Clinician Abuse: Electronic Health Records

This month, the print version of the Emergency Medicine Journal features an article from a group including Jeffrey Perry and Ian Stiell on a topic near and dear to our hearts – Electronic Health Records. While the next generation of physicians will never remember a time of charting on paper, the majority of practicing physicians recall such times – and many office-based practices may yet still use paper.

In the Emergency Department, however, one of our most valuable assets is time – and all such times are increasingly measured and under greater scrutiny as quality and efficiency metrics. With an eye towards this, Perry et al performed an observational, before-and-after, study comparing time spent in documentation on non-traumatic chest pain between paper charting and electronic charting. Paper charting required a mean of 6.1 minutes per patient, while electronic charting required 9.6 minutes. If one assumes this charting differential is generalizable to other complaints, and multiply such by a very reasonable 2 patients per-hour on an 8- or 9- hour shift – suddenly you’re looking at an additional hour of documentation time. Unsurprisingly, qualitative survey of clinicians found universal disfavor of electronic charting.

I shine a light on this article in the context of the ongoing American Medical Informatics Association Annual Meeting in Washington, DC (#AMIA14). If you spend any time perusing the social media or press releases from the meeting, all the hype is about “Big Data”, FHIR, and hackathons – advanced applications of clinical informatics, essentially, assuming an integrated Electronic Health Record infrastructure. What’s been utterly lost in the rush to the future are the basic considerations clinicians struggle with on a daily basis – carving out enough face-time with patients to deliver the best possible care. With initiatives such as “Meaningful Use” in the United States providing mandates for EHRs, the emphasis has clearly been on checking boxes for federal reimbursement – and hardly responsive to clinician concerns.

Patient satisfaction” is an overwhelming industry mandate – what happened to clinician satisfaction?

Reference: “Assessment of the impact on time to complete medical record using an electronic medical record versus a paper record on emergency department patients: a study

Highlights from the December edition: EMJ

Paul Middleton: Associate Editor EME

Editor’s Choice: ED and GP patients

Causes of Emergency department crowding are complex, but the proportion of ‘inappropriate GP patients’ has often dominated the debate. Recent Australian research suggested that ∼10% of patients could be classified as appropriate for general practice, whilst demonstrating that the preferred government methodology doubled these figures.

In this issue, Harris and McDonald investigate the case-mix of patients attending ED, GPs, a walk-in clinic (WIC) and an out-of-hours (OOH) telephone service. There was a similar case-mix of presentations to the WIC, OOH and GP, with the only difference being respiratory illness presented more frequently to GPs. Injuries were 12 times as likely to be seen in ED, whereas non-traumatic musculoskeletal conditions were twice as likely to be seen in GP practice. Patients were also 4 times more likely to present to ED with chest pain suggestive of myocardial ischaemia as compared with non-ED sites.

These findings, although based on a small sample of a highly diverse population, demonstrate that patients are making relatively sophisticated choices. This paper highlights that, rather than concentrating on the blunt tools of “reducing ‘inappropriate’ attendances”, governments need to take note of Gerry Fitzgerald’s comment that there are “…not general practice patients or ED patients; there are just patients, who need medical care”, and our job is “…to understand those needs and to provide accessible, affordable and quality services that meet those needs. Patients should not be blamed for our failure to do so.”

Sepsis survey

Almost 13 years ago, Manny Rivers changed the paradigm for the sepsis syndrome with the outcomes of Early Goal Directed Therapy (EGDT). Since then, studies from PROCESS to ARISE have suggested that EGDT is not in itself more successful in preventing sepsis mortality, but that a high-quality, process-of-care approach results in the best outcomes. Jiwaji et al surveyed ED and ICU consultants across Scotland, with a 2/3 response rate, and compared approaches to sepsis resuscitation. Almost 90% of ED consultants used normal saline to resuscitate, compared to only a quarter of ICU consultants; many of the ICU group preferred Hartmann’s, but 63% used gelofusine, despite little evidence for its benefit. Half as many again ICU consultants initiated central venous and intra-arterial monitoring in the ED compared with ED consultants, and similar proportions used specific transfusion triggers. This variability suggests the need for harmonisation of approach with the patient remaining the central concern, whoever is providing care. In a time-critical environment, recognition of which is an undoubted result of Rivers’ work, ED and ICU need to work towards common skill sets and protocols to ensure that early recognition, source control, antimicrobial therapy, fluid resuscitation and escalation remain the fundamental goals of sepsis treatment.

Basic Life Support

Exponentially growing levels of evidence supports the primacy of early recognition of cardiac arrest, immediate instigation of high-quality CPR and urgent defibrillation. In the last 20 years, ubiquitous courses in BLS train essential psychomotor skills, but these skills deteriorate in weeks or months. Video-based Practice While Watching (PWW) programs, with participants observing a standardised video with an instructor, have been successful in initial skill teaching and maintenance, but Na and colleagues investigated a novel small group discussion and debriefing (SGD) program, allowing participants to watch themselves and discuss with an instructor. 2000 people were studied. Healthcare professionals’ (HCPs) performance of compression skills was better using SGD compared to PWW methods, but showed no difference in non-compression skills (ventilation, AED use etc). In non-HCPs there was a significant improvement in both sets of skills using the SGD method. This interesting study points the way to possible mass-instructional methods that could be highly useful in community and HCP education in order to improve the often dire outcomes of cardiac arrest.

Capillary refill

Although normal finger capillary refill time (CRT) is considered to be less than 2 seconds, upper limits of 4 seconds may be seen at the chest or foot, and in the upper CRT limit in neonates may be up to 5–7 seconds. Longer times are seen in lower extremities and lower skin temperatures. Schriger and Baraff also showed that CRT varied with age and gender, with approximately 2 seconds for children and men, and longer times for women and the elderly.

We know that turning a continuous variable into an ordinal or categorical variable loses both information and precision, but clinical practice often demands these simplifications. Mrgan and colleagues assessed the relationship between CRT and with mortality as both categorical and continuous variable in 3000 patients. Although based on limited data, multivariate analyses showed no relationship between CRT and either 1 or 7 day mortality when used as a categorical variable, as in the Trauma Score, but when used according to the Schriger and Baraff definitions, CRT was associated with odds ratios of mortality of 5.8 and 4.2, with, however, very wide limits of agreement. The authors concluded that CRT should really be used as a continuous variable, but implementation of this statistically sound approach will be challenging without substantial further research.

Light rather than heat in stroke?

Stroke treatment over recent years has generated a lot more heat than light, but no one can disagree that stroke evolution is time-dependent. The PIL-FAST study casts an intriguing light on the challenges of research into a time-dependent pathology, seeing the patient journey as an emergency care continuum and implementing pre-hospital interventions.

This pilot study by Shaw et al investigates the ability of an ambulance service to implement a randomised controlled trial (RCT) in the prehospital phase of stroke care, treating hypertension using lisinopril or placebo The truly illuminating aspects of this study are the difficulties encountered, and the subsequent limitations imposed on this research. Of 1463 suspected stroke admissions only 40 fulfilled inclusion criteria, and of these only 14 were recruited; some missing enrolments were caused by the attendance of a PIL-FAST trained paramedic to only one third of cases, with only 58% of those patients being enrolled. 76 from an eligible 200 paramedics volunteered to be trained in the research protocol. Paramedic concerns about longer scene times among those recruited did not materialize. A new paramedic record system was introduced during the study, preventing the investigators to review the entire trial period. Most worrying, these groups identified concerns relating to ‘professional boundaries’ despite apparent ‘enthusiasm for research’.



Paul Middleton

EMJ Associate Editor

Highlights from November edition: EMJ

Triage category and prediction of longer-term outcomes

Triage identifies patients who require the most urgent attention, and allows stratification of scarce resources. Many emergency presentations conceal a multitude of sins, with few as all-encompassing as syncope. The broad range of conditions that provoke, mimic or originate as syncope means that predicting those most risk in this broad group relies on exhaustive and penetrating questioning and examination.

Bonzi’s retrospective study on 678 syncope patients found that the triage process was poorly predictive of adverse events at 10 days. They also examined an OESIL score, and found that previous cardiac history and abnormal ECG were predictive of later disasters. This paper highlights that triage, for all its uses in managing flow in an ED, is no substitute for early, informed, careful risk-stratification, and that it will not perform well in an area for which it was never designed.

Traumatic head injury triage

A cohort study by Fuller et al from TARN investigated the classification of adult head injury patients by the London Ambulance Service (LAS) and the Head Injury Transportation Straight to Neurosurgery (HITS-NS) criteria.

Bypass of major trauma patients to definitive care is a common theme in many trauma systems, and one challenge is to manage intracranial injuries needing urgent neurosurgical intervention, in the context of physiological instability from multisystem injury. Head injured patients are particularly vulnerable to hypoxia and hypotension, so to accurately balance the risk between these competing priorities a triage tool which accurately predicts the presence of intracranial injury is necessary.

In 6559 patients, Fuller found that the both tools showed poor sensitivity for a significant traumatic brain injury, when compared to a reference standard, of 44.5% and 32.6% respectively. Adding bleeding disorders, vehicle entrapment and age ≥55 to the LAS rule increased sensitivity to 74%.

The investigators showed under-triage rates for significant TBI of 67.4% and 55.5% for HITS-NS and LAS, with false negative cases often comprising older patients with less severe injuries and low falls. The poor performance of these triage rules underlines difficulties in patient disposition, even within a mature trauma system. This paper adds to the debate about which strategy is superior, however without clear evidence that outcomes in head injured patients stabilised at a trauma centre and then transferred for neurosurgical intervention are worse than those for patients taken directly to a specialist centre with possible under-resuscitation, the emphasis on initial trauma centre management will remain.

High sensitivity cardiac troponin T in infection—more outcome prediction

De Groot points out that 13% of patients who meet criteria for early goal directed therapy go to a normal ward, when disposition is guided by either Mortality in ED Sepsis (MEDS) or Predisposition, Infection, Response and Organ-Failure (PIRO) score, and suggests that this could be improved by the addition of a biomarker reflecting myocardial damage from hypoperfusion, highly sensitive cardiac troponin T (hs-cTnT).

They found increased odds of hospital death by 2.2 with hs-cTnT in the third quartile compared with the second, and 5.8 if it was elevated to the fourth quartile. hs-cTnT also showed good discrimination measured by the area under the (AU) ROC curve, and was an independent and more powerful predictor than the MEDS or PIRO scores alone. However, like many sophisticated (and expensive) biomarkers, hs-cTnT correlation with other reliable predictors of outcomes may not help to guide us practically in our choice of intervention, however may assist us in our efforts to engage the arbiters of higher levels of care. But the greatest usefulness of this study may be in the finding that hs-cTnT in the lowest quartile predicted a zero risk of death.


The way we think about our patients, the processes of diagnosis, and the intrinsic organisation in the way physicians integrate information are topics of huge interest for many. Gestalt derives from a German school of psychology and suggests that we can discern a whole concept or image in parallel with perceiving the fragmented pieces of information that form the whole; the “the whole is other than the sum of its parts”. This ability is likely to be intrinsic to the effective practice of emergency medicine, and is likely to involve subtle cues such as lack of facial expression, recently shown to be associated with the presence of cardiovascular disease.

Body studied the use of gestalt in the diagnosis of chest pain by inducing emergency physicians to make a graded estimate of the likelihood of an ACS. Treating physicians were blinded to initial troponin level and the outcome, although they had access to the ECG and other information.

In 451 patients with chest pain, of whom 81 had an AMI, unstructured clinical judgment had moderate overall diagnostic accuracy, with an AUROC curve of 0.76, but was insufficient to rule in or rule out ACS in the ED. However, a normal ECG and initial troponin added to physician gestalt would enable 25% of patients to be safely discharged, and using high-sensitivity troponin would increase this figure to 40%.

Procedural sedation for cardioversion

Propofol, methohexital, thiopentone and etomidate were identified in an EMJ review as good choices for procedural sedation in cardioversion, largely due to their short onset, duration and recovery time, and propofol has been described as the closest to an ideal agent for cardioversion.

Kaye and Govier collected data from a case series of 100 patients given propofol for ED cardioversion of both atrial and ventricular tachycardias, and demonstrated minimal complications and no sentinel adverse events. They concluded that propofol 1 mg/kg was safe in patients undergoing ED cardioversion, with a similar level of safety using a 0.5 mg/kg dose in patients with haemodynamic compromise.

What do you believe? with Iain Beardsell.

SONY DSCA change is as good as a rest, or so the saying goes. Working in Emergency Departments we are constantly changing. Many of these changes are directed at the processes within the ED, continually striving to find the “golden bullet” solution to the “four hour question”.

Over the first six years of my consultant career the department I work in, like many others across the UK I’m sure, has been subject to constant change . These have come in different guises: “Lean”; Service Improvement; Perfect Week; the list goes on. Many of these are run by external agencies, at huge cost, all hoping to solve the dominant question in Emergency Medicine – How do we achieve the four hour target

Like, I suspect, many Emergency Physicians I have a very short attention span. This was part of the reason I chose the specialty that I love. Not unlike Martin Sheen’s President Bartlett of West Wing fame, the question on my lips most often is “What’s next?”. This serves me well when seeing patients, but not when I require the sustained interest required for successful change. We throw ourselves into projects, but over time this quickly wanes and the much vaunted developments are cast aside for the next new thing. The last few years in our ED are strewn with unsustained changes and I’d estimate that no more than one in ten ideas, no matter how promising or useful, have continued beyond six months after their inception.

Why is this? It can’t simply be that we lose interest. I recently watched a “TED” presentation that struck a chord.

In his talk Simon Sinek, an author best known for popularizing the concept of “the golden circle” describes a simple but powerful model for inspirational leadership all starting with the simple question “Why?”. As I watched, I realised that many of these changes over the years I had been happy to participate in, but I just didn’t believe in them. Apart from the temporal reasons with which we are obsessed I didn’t know why we were changing. We have keep doing new things, yet our “performance” hasn’t improved, in fact it has got worse.

As doctors and nurses in Emergency Departments we chose our career paths, I hope, because we believed in the best care for all, especially those with life threatening illness, at any time of day or night. This is our fundamental belief. Why is it, then, that we struggle to to adopt and maintain these changes that may help us towards that goal?

As Sinek discusses in his talk, it isn’t necessarily that the ideas we try to implement are bad, but because the premises on which they are based do not address our beliefs. There is a fundamental disconnect between the four hour target and what we think is best for our patients. Of course this is untrue – a faster, more efficient process for seeing people must be better for many, but with years of government scrutiny and management interference we have simply refuse to believe this anymore. We are, in general, a stubborn bunch and will not have others force their beliefs on us without the appropriate analysis

Change goes on apace in my department, as I am sure it does in yours, but it is my belief that it is time for us to pause and rethink what and why we are changing. Constant, rushed implementation of quick fixes that the clinical team do not believe in, but merely participate in, simply will not work. It is time for us to reappraise what we, as doctors and nurses, believe and then to proclaim these beliefs to others.

So I ask you all – what do you believe in? What does your department stand for? What is your vision? I asked this question of colleagues recently and was met with blank, rather guilty stares. We simply did not know. I’m sure you could come up with a few without any thought: to provide evidence based compassionate care to all, whenever they need it; to educate and encourage all staff so that work is not just a job, but a vocation; that no patient should be in pain; that we should aggressively resuscitate all those who require and desire it and tenderly and gently care for those who life is at its end. Articulating these visions and beliefs is easy – the real challenge is making them a part of your ED’s philosophy and daily life.

Of course, the irony is that none of these beliefs in anyway contradict the aims of the four hour standard. In fact they compliment it – evidence based care is efficient and limits unnecesssary testing and giving appropriate pain relief early facilitates discharge. And a happy clinical team, who work together will always, always be more effective and efficient.

We need a rest from the change. We need to look within ourselves and find what it is we believe in and then work towards these visions with passion and enduring commitment. We need to ask others, managerial and political, to trust us, to help us work towards achieving what we believe in and to join us on the journey. Given this opportunity we will provide the best emergency care we possibly can (including achieving government set targets). And that is my fundamental, unshakable belief.




The Role of IO in Trauma: A #FOAMed Debate

The Emergency Medicine Journal recently published a review of intraosseous access experience from the Royal Army Medical Corps. This review documents 1,014 IO devices and 5,124 infusions of blood products, medications, and fluids. There were no major complications, and the rate of minor complications was extraordinarily low – the most frequent being device failure, occurring approximately 1% of the time.

But, what is the role of intraosseous access in trauma?

Who is Dr. Brohi, you may ask? Just the head of the LondonTIER, Professor of Trauma Sciences in the Blizard Institute, Barts and the London School of Medicine & Dentistry, and Consultant Trauma & Vascular Surgeon at Barts Health NHS Trust. Someone whose opinion is worth a listen. If you have any doubts, watch him speak at SMACC GOLD.

To say his comment spurred a rivulet of FOAM would be an understatement. To see the entire thread of responses and branching conversations, start here and don’t stop scrolling. But, a few of the highlights:

What do you think?  Do you agree – the IO is, as used by the Royal Army Medical Corps (RAMC), a temporary tool prior to definitive access in a trauma center?  Or, do you find utility, even in the setting of a fully capable trauma resuscitation?

Highlights from the October issue of EMJ

EMJ_100x100Emerg Med J 2014;31:793 doi:10.1136/emermed-2014-204282

Highlights from this issue

  1. Ian K Maconochie, Deputy editor

Conducting emergency research when consent and consultation are a challenge (editor’s choice)

Studies in patients with emergency conditions that render them unable to give consent have been very difficult to conduct owing to ethical considerations. The guidance offered in the commentary by Gavin Perkins should bring significant benefit to this under researched population, an example of which is seen in this month’s editor’s choice: Long-term pain prevalence and health-related quality of life outcomes for patients enrolled in a ketamine versus morphine for pre-hospital traumatic pain randomised controlled trial. This is a follow up report on trauma patients who participated in a randomised trial of pain relief in the pre-hospital setting. The initial paper found that ketamine had significantly better analgesic effects than morphine; however regardless of treatment, persistent pain is still a big problem for many patients at 6 months, affecting quality of life.

Comparison of intubation modalities in a simulated cardiac arrest

Advances in intubation techniques include video assisted devices (VAD). This study looked at how long the procedure takes with 2 different modes of intubation, either direct laryngoscopy (DL) or using VAD, with and without bougie.

Twenty emergency physicians with prior training in these modes of intubation intubated a mannequin with a difficult airway on a hospital bed whilst continuous CPR was delivered.

Did the VAD improve time to intubation, and when a bougie was used, was this quicker than DL?

VAD was quicker than DL (median 20.6 seconds, IQR 17.7–27.1 as compared with 27 seconds, IQR 20.3–35.4.) However, using a bougie with the VAD added considerable time: 60.1 seconds (IQR 39.1–99). This important result leaves some questions: is a bougie really useful in this situation? Is its use deleterious? Maybe a future study looking at bougie use in the difficult airway in adults and children should be planned.

The effect of elevated serum alcohol on the outcome of severely injured patients

This retrospective cohort study looked at 184 criteria-selected patients admitted to Trauma Unit at the University Hospital between October 2008–December 2009 with injury severity scores above 17. Patients were stratified into 2 groups: blood alcohol level positive (BAL+) with >5% level of alcohol, and those with lower/no blood alcohol level (BAL–).

Injury severity scores were similar in the groups, but there was more traumatic brain injury in the BAL+ patients.

There was no significant difference in mortality between the 2 groups, the causes being similar in both. Nor were there significant differences in length of stay in hospital and ICU, or duration of ventilation.

Does this mean that alcohol has no effect? The jury is still out. Similar studies are needed from multiple centres with aggregated data to address this question.

The sad truth about the SADPERSONS Scale: an evaluation of its clinical utility in self-harm (reader’s choice)

This SADPERSONS score, devised in the US in 1983 for medical education, is supposed to help identify individuals at risk following a suicide attempt. Despite prior studies showing a lacklustre performance, the score continues to be used in EDs. The study in this issue followed 126 consecutive individuals of all ages presenting to a large UK general hospital with self-harm (including poisoning), to see if they re-presented to the ED within 6 months. All patients were also assessed by the specialist self-harm team. Using the previously recommended cut-off score of ≥7, SADPERSONS failed to identify 80% of subsequent self-harm and 50% of those who needed further secondary management. The authors conclude that use of the score by itself is insufficient to ensure that optimal care can be delivered.

A population based study on the night-time effect in trauma care

This retrospective study reviewed 1940 cases in the Emilia-Romagna area of Italy (with 4.5 million inhabitants), which has had a centralised trauma system since 2006 Out-of-hours and in-hours mortality of trauma patients was examined including, unusually, patients transferred from to the major trauma centre from the 84 satellite hospitals in this region.

There were fewer secondary night–time transfers but with an increased risk of mortality in this group. Another interesting finding is that only 40% of patients with severe trauma came to the major centre, a figure which the authors say, is paralleled in other health systems in the world.

The night-time effect on mortality is attributed to the ‘lack of homogenous transfer protocols and of a standard level of pre-hospital care around the clock’. It would be interesting to see what the impact of addressing these issues might be and to hear from other health systems if similar problems are found in trauma care networks.

Sustained health-economic effects after reorganisation of a Swiss hospital emergency centre: a cost comparison study

Does a triage system plus a co-located GP unit reduce costs in delivering care? The answer appears that it does. In this study from Switzerland, the cost reduction overall was a staggering 417 000 Euros. Can you show cost reduction if you have a similar system in place?

Randomised trial comparing the recording ability of a novel, electronic documentation system with the AHA paper cardiac arrest record

Sixteen anaesthetists were asked to view pre-recorded PEA or VF arrests and document what happened using paper and electronic systems. There were fewer missed events, less irrelevant information noted and fewer mistakes made in documenting those events using the electronic system. It seems the quality and meaning of the data is enhanced by an electronic recording system.

An evaluation of the referral process in the emergency department

This is an area fraught with misunderstanding and potential upset if things go wrong! Miscommunication is frequently cited in serious events, but is commonplace in delivering healthcare. This study looked at how ED and non-ED clinicians felt about referring patients and offers some solutions to this key area of patient care.

And still more…

In addition to the other articles and features in the October issue, EMJ will be publishing an on-line issue with free, full-text access to all articles for the next three months. Find it from September 30th here