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1’s and 0’s of wisdom: Don’t be afraid

Monday, November 4th, 2019 | Rory | 2 Comments

Gutenstein M. Daring to be wise: We are black boxes, and artificial intelligence will be the solution. Emergency Medicine Australasia. 2019 Oct;31(5):891–2. EZProxy link

A very well written and thoughtful piece on the future of emergency medicine in a technologically advanced age. There are many similarities between emergency and rural medicine – e.g. just substitute overwhelming patient and time pressure with (professional and geographic) isolation and workforce shortages – and the technology is and will have a very positive effect on the care of our patients – if we let it. I don’t think we will lose our jobs, we will work differently – hopefully more enabled, with more compassion and more satisfaction (and more time at the beach?)

Abstract

Emergency physicians seek wisdom through personal resilience, deliberate reasoning, clinical consensus and reflective practice. However, there is a limit to how useful psychological training, clinical guidelines and audit initiatives can be in the face of inherent human fallibility, increasing system complexity and escalating demand. Wisdom may be more easily attained through the careful design of new technology and this should be a priority for the emergency medicine community.

Marc is a convener of GENA 723 Trauma and Emergency Medicine in Rural Settings and the Rural Inter-professional Simulation Course. You can find out about both these courses at the Rural Postgraduate Page

Development of the Rural Inter-professional Simulation Course

Monday, February 18th, 2019 | Rory | No Comments

RISC

Gutenstein M, Kiuru S, Withington S. Development of a Rural Inter-professional Simulation Course: an initiative to improve trauma and emergency team management in New Zealand rural hospitals. Journal of Primary Health Care [Internet]. 2019 [cited 2019 Feb 17]; Available from (Open Access): http://www.publish.csiro.au/?paper=HC18071

Fresh publication from three conveners from the Rural Postgraduate Programme and founders of the RISC. A very topical publication especially given two papers recently published (by the same author) in two Australian Journals detailing that rural doctors want and need more training in emergency and trauma.(1,2) Perhaps NZ is ahead of the game on this one!

Information about RISC

Abstract

BACKGROUND AND CONTEXT: New Zealand is a largely rural nation. Despite the regionalisation of trauma services, rural hospitals continue to provide trauma and emergency care. A dedicated rural inter-professional team-based simulation course was designed, as part of a wider strat- egy of using simulation-based education to address the disparity in experience and training for rural hospital teams providing emergency and trauma care.

ASSESSMENT: A pre-course questionnaire identified learning needs. Post-course evaluationand a follow-up survey assessed participants’ perception of the course, and whether lasting changes in clinical or organisational practice occurred.

RESULTS: Three courses were provided over 2 years to 60 interprofessional participants from eight rural hospitals. The course employed an interprofessional faculty and used skill work-shops and high-fidelity trauma simulations to address learning needs identified in pre-courseresearch. Evaluation showed the course to be an effective learning experience for partici- pants. The post-course survey indicated possible lasting changes in team performance and rural hospital protocols. This educational strategy also allowed the collection of research data for investigating rural team dynamics and interprofessional learning.

STRATEGIES FOR IMPROVEMENT: Further development of rural interprofessional simulation courses should include more diverse clinical content, including paediatric and medical sce-narios. Participant access was sometimes limited by typical rural challenges such as hospital staffing and locum availability.

LESSONS: Rural simulation-based education is both effective for rural trauma team training and a vehicle for rural research; however, there are challenges to participant access and course sustainability, which echo the rural–urban disparity.

References

1. Pandit T, Ray R, Sabesan S. Review article: Managing medical emergencies in rural Australia: A systematic review of the training needs. Emergency Medicine Australasia. 2019;31(1):20–8.

2. Pandit T, Sabesan S, Ray RA. Medical emergencies in rural North Queensland: Doctors perceptions of the training needs. Australian Journal of Rural Health. 2018;26(6):422–8.

Fluid therapy: A review

Friday, January 18th, 2019 | Rory | No Comments

Fluid therapy in the emergency department: an expert practice review

Harris T, Coats TJ, Elwan MH Fluid therapy in the emergency department: an expert practice review Emerg Med J 2018;35:511–515.

Open Access

Comment:

Take homes: Not sure anything too new here – read the article, it’s free

  • Crystalloid > colloid
  • Balanced (Hartmann, PlasmaLyte) may be > unbalanced (0.9% NaCl)
  • Don’t assume ED patient same as ICU patient – i.e. don’t apply same guidelines – this goes for patients in Rural NZ!
  • Not too much, not too little: guideline driven therapy (e.g. Surviving sepsis) may be detrimental.
  • Assessment of fluid status difficult – need some ED / Rural studies
  • PO safer than IV

Abstract

Intravenous fluid therapy is one of the most common therapeutic interventions performed in the ED and is a long-established treatment. The potential benefits of fluid therapy were initially described by Dr W B O’Shaughnessy in 1831 and first administered to an elderly woman with cholera by Dr Thomas Latta in 1832, with a marked initial clinical response. However, it was not until the end of the 19th century that medicine had gained understanding of infection risk that practice became safer and that the practice gained acceptance. The majority of fluid research has been performed on patients with critical illness, most commonly sepsis as this accounts for around two-thirds of shocked patients treated in the ED. However, there are few data to guide clinicians on fluid therapy choices in the non-critically unwell, by far our largest patient group. In this paper, we will discuss the best evidence and controversies for fluid therapy in medically ill patients.

DOI link

High-STEACS: making a difference?

Friday, October 19th, 2018 | Rory | No Comments

Shah ASV, Anand A, Strachan FE, Ferry AV, Lee KK, Chapman AR, et al. High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome: a stepped-wedge, cluster-randomised controlled trial. The Lancet. 2018 Sep;392(10151):919–28.

Large trial that showed no difference in patient outcomes (mortality, major adverse cardiac events) despite an increase in the number of patients re-classified as having NSTEMI with the high-sens assay compared to a contemporary troponin assay. These patients were older and female (a lower cutoff is used in the high-sens but not the contemporary assay for females).

These Scottish hospitals used the troponin in a different way to that used in most NZ urban hospitals, where there is an accelerated chest pain pathway, which limits external validity. The sites tested at 0hrs and 6–12hrs.

Some NZ rural hospitals use high-sens troponin but most use a point-of-care assay. Few if any use a contemporary troponin, but this is still being reported in community laboratories. It is unclear what this means for those using the point-of-care test.

I think that it is becoming clear that the value of the high-sensitivity troponin assay is in allowing an earlier, rather than a better risk assessment.

deeper analysis at The Bottom Line

Summary

Background High-sensitivity cardiac troponin assays permit use of lower thresholds for the diagnosis of myocardial infarction, but whether this improves clinical outcomes is unknown. We aimed to determine whether the introduction of a high-sensitivity cardiac troponin I (hs-cTnI) assay with a sex-specific 99th centile diagnostic threshold would reduce subsequent myocardial infarction or cardiovascular death in patients with suspected acute coronary syndrome.

Methods In this stepped-wedge, cluster-randomised controlled trial across ten secondary or tertiary care hospitals in Scotland, we evaluated the implementation of an hs-cTnI assay in consecutive patients who had been admitted to the hospitals’ emergency departments with suspected acute coronary syndrome. Patients were eligible for inclusion if they presented with suspected acute coronary syndrome and had paired cardiac troponin measurements from the standard care and trial assays. During a validation phase of 6–12 months, results from the hs-cTnI assay were concealed from the attending clinician, and a contemporary cardiac troponin I (cTnI) assay was used to guide care. Hospitals were randomly allocated to early (n=5 hospitals) or late (n=5 hospitals) implementation, in which the high- sensitivity assay and sex-specific 99th centile diagnostic threshold was introduced immediately after the 6-month validation phase or was deferred for a further 6 months. Patients reclassified by the high-sensitivity assay were defined as those with an increased hs-cTnI concentration in whom cTnI concentrations were below the diagnostic threshold on the contemporary assay. The primary outcome was subsequent myocardial infarction or death from cardiovascular causes at 1 year after initial presentation. Outcomes were compared in patients reclassified by the high-sensitivity assay before and after its implementation by use of an adjusted generalised linear mixed model. This trial is registered with ClinicalTrials.gov, number NCT01852123.

Findings Between June 10, 2013, and March 3, 2016, we enrolled 48282 consecutive patients (61 [SD 17] years, 47% women) of whom 10360 (21%) patients had cTnI concentrations greater than those of the 99th centile of the normal range of values, who were identified by the contemporary assay or the high-sensitivity assay. The high- sensitivity assay reclassified 1771 (17%) of 10 360 patients with myocardial injury or infarction who were not identified by the contemporary assay. In those reclassified, subsequent myocardial infarction or cardiovascular death within 1 year occurred in 105 (15%) of 720 patients in the validation phase and 131 (12%) of 1051 patients in the implementation phase (adjusted odds ratio for implementation vs validation phase 1·10, 95% CI 0·75 to 1·61; p=0·620).

Interpretation Use of a high-sensitivity assay prompted reclassification of 1771 (17%) of 10 360 patients with myocardial injury or infarction, but was not associated with a lower subsequent incidence of myocardial infarction or cardiovascular death at 1 year. Our findings question whether the diagnostic threshold for myocardial infarction should be based on the 99th centile derived from a normal reference population.