Towards evidence-based emergency medicine

Horner, D. (2017) Emergency Medicine Journal. 34(5) pp. 331-334.

BestBETS

Image source: BEstBETS

Best Evidence Topic reports (BETs) summarise the evidence pertaining to particular clinical questions. They are not systematic reviews, but rather contain the best (highest level) evidence that can be practically obtained by busy practicing clinicians. The search strategies used to find the best evidence are reported in detail to allow clinicians to update searches whenever necessary. Each BET is based on a clinical scenario and ends with a clinical bottom line which indicates, in the light of the evidence found, what the reporting clinician would do if faced with the same scenario again.

The BETs published below were first reported at the Critical Appraisal Journal Club at the Manchester Royal Infirmary or placed on the BestBETs website. Each BET has been constructed in the four stages that have been described elsewhere. The BETs shown here together with those published previously and those currently under construction can be seen at http://www.bestbets.org. Two BETs are included in this issue of the journal.

Read the full abstract here

Retrospective observational study of emergency admission, readmission and the ‘weekend effect’

Shiue I, McMeekin P, Price C. Retrospective observational study of emergency admission, readmission and the ‘weekend effect’. BMJ Open 2017;7:e012493. doi: 10.1136/bmjopen-2016-012493 

Excess mortality following weekend hospital admission has been observed but not explained. As readmissions have greater age, comorbidity and social deprivation, outcomes following emergency index admission and readmission were examined for temporal and demographic associations to confirm whether weekend readmissions contribute towards excess mortality.

Design A retrospective observational study. Individual patient Hospital Episode Statistics were linked and 2 categories created: index admissions (not within 60 days of discharge from an emergency hospitalisation) and readmissions (within 60 days of discharge from an emergency hospitalisation). Logistic regression examined associations between admission category, weekend and weekday mortality, age, gender, season, comorbidity and social deprivation.

Setting A single acute National Health Service (NHS) trust serving a population of 550 000 via 3 emergency departments.

Participants Emergency admissions between 1 January 2010 and 31 March 2015.

Outcome measure All-cause 30-day mortality.

Results Over 5 years there were 128 966 index admissions (74.7% weekday/25.3% weekend) and 20 030 readmissions (74.9% weekday/25.1% weekend). Adjusted 30-day death rates for weekday/weekend admissions were 6.93%/7.04% for index cases and 12.26%/13.27% for readmissions. Weekend readmissions had a higher mortality risk relative to weekday readmissions (OR 1.10 (95% CI 1.01 to 1.20)) without differences in comorbidity or deprivation. Weekend index admissions did not have a significantly increased mortality risk (OR 1.04 (95% CI 0.98 to 1.11)) but deaths which did occur were associated with lower deprivation (OR 1.24 (95% CI 1.11 to 1.38)) and an absence of comorbidities (OR 1.17 (1.02 to 1.34)).

Conclusions Associations with emergency hospitalisation were not identical for index admissions and readmissions. Further research is needed to confirm what factors are responsible for the ‘weekend effect’.

 

Safer, faster, better – transforming urgent and emergency

Adopt the tried and tested principles and implement good practice in delivering urgent and emergency care | NHS Improvement

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This document is designed to help frontline providers and commissioners deliver safer, faster and better urgent and emergency care to patients of all ages, collaborating in UECNs to deliver best practice.

It sets out design principles drawn from good practice, which have been tried, tested and delivered successfully by the NHS in local areas across England. However, the guide should not be taken as a list of instructions or new mandatory requirements. Implementation should be prioritised taking into account financial implications and local context.

This document has been prepared by NHS England in conjunction with the Emergency Care Intensive Support Team (ECIST). Contributions have been sought from the review’s delivery group (comprising a wide range of experts in urgent and emergency care services, as well as patient representatives).

Read the full guide here

Extended hours in primary care linked to reductions in minor A&E attendances

National Institute for Health Research Signal
Published: Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis, Whittaker, W.,Anselmi, L.,Kristensen, S. R. PLoS One Volume 13 Issue 9 , 2016

Practices which offered additional appointments showed a reduction in the number of their patients attending emergency departments (also known as A&E) for minor conditions. There was no overall reduction in emergency visits. Costs were reduced for emergency departments but by less than the cost of the additional appointments. The study did not evaluate whether or not this is cost saving to the health service as a whole nor if health outcomes were improved.

Emergency departments are increasingly busy and patients are waiting longer to be treated. Commissioners and providers have been interested in interventions which may help to reduce these hospital pressures.

This NIHR-funded study funded 56 general practices in Manchester to offer extra appointments during evenings and weekends as part of a larger programme to improve primary care. There was a 26.4% relative reduction in “minor” A&E visits (10,933 fewer visits), compared to 469 practices which did not offer additional appointments.

Nationally, policy-makers aim to encourage patients with minor conditions to attend alternative services, including primary care. These findings suggest additional appointments may help reduce minor A&E visits but may be more costly overall.

Ethical Use of Telemedicine in Emergency Care

American College of Emergency Physicians(2016) Annals of Emergency Medicine68(6) p. 791

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  • The American College of Emergency Physicians (ACEP) believes that EDs using telemedicine should make this form of care accessible regardless of race, religion, sexual orientation, location, or ability to pay.

  • ACEP believes that EDs and hospitals should ensure that their telemedicine systems and practices provide patients with at least the privacy and confidentiality required under HIPAA. This includes ensuring that their equipment and technology are up-to-date and secure.

  • ACEP believes that telemedicine decisions relating to patient care, referrals, and transfers should be based on the patient’s health care needs.

  • ACEP supports the establishment of standards for telemedicine practitioners and development of related quality assurance and educational programs to develop the discipline.

  • ACEP supports legislative efforts that would allow single-state licensing to be sufficient for telemedical practice throughout the United States.

  • ACEP believes that all aspects of the telemedical consultations between advance medical practitioners (ie, physicians, nurse practitioners, and physician assistants) are subject to the same informed consent and refusal standards as face-to-face medical encounters.

Read the full abstract here

Practical Guidelines for the Use of Electronic Applications by Advanced Practice Nurses in the Emergency Department

Morgan, V.A. Journal of Emergency Nursing. Published online: October 20 2016

email-1345921_960_720Although numerous electronic applications are available to health care providers on enabled devices such as smartphones and tablets, these resources remain underutilized. Available literature suggests that utilizing electronic applications provides a number of benefits, including improved ability to make quick yet accurate decisions, improved knowledge of evidence based practices, a corresponding reduction in error rates, and an increase in quality improvement measures. These benefits translated into a reduction in adverse events and hospital lengths of stay.

Read the abstract here

Understanding patient flow in hospitals

The Nuffield Trust, October 2016

This briefing warns that the NHS can no longer find enough bed space to move patients through hospitals quickly and meet key A&E targets – and that its practice of counting patients at midnight means that the true scale of the squeeze is being missed. It estimates that 5.5 per cent of beds need to be free for cleaning and preparation if patients are to be moved through quickly enough to meet the commitment to admit or transfer emergency patients within four hours.