EMA August 2013

Issue 4 (Vol. 25) of Emergency Medicine Australasia published online on 2 August 2013

First Do No Harm. In Fact, First Do Nothing, at Least not a Cannula (#FOAMed) This thought provoking editorial considers the potential cascade of over-investigation, diagnosis and treatment that may be initiated in the ED. Using the example of peripheral intravenous catheters (PIVC), where a recent study (Pain With No Gain?) demonstrated that 50% of PIVCs inserted in adult patients went  unused, Egerton-Warburton (@First_do_noharm) one of that article’s authors, and Ieraci (@SueIeraci) contend that investigations and procedures should only be performed in the ED when absolutely necessary. ‘Not doing stuff’ is a difficult paradigm shift as this can challenge current practice and ED attitudes to be ‘hand’s on’, but must to be considered in minimising risk and improving overall care to patients.

Point of care testing in snakebite: an envenomed case with false negative coagulation studies  (#FOAMed) Early detection of venom-induced consumptive coagulopathy (VICC) in Australian snake bite is a key step for initiating anti-venom. Point-of-care (POC) testing for international normalised ratio (INR) and D-dimer are available, and may be used in smaller or rural hospitals where on-site laboratory coagulations studies are not readily available. However, Cubitt and colleagues report a case of severe tiger snake envenoming with VICC where POC testing for INR and D-dimer was falsely normal. This case questions the reliability of current POC testing for snake bite coagulopathy.

Timing of appropriate antibiotics in patients with septic shock: a retrospective cohort study (Abstract) Severe sepsis is a major public health issue in Australasia and around the world, with more than 11% of patients admitted to ICU suffering from this condition. Early antibiotic therapy is known to be highly beneficial in severe sepsis. This retrospective cohort study from Cullen et al, examines factors associated with delay in commencing antibiotics for patients presenting to an ED with severe sepsis.  These delays were greater for those patients not seen by an emergency physician, where the diagnosis of sepsis was not initially considered, and when therapy was deferred pending investigations. Improvement in care of these critically ill patients is needed through raising awareness of this common condition, and ensuring the availability of early senior emergency physician review

Do patients die well in your Emergency Department? (Abstract) The increasing numbers of older patients presenting with acute exacerbations of chronic illness and complex geriatric syndromes pose significant challenges to the practice of emergency medicine in Australasia. This perspective, from Arendts and Lowthian, calls for a proactive approach to geriatric emergency medicine practice, research, education and policy development. There are several areas where ED processes can be improved, including quality of geriatric clinical care in the ED, up-skilling the emergency physician workforce in areas of geriatric medicine and introduction of evidence-based models and systems of care that better meet the needs of older patients. However, the greatest gains in addressing this issue are likely to be achieved outside the ED. As such, a framework for research and policy development is proposed to improve care for older people with less hospital occupancy through strategies that avoid ED attendances, reduce hospital admissions from ED, improve ED clinical care for common geriatric presentations and avoid ineffective or futile treatment at times of critical illness

Accelerated diagnostic protocol in the assessment of ED patients with possible acute coronary syndrome (ACS)  (Abstract) George and colleagues short report on the Nambour Short Low-Intermediate Chest (SLIC) pain project outlined a trial implementation of the ADAPT accelerated diagnostic protocol (ADP) on a cohort of ED patients with undifferentiated chest pain and possible ACS, in the context of facilitating the current time-critical access targets (NEAT)  in these patients. This SLIC trial demonstrated that the ADAPT ADP can be safely and effectively implemented in standard local clinical practice. The ADAPT protocol facilitated the early discharge of approximately 20% of ED patients with undifferentiated chest pain, with no adverse events reported within 30 day follow up. This was achieved with a significant reduction in ED LOS and improvement in NEAT performance. The findings suggest that with appropriately validated protocols, safe high quality care can be provided in an environment of increasing demand, performance indicators and cost containment.