Deep Venous Thrombosis in Trauma: Implications for Hospitals and Patients.

The objective of this study was to determine the prevalence of chronic DVT in hospitalized trauma patients | Journal of Trauma and Acute Care Surgery

B0008083 Blood clot in a vein

Image source: Annie Cavanagh – Wellcome Images // CC BY-NC 4.0

Deep venous thrombosis (DVT) is considered a preventable complication in trauma patients. Hospitals risk financial penalties for DVT rates above accepted benchmarks. These penalties do not apply to chronic DVT which develop prior to admission. Lower-extremity duplex ultrasound (LEDUS) can detect characteristics of thrombus chronicity, allowing differentiation of chronic from acute DVT.

LEDUS can identify chronic DVT, which represents nearly 30% of all DVT found on initial screening LEDUS in trauma patients. Those with chronic DVT should receive pharmacologic and mechanical prophylaxis because of the incidence of progression and new acute DVT. They should also be counseled regarding the possibilities of recurrence and chronic venous insufficiency.

Full reference:Cannon, K.A. et al. (2017) The Prevalence of Chronic Deep Venous Thrombosis in Trauma: Implications for Hospitals and Patients. Journal of Trauma and Acute Care Surgery: Post Acceptance: 31 August 2017

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Recognition and treatment of severe sepsis in the emergency department

Retrospective study in two French teaching hospitals | BMC Emergency Medicine

Sepsis management in the Emergency Department remains a daily challenge. The Surviving Sepsis Campaign (SSC) has released three-hour bundle. The implementation of these bundles in European Emergency Departments remains poorly described.

The main objective was to assess the compliance with the Severe Sepsis Campaign 3-h bundle (blood culture, lactate dosage, first dose of antibiotics and 30 ml/kg fluid challenge). Secondary objectives were the analysis of the delay of severe sepsis recognition and description of the population.

Full reference: , P. et al. (2017) Recognition and treatment of severe sepsis in the emergency department: retrospective study in two French teaching hospitals. BMC Emergency Medicine. Published online: 30 August 2017

Emergency Nurse Implementation of the Brief Smoking-Cessation Intervention

This project explored the feasibility and acceptability of a brief smoking-cessation intervention as part of emergency nursing practice | Journal of Emergency Nursing

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Smoking is the single most avoidable risk factor for many health problems such as cardiovascular disease and pulmonary dysfunction. Emergency departments provide care for many patients who smoke. Patients who smoke and are discharged to home from emergency departments do not customarily receive smoking-cessation information.

Emergency nurses felt comfortable performing the smoking-cessation intervention, suggesting that training was effective. Data indicated that patients were consistently advised to quit smoking. Results suggest that brief smoking-cessation interventions are feasible and acceptable in emergency settings. The training and protocol could be used in other emergency departments, and lessons learned can guide future efforts by emergency nurses to help patients quit smoking.

Full reference: Simerson, D. & Hackbarth, D. (2017) Emergency Nurse Implementation of the Brief Smoking-Cessation Intervention: Ask, Advise, and Refer. Journal of Emergency Nursing. Published online: 29 August 2017

 

Appropriate support and services provided to frequent attenders

Interventions designed to help Emergency Department (ED) staff manage frequent attenders are labour-intensive and only benefit a small sample of frequent attenders | Emergency Medicine Journal

We aimed to use the in-depth knowledge of health professionals with experience of working with ED frequent attenders to understand the challenges of managing this group of patients and their opinions on providing more appropriate support.

Twelve health professionals were interviewed. Three groups of frequent attenders were identified: people with long-term physical conditions, mental health problems and health-related anxiety. Underlying reasons for attendance differed between the groups, highlighting the need for targeted interventions. Suggested interventions included improving self-management of long-term physical conditions; creating a ‘go-to’ place away from the ED for patients experiencing a mental health crisis; increasing the provision of mental health liaison services; and for patients with health-related anxiety, the role of the GP in the patients’ care pathway was emphasised, as were the benefits of providing additional training for ED staff to help identify and support this group.

Full reference: Ablard, S. et al. (2017) Can more appropriate support and services be provided for people who attend the emergency department frequently? National Health Service staff views. Emergency Medicine Journal. Published Online First: 31 August 2017

Factors influencing admission to hospital from the emergency department

The number of emergency admissions to hospital in England and Wales has risen sharply in recent years and is a matter of concern to clinicians, policy makers and patients alike. However, the factors that influence this decision are poorly understood | BMJ Open

Findings: Departmental factors such as busyness, time of day and levels of senior support were identified as non-clinical influences on a decision to admit rather than discharge patients. The 4-hour waiting time target, while overall seen as positive, was described as influencing decisions around patient admission, independent of clinical need. Factors external to the hospital such as a patient’s social support and community follow-up were universally considered powerful influences on admission. Lastly, the culture within the ED was described as having a strong influence (either negatively or positively) on the decision to admit patients.

Conclusion: Multiple factors were identified which go some way to explaining marked variation in admission rates observed between different EDs. Many of these factors require further inquiry through quantitative research in order to understand their influence further.

Full reference: Pope, I. et al. (2017) A qualitative study exploring the factors influencing admission to hospital from the emergency department. BMJ Open. 7:e011543.

The growing evidence on high-intensity hospital care

Despite wide variation in the amount we spend on care, patients’ outcomes are often the same. So clearly, we should just do less. Indeed, given the growing problems of overdiagnosis and overtreatment, less is more | Emergency Medicine Journal

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As emergency physicians, we deliver a fair amount of high-intensity care. Yes, good care can sometimes be as simple as an astute diagnosis or a kind word. But it can also involve cross-sectional imaging, invasive procedures and hospital admission. At the right time and for the right patient, we believe, this care can be the difference between life and death.

And yet this care is coming under increasing scrutiny from payers and policy makers.

While emergency care accounts for a small fraction of direct health system costs, the decision to admit a patient to the hospital is an expensive one indeed. There are many good reasons to send patients home—reducing crowding, avoiding hospital-acquired infections and more. But the driving force behind efforts to reduce admissions today is simple: to reduce costs. As a result, physicians everywhere face increasing pressure to discharge patients to home.

This poses a particular dilemma for emergency physicians. On one hand, the rest of the world seems very certain we should be sending more patients home. On the other, our experience suggests that failures of risk stratification and mistriage to home can have terrible consequences.

Full reference: Obermeyer, Z. (2017) Is less more, or is it less? The growing evidence on high-intensity hospital care. Emergency Medicine Journal. Published Online First: 18 August 2017. 

Emergency department care

Emergency department care – best practice guideline

The Royal College of Emergency Medicine has published a Best Practice Guideline Emergency department care.   Developed to help medical staff within Emergency Departments provide better care for patients, this publication is a fifty-point checklist that covers all aspects of emergency care including the patient environment and pathway; education about care; care of elderly patients, children and those with complex needs; team working and leadership.