Primary Survey June 2018. Emergency Medicine Journal

This month the primary survey is collated and written by Edward Carlton, Associate Editor, EMJ.

Editor’s Choice: Controversies in Sepsis

In this issue of the Emergency Medicine Journal (EMJ) we have two papers exploring tools to predict critical illness in sepsis. Two retrospective cohort studies, in ED patients with suspected sepsis/infection, evaluate the diagnostic accuracy of the relatively novel qSOFA (Sepsis-3 2016) in comparison to existing sepsis prediction tools such as the National Early Warning Score (NEWS), SIRS and serum lactate measurements. The first multicentre US analysis of 3743 patients, by Rodriguez and colleagues (see page 350), compares qSOFA with existing tools in predicting death, vasopressor use or ICU admission within 72 hours of ED attendance. By demonstrating and improved, or similar specificity for the primary outcome across a range of scores, the authors conclude that qSOFA criteria performed as well or better than existing tools in predicting critical illness. The second single centre UK analysis of 1818 patients, by Goulden and colleagues (see page 345), again compares qSOFA with existing tools, including the widely used NEWS, in predicting in-hospital mortality and ICU admission. The authors argue that by demonstrating equivalent or superior performance of NEWS in comparison to qSOFA, that the value of qSOFA could be called into question in institutions where NEWS was already in use.

In the accompanying commentary to these analyses, Bernard Foëx eloquently appraises the data and raises some pertinent points which will be relevant to practicing EM clinicians (see page 343). The question remains unanswered as to how best to apply such prediction tools in the undifferentiated ED population, in whom sepsis may be just one possible cause of critical illness, and the focus on sepsis risks prioritising this as a cause of critical illness or deterioration at the expense of other diagnoses.

Swabs and spinal fluid

Continuing the infection theme, in this issue we include a short report by Acquisto et al (see page 357), who evaluate the use of nasal swabs for MRSA rapid screening in patients with skin and soft tissue infections. In comparison to wound culture, nasal swabs had a high diagnostic accuracy for the presence of MRSA (Positive Predictive Value 85.7%). At a time when antibiotic guardianship is increasingly important, the use of rapid screening for resistant infection may improve our prescribing practices in future.

Garcia and colleagues (see page 361) take a further step forward in limiting antibiotic prescribing in their evaluation of an outpatient management strategy for children at low risk of bacterial meningitis. This multicentre observational analysis from Spain explores an outpatient management strategy (without antibiotics) in paediatric patients with a clinical suspicion of meningitis, pending cerebrospinal fluid culture results. Of 182 children, 45 were identified as low risk for bacterial meningitis within the ED and managed as outpatients without antibiotics, none of whom were finally diagnosed with bacterial infection. While this strategy may well need refining, we welcome initiatives that reduce antibiotic prescribing and allow more patients to be managed on outpatient ambulatory pathways.

Exploring gender in Pre-Hospital care

Importantly, at EMJ, we are seeing an increasing number of manuscripts exploring potential gender disparities in emergency care. By undertaking a retrospective registry analysis of out of hospital cardiac arrest patients in New Zealand, Dicker and colleagues (see page 361) demonstrate that although women suffer cardiac arrest at less than half the rate men do and are older when they do so, after adjusting for confounders, there appear to be no gender differences in 30 day survival.

Triage across time zones

As an international emergency medicine journal, it is important to highlight important undertakings in exotic locations. This issue is no exception, with two papers evaluating triage scales in unfamiliar environments including Afghanistan, Haiti and Japan. Different triage scores may perform differently across populations and locations, with few developed designed specifically for low income countries. An exploratory analysis, using case vignettes and nursing staff evaluation by Dalwei et al demonstrates that the South African Triage Score may be applicable in such environments (see page 379). Kuriyama and colleagues validate the Japan Acuity and Triage Scale, based on the Canadian Triage Scale, in another example of an accepted triage tool being applied successfully across time zones (see page 384).

The marauding terrorist

Lastly, our Reader’s Choice provides an important overview for any Emergency Physician as, sadly, the potential for marauding terrorist attacks becomes more widespread. Ravi Chauhan and colleagues review major incident management for those of us unfamiliar with such attacks together and include some of the lessons learnt from recent horrific events (see page 389).

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Primary Survey May 2018. Emergency Medicine Journal.

This month’s primary survey is brought to you by Caroline Leech, Associate Editor, EMJ.

Does a brief intervention in the ED reduce illicit drug use?

Health promotion is critical in Emergency Medicine (EM), and Brief interventions (BI) for alcohol use are well established. This prospective cohort study assessed the efficacy of a BI for drug use in a US Emergency Department. As expected there was a large loss to follow-up (40% and 44% in each arm) resulting in an underpowered study and we don’t know if some of those were due to mortality from drug use. The BI lasted for 20–30 min with a significant number of questions, which might be hard to achieve in a time-pressured department. However, the study failed to demonstrate any reduction in self reported drug use or an increase in drug treatment service utilisation over a twelve-month period. In the accompanying commentary, Richard Saltz discusses how we still have a responsibility to address this important public health problem.

Paediatric intubation: how low do you go?

Many Emergency physicians use the Advanced Paediatric Life Support calculation of age in years/2+12 cm to calculate the length of an oral endotracheal tube at intubation. This study retrospectively analysed the images of 499 Korean children undergoing CT of the neck and measured the distances on scan from the mid-incisor to the mid trachea. They derived a decision formula based on weight for infants (5.5 + (0.5 x weight in kg)) and height for children (3 + (0.1 x height in cm) which performed better than the APLS formula or the Broselow tape at validation. Further studies would need to be conducted to validate this calculation in other populations.

What is positionality in quantitative studies?

I’ll be honest: I didn’t know what the words ‘positionality’, ‘constructivism’ and ‘reflexivity’ meant until I read this fascinating article by Anisa Jafar. The idea is that when appraising quantitative medical studies, you really need to know why the researchers were interested in the topic and what position they hold, to see how they might generate and interpret the results. The example of Rivers’ famous study on early goal directed therapy eloquently describes how this might be relevant when assessing the validity of research conclusions.

Physician productivity is not a simple sum

Emergency Departments commonly use productivity to plan staffing and judge individual performance according to the average number of patients seen per hour. This retrospective American study found that the number of patients seen by EM Attendings (Consultants) declined with every subsequent hour of the 8–9 hour shift. Is this fatigue or accumulation of patients waiting results? Additional patient arrivals in the ED were associated with a modest increase in hourly productivity but this was lost towards the end of the shift. Differences between the three studied sites also emphasise the importance of using local data to assess productivity.

Does ED overcrowding impact on clinical care for medical patients?

It is getting to shift changeover time and the Emergency Department is very busy with long waits to be seen. Do patients get less comprehensive investigations and treatment at these times? And are they more likely to be referred for medical admission inappropriately? This Canadian study found that for patients with COPD, heart failure or sepsis there was no difference for patients referred at the end of a shift compared with in the middle and the same for patients referred at times of high compared with low surge. Conversion rates (ie, actual admissions) after referral were >93%. The authors agree that the results may vary for other less obvious medical diagnoses.

Differences in epidemiology and outcomes for elderly versus young STEMI patients

This paper from Singapore is a registry review of over 14K patients who had STEMI with a comparison of the under 65 and over 65-years-old age groups. The elderly patients were less likely to receive primary PCI with greater rates of late presentation, patient refusal, contraindications and more co-morbidities to weigh up in the risk-benefit analysis. Median symptom to door times were 26 min longer, and door to balloon times were 9 min longer in the elderly group: this may be due to the fact that 28% of older patients had no chest pain. The authors conclude that the absence of primary PCI is likely to worsen outcomes for the over 65 year age group but in the over 85 year patients the survival benefit is less pronounced and requires an individual risk-benefit analysis.

Image challenge

Test yourself on the chest x-ray and diagnose why the patient had acute chest pain following tooth extraction. You will probably have seen the condition before but this case is an unusual cause!

IVC ultrasound and NIV

We continue to search for the optimal diagnostic modality to assess volume status and fluid responsiveness in the resus room. The winners to date remain the passive leg raise and the use of a fluid bolus. Ultrasound measurements of the IVC diameter can be used to examine fluid responsiveness in the ventilated or spontaneously breathing patient but what about in the patient having positive pressure with non-invasive ventilation? And can you use the axillary vein as a surrogate for the IVC? Spoiler alert: don’t buy another ultrasound machine just yet.

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Caroline Leech

Playing dress up!

We all want to make coming to hospital a pleasant and memorable (but not for the wrong reasons!) experience for children. It changes the way we act, the way we talk, and the amount of cuddly toys we attach to our stethoscope whilst the infection control team have their backs turned… We also adjust the environment, making it colourful and full of decoration and art. We have play therapists to provide distraction from the clinical aspects. We make sure kids can be with their families. But, does it change the way we dress? Should it?

In this month’s EMJ Supplement, a short but colourful article by Jillian Boden, Sian Butterworth and Graham Roberts – all paediatricians out of Portsmouth and the Isle of Wight. In order to assess whether children have a preference over what a doctor wears, they took two sets of photos of a male and female wearing different clothing that you might see on a jaunt around the hospital. The five modes of dress were a suit (and tie), officewear (smart casual with a collared shirt and smart trousers but no jacket), blue scrubs, colourful fun scrubs (think cheesy 90s kids TV), or the good old-fashioned white coat (short-sleeved of course).

They showed these photos to around 100 children aged 4-10 years old attending outpatients at a district general hospital and asked them to pick their favourite, as well as the one that met key descriptors such as ‘friendly’ or ‘scary’. The team found that children overall preferred their doctor to wear blue scrubs and found this outfit the most friendly and least scary. Not surprisingly, the suit took the ‘clever’ vote. Interestingly, however, fun scrubs were perceived to be scary by just over 20% of the children surveyed. To be fair the scrubs chosen had some quite bright yellow trousers and I can see how the kids could have been concerned – it looked like the doctors had just come back from staffing a holiday club in Hawaii!

The authors concluded that blue scrubs should be considered as uniform policy to ensure children are kept comfortable in the hospital environment. Of course this study appears to have been done in a district general hospital on the south coast, and it would be interesting to see if these views align with children in other parts of the country.

But why do children have such views on how doctors dress? Do they go completely on the outfit itself and how it makes them feel? Are they recalling those doctors they liked and didn’t like? Or are there other cultural considerations, such as who they look up to during their daily TV viewing?

If we look at doctors on television who appeal to a younger audience, it’s a bit of a mix. Doc McStuffins rocks the white coat, Dr Ranj generally goes suit or white coat, Dr Chris and Dr Xand of Operation Ouch wear blue and green scrubs, and Dr Brown Bear of Peppa Pig fame has either painted his body blue, or is in some kind of blue onesie. It’s such a mix!

Maybe what we can take from this is how kids rate TV doctors? A good article to read this month so don’t forget to read the supplement!

How about your hospital? What do you wear in your paediatric ED? In the children’s ward? What’s your experience? Let us know.

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Chris