published on 28 May, reveals the extent of the capacity and staffing issues experienced by emergency departments, which is having a negative impact on staff morale and retention, as well as on patient care.
For example, there should be one whole-time equivalent consultant for every 4,000 annual attendances, but the report states that this ratio currently stands at 1:7052. What’s more, some 45% of the total EM workforce is made up by trainee doctors, posing a potential threat to service provision, especially out of hours.
Another particularly pressing issue, the RCEM notes, is the ageing pool of consultants employed within emergency departments. Some 29% of its consultant members are now aged over 50. Many are doing fewer hours during this stage of their careers, and ‘with a third of the workforce approaching retirement age at the same time, we may witness a mass exodus of experienced senior clinicians’, the report states.
These issues have resulted in an overreliance on locum staff, which takes a significant percentage of the wage bill.
Highlighting that the system is stretched beyond capacity and requires the next generation of EM doctors to bolster it, the RCEM’s president Dr Adrian Boyle said: ‘You have to keep the topping up the team, and that is why we are urgently calling on the Government to commit to ensuring there will be at least 120 extra training places for EM doctors every year for at least six years.’
This recommendation from the report, which would see more than 700 new trainee EM doctors being trained between 2024 and 2030, aims to help achieve safe staffing levels, ease pressure on existing staff and support capacity and resilience in emergency departments.
Dr Boyle concluded: ‘We are still waiting for the long-promised NHS workforce plan. And it is becoming increasingly important that this is published as soon as possible to avoid the crisis in the NHS worsening; and that it contains specific numbers, details and costings. Nothing less would be a disservice to our members, their colleagues, to patients and the public.’
Staffing shortages are being seen across the UK and Europe, with a mass-exodus of hospital and healthcare staff being widely reported. In the UK, the much-anticipated NHS workforce plan has indeed been delayed once again as rumours circulate around its prohibitively high cost.
25th May 2023
The use of short-stay wards located in an emergency department (ED) and managed by emergency care clinicians, benefits patients by reducing their length of stay (LOS) and 28-day mortality risk, according to the findings of a retrospective study by Korean researchers.
Published in BMC Emergency Medicine, the researchers hypothesised that ED clinician care within the ESSW was more likely to reduce patient’s LOS in the department and without affecting overall clinical care. They retrospectively analysed adult patients who visited the ED at a tertiary academic hospital in Seoul.
The patients were divided into three groups: those admitted to the ESSW and treated within the ED (ESSW-EM); those admitted but treated by other departments (ESSW-Other) and those who were admitted to general wards (GW). The researchers had a single, co-primary outcome which was ED length of stay and 28-day mortality.
A total of 29,596 patients were included in the analysis, with 31.3% categorised as ESSW-EM and 59.8% as GW.
When comparing ED LOS, the researchers found that the shortest time was for those in the ESSW-EM group (mean 7.1 hours). The mean ED LOS was 8.0 hours and 10.2 hours in the ESSW-Other and GW groups respectively (p < 0.001 for both comparisons). In addition, 28-day hospital mortality was 1.9% for the ESSW-EM group and 4.1% for the GW group (p < 0.001).
Using multivariable logistic regression analyses, being in the ESSW-EM group was independently associated with a lower hospital mortality compared with both the ESSW-Other group (adjusted p = 0.030) and the GW group (adjusted p < 0.001).
With patients’ LOS being a potential surrogate marker for overcrowding, the authors suggested that admission to an ESSW, under the care of emergency care clinicians, is a potentially effective strategy to alleviate emergency department overcrowding and improve patient outcomes.
Emergency department boarding, or overcrowding, is known to increase both hospital LOS and mortality. Consequently, in an effort the alleviate overcrowding, many Westernised countries have introduced a waiting time target, to reduce the time spend by patients in the department. This target has often been set at four hours and there is some evidence that it does reduce mortality rates. Nevertheless, a systematic review in 2010 concluded that the introduction of such targets, has not resulted in a consistent improvement in care.
An alternative proposed solution to reduce ED overcrowding and the associated mortality risks, is to have short-stay units within the ED. These emergency department short-stay wards (ESSW) are specific areas within the department designed to provide short-term care for a selected group of patients and hopefully to alleviate overcrowding.
While a potentially promising approach, a systematic review in 2015 noted insufficient evidence to make any firm conclusions on either the effectiveness or safety of short-stay units compared with inpatient care. Nevertheless, other work has shown that use of an ESSW is associated with a low rate of subsequent ICU admission. In contrast, an ESSW designed to manage patients with cardiac problems, actually increased patient’s hospital LOS.
Despite the limitations of the evidence, no previous studies have explored the potential benefit of using emergency care clinical staff within the ESSW.
4th May 2023
Nausea and vomiting were responsible for 1.6 million US emergency department (ED) visits in 2007. Antiemetic drugs such as ondansetron and metoclopramide are effective. Despite this, there is a lack of evidence to support the efficacy of one drug over any other. There is some evidence that inhaled isopropyl alcohol (IPA) appears effective for post-operative nausea and vomiting (PONV). For example, 70% inhaled IPA is more effective than promethazine in PONV. How well inhaled IPA compares to other anti-emetics is currently unknown.
The present meta-analysis searched for trials using IPA to treat adult ED patients with nausea and vomiting. The primary outcome was set as a change in nausea severity, measured by a validated scale.
Inhaled isopropyl alcohol and nausea reduction
Only two trials with a total of 195 patients met the inclusion criteria. The pooled decrease in nausea severity was 2.18 on a 0-10 scale, favouring inhaled IPA over placebo. A further trial comparing inhaled IPA and oral ondansetron did not meet the inclusion criteria but was useful for a secondary analysis. This analysis found a similar decrease in nausea (2.16).
There were no differences between inhaled IPA and placebo for the number of vomiting episodes.
The authors report that the available evidence suggests that inhaled IPA significantly reduces self-reported nausea in patients presenting to the ED with the condition. However, they note that only 275 participants have evaluated the intervention, adding the need for larger trials of the intervention.
Low back pain (LBP) is responsible for nearly 5% of all emergency department visits. Opioids and NSAIDs are useful emergency department (ED) treatments for acute LBP. Moreover, skeletal muscle relaxants, including diazepam (DP) and methocarbamol (MC) can serve as viable alternatives. Despite this, there is insufficient evidence to identify whether any one class of medication has a net advantage.
This lack of evidence led to researchers to undertake the current study. This double-blind RCT set out to compare intravenous DP with MC in acute non-traumatic musculoskeletal LBP. Both groups of patients also received morphine. Pain assessment was performed using a simple numeric rating scale, NRS, ranging from 0 (no pain) to 10 (worst possible pain). The primary outcome was the difference in pain relief post-intervention after 60 minutes.
Diazepam and post-intervention pain relief
There were 101 patients with 51 who received diazepam. Pain scores were lower with both treatments in comparison to baseline levels (p < 0.001). After 60 minutes, pain score reductions were slightly greater with DP (p = 0.048). The length of stay in the ED was similar between the two groups (MC = 5.9 hours vs DP = 4.8 hours, p=0.365). However, patients receiving diazepam were more likely to report drowsiness (4% vs 15% , p = 0.001).
These findings led the authors to concluded that DP and MC gave rise to similar pain relief after 60 minutes. Nevertheless, DP use may be associated with more drowsiness.
Upper gastrointestinal (GI) bleeding mortality is 5-10% largely due to peptic ulcers and portal hypertensive gastropathy. A common scoring system to evaluate patients with upper GI bleeding is the Glasgow-Blatchford Score (GBS). In fact, the European Society of Gastrointestinal Endoscopy suggests that a GBS score of <1 prior to endoscopy, indicates a low risk of re-bleeding. Both GBS and a modified version appear to be moderately accurate for decision-making in those with an upper GI bleed. CANUKA has a similar performance to the GBS and more accurately identifies those with a low risk for adverse outcomes. Nevertheless, currently, there is a lack of comparative data on these three systems.
Recently, researchers sought to compare the effectiveness of each system for identifying patients at low risk of death or the need for a subsequent intervention. Using a retrospective approach, the team considered emergency department patients with an upper GI bleed. They explored the need for blood transfusion, endoscopic haemostasis or re-bleeding within seven days. The scoring system sensitivity, specificity, positive and negative predictive values were used as outcome measures. Cut-off thresholds for low risk of the GBS, the modified version (mGBS) and CANUKA were set at <1, 0 and <2 respectively.
GBS and CANUKA identification of low-risk upper GI bleeding patients
There were 386 patients with a median age of 60 years (65.3% male) with sufficient data to calculate the three scores.
Using the threshold levels for GBS, mGBS and CANUKA, 24.9%, 18.2% and 18.9% of patients respectively, were at low risk. Furthermore, with these cut-off levels, only 2.2%, 4.6% and 0% respectively, required a further intervention. Sensitivity values with these cut-offs were broadly similar (98.2% to 100% for CANUKA). The negative predictive values ranged from 97.8% (GBS) to 100% for CANUKA. In addition, no deaths occurred for patients identified as being at low risk.
These findings led the authors to conclude that a Glasgow-Blatchford score of <1 and a CANUKA score of <2 appears to be safe for identifying patients at low risk of death or the need for an intervention following an upper GI bleed.
Acute dyspnoea is a common complaint within an emergency department (ED). Dyspnoea is also a common symptom of an acute myocardial infarction (MI), affecting nearly two-thirds of patients. This consequently necessitates prompt patient assessment. High-sensitivity cardiac troponin T (CTT) can quickly assess patients with chest pain to rule out an MI. Nevertheless, elevated cardiac troponin T levels can also occur in those experiencing chest pain without an MI.
In the current study, researchers set out to determine role of CTT in ED patients presenting with acute dyspnoea not due to an acute MI. Adult patients with acute dyspnoea were included and CTT levels measured together with their clinical history. CTT levels were divided into three levels: <15, 15-100 and >100 µg/l. An analysis provided the three-month relative risk of mortality with adjustment to models for a patient’s clinical history.
Cardiac troponin and three-month mortality risk
A sample of 1001 patients had usable data. With CTT levels < 15 set as the reference point, a CTT level between 15 and 100 gave rise to a more than three-fold higher mortality risk (Hazard ratio, HR = 3.68 (95% CI 1.72-7.84). The mortality risk was even higher with levels above 100 µg/l (HR = 10.523, 95% CI 4.46-24.80).
Patients with higher cardiac troponin levels were generally older, had a higher number of co-morbidities and more severe symptoms. The researchers felt that the data highlighted the value of CTT as an important risk factor in acute dyspnoea without a cardiac cause.
5th April 2023
Neutrophil CD64 level measurement in emergency department (ED) patients with a suspected bacterial infection, has a both a high specificity and positive predictive value for diagnosing a bacterial infection. However, low levels cannot be used to rule out these infections, according to the findings of a study by the COVPACH study group.
Infections are a common ED presentation that require diagnostic biomarkers to enable the differentiation between those of a bacterial or viral origin. C-Reactive Protein (CRP) is one such marker that appears to act as a surveillance molecule for altered self and certain pathogens. Levels of CRP increase very rapidly in response to trauma, inflammation, and infection although CRP has been found to be neither sufficiently sensitive or specific to identify bacterial infections, particularly with lower respiratory tract infections. Although other markers such as the white blood cell (WBC) count and erythrocyte sedimentation rate can be used, the WBC count has a low sensitivity and specificity for a bacterial infection. An alternative marker is the neutrophil CD64 level with one meta-analysis concluding that it could be a promising and meaningful biomarker for diagnosing bacterial infection. In addition, while neutrophil CD64 demonstrates moderate performance in diagnosing sepsis in critically ill patients, whether it helps to diagnose bacterial infections within the ED where an answer is rapidly needed, is less clear and was the purpose of the current study.
Researchers examined the value of neutrophil CD64 (nCD64) in a study with COVID-19 suspected patients who visited the ED and for which a definitive diagnosis was made. Blood samples were analysed within 2 hours after presentation and patients categorised as having either a bacterial, viral, and non-infectious disease. The team then determined the diagnostic value of nCD64 and compared this to those of CRP and WBC counts.
Neutrophil CD64 as a biomarker for bacterial infections
A total of 182 patients with a median age of 63 years (52.7% male) were included and of whom, 43% had a confirmed bacterial infection and 35% a viral infection.
The median nCD64 level was higher in bacterial compared to viral infection (p = 0.004) and the non-infectious group (p < 0.0001). However when analysing the area under the receiver operating characteristics curve, there were no significant differences between the three biomarkers.
Using a cut-off of 9.4 units for nCD64, the corresponding positive predictive value was 1.00 and the specificity was 1.00 although the sensitivity was only 27%.
The authors concluded that nCD64 had a high specificity and positive predictive value for diagnosing a bacterial infection but noted how a low nCD64 could not be used to rule out a bacterial infection. They added that nCD64 should be combined with additional tests to form an algorithm that adequately diagnoses infectious diseases.
Citation
van de Ven NLM et al. Point-of-care neutrophil CD64 as a rule in diagnostic test for bacterial infections in the emergency department. BMC Emerg Med 2023
Among patients presenting at an emergency department (ED) with cannabis intoxication, almost half presented with cardiovascular (CV) symptoms according to the findings of a retrospective analysis by researchers from Amsterdam, the Netherlands.
In a study with 10,000 students, cannabis was rated as the most favourable most commonly used tobacco product the past 30 days and also perceived as the least harmful when compared to electronic cigarettes and cigarettes themselves. However, cannabis use is not without risks and one systematic review found that the data from 29 observational studies, suggested an association between cannabis-based product use and cardiovascular disease, with the strongest evidence for ischaemic heart disease. There is also data to suggest that cannabis use is associated with an increased risk of cardiac dysrhythmia, which is rare but may be life-threatening. As a result, there remains some uncertainty over whether patients who present at an ED with cannabis intoxication should undergo a full cardiovascular evaluation.
In the current study, the Dutch team retrospectively analysed data on a convenience sample of all self-reported cannabis-intoxicated adult patients who presented at an Amsterdam ED. Individuals who were intoxicated due to mixed recreational drug use were excluded and presenting symptoms were categorised as either CV-related (e.g., palpitations, chest pain and syncope) or non-cardiovascular (like nausea and vomiting).
Cardiovascular symptoms and cannabis intoxication
A total of 1689 individuals with a mean age of 31.9 years (62.4% male) were included in the study.
Overall, 47.2% presented with cardiovascular symptoms and which included palpitations (57.6%), chest pain (12.9%) and syncope (36.8%). Among those with CV-related symptoms, 8 had complications including ST elevation myocardial infarction, non-ST elevation myocardial infarction, atrial fibrillation and AV-nodal re-entrant tachycardia. Other ECG abnormalities observed were ischaemic ECG changes, first-degree atrioventricular block, premature atrial complexes, ventricular extrasystoles, prolonged corrected QT interval, and a Brugada type 1 pattern. Fortunately, all of these resolved spontaneously during the observational period.
The authors concluded that while the clinical relevance of cardiovascular symptoms is largely unknown, cannabis-intoxicated patients should have a cardiac evaluation, and symptoms should not just be considered benign.
Citation
Gresnigt F et al. Incidence of cardiovascular symptoms and adverse events following self-reported acute cannabis intoxication at the emergency department: a retrospective study. Emerg Med J 2023
Administration of intra-vesical tranexamic acid to a Foley catheter in patients with gross haematuria, prior to continuous bladder irrigation, reduced both the length of stay in the emergency department (ED) and the duration of catheter placement, according to a before and after study by Korean researchers.
Macroscopic or gross haematuria is a commonly seen condition in the ED and for which there are a variety of causes. In gross haematuria, it is necessary to ensure that patients are not in urinary retention due to clot formation and in cases of clot retention, a three-way Foley catheter is used, to allow irrigation fluid to be passed through the bladder, clearing clots from the site of bleeding. Tranexamic acid has haemostatic effects and hinders fibrinolysis and clot degradation and while the drug has been used to control bleeding in conditions such as epistaxis, whether it can affect spontaneous bleeding from the lower urinary tract is less clear. However, to date, one small study in which bladder irrigation, local intra-vesical tranexamic acid and placebo were injected into the bladder via Foley catheter, found that the drug could significantly reduce the volume of required serum for bladder irrigation to clear urine.
Based on these encouraging preliminary findings, in the current study, the Korean team hypothesised that the use of tranexamic acid in those with gross haematuria, would reduce the duration of patient’s stay in the ED as well as the length of time for which Foley catheter placement was required. They conducted a ‘before’ and ‘after’ retrospective single-centre study, and examined the impact of using tranexamic acid in patients after a certain cut-off date (March 2022) and compared outcomes for patients before the specified date, i.e., those for whom tranexamic acid had not been used. The team set the primary outcomes as the length of stay in the ED and the duration of Foley catheter placement. The secondary outcomes were the admissions and the revisits for continuous bladder irrigation within 48 h after discharge.
Intra-vesical tranexamic acid and duration of ED stay
A total 159 patients with a mean age of 79.4 years (93.5% male) were included, with 86 in the ‘after’ group.
The results showed that the median length of stay in the ED was significantly shorter in the ‘after’ group (274 vs 411 minutes, p < 0.001). In addition, the median duration of the Foley catheter placement was also shorter (145 vs 308 minutes, p < 0.001).
There were also a lower proportion of ED visits among those given tranexamic acid (2.3% vs 12.3%, p = 0.031) as well as a trend towards less hospital admissions (29.1% vs 45.2%, p = 0.052).
The authors concluded that a reduction in length of stay of gross haematuria patients was observed after the implementation of intra-vesical tranexamic acid injection via a Foley catheter and called for further studies to confirm these findings.
Citation
Choi H et al. Impact of intravesical administration of tranexamic acid on gross hematuria in the emergency department: A before-and-after study. Am J Emerg Med 2023
An analysis by Korean researchers of patients admitted to an emergency department (ED) with a rib fracture diagnosed on chest radiography has identified important fracture characteristics indicative of significant intra-thoracic and intra-abdominal injuries that require assessment by chest computed tomography (CT).
The ribs are frequently affected by a blunt or penetrating injury to the thorax and within an ED, it is vital for the interpreting radiologist to not only identify the presence of rib injuries but also alert the clinician about organ-specific injury. A CT chest plays a major role for the in-vivo assessment of the body composition at the tissue/organ level and is the imaging modality of choice for accurate delineation of rib fractures and associated internal injuries. However, the main limitation associated with the use of CT scan is the ionising radiation patient burden. Consequently, identification of rib fracture features that could enable more appropriate use of a chest CT for such patients are warranted.
In the current study, the Korean team retrospectively analysed adult patients diagnosed with rib fracture due to blunt chest trauma that was diagnosed based on chest radiography and who underwent a chest CT examination. The researchers set the primary outcomes as intra-thoracic and intra-abdominal injuries that could be identified on a chest CT.
Rib fracture characteristics and need for a chest CT
A total of 401 patients with a mean age of 58 years (29.5% female) were included and of whom, 279 had any intra-thoracic or intra-abdominal injuries.
Overall, there was a higher number of rib fractures in those who sustained significant internal injuries (p < 0.001) and a higher level of bilateral fractures (p = 0.001).
In regression analysis, the number of fractures (adjusted odds ratio, aOR = 1.44, 95% CI 1.16 – 1.78), lateral fractures (aOR = 2.80) and posterior rib fractures (aOR = 3.18) were all independently associated with intra-thoracic and intra-abdominal injuries. Other factors also independently associated with such internal injury were the requirement of O2 supplementation, mechanical ventilator use, requirement of transfusion, pelvic bone fracture and extremity fracture.
The authors concluded that among blunt trauma-induced rib fracture patients, posterior and lateral fractures, more than three fractures, the need for O2 supplementation were the most important factors indicating the need for chest CT to identify intra-thoracic and intra-abdominal injuries in the emergency department.
Citation
Kim W et al. Characteristics of rib fracture patients who require chest computed tomography in the emergency department. BMC Emerg Med 2023
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