Preceded by several days of slightly fevered media coverage, the Francis Report was finally published in the first week of February.1 Its breadth is wide, its analysis is forensic in detail, its findings are embarrassing (to put it mildly) and its recommendations (all 290 of them) are game changing. If implemented, Francis will have a bigger impact on the NHS than Kennedy did after Bristol. It makes compelling reading.
Here are a few snippets (from the section listing the inquiry's findings) that are of immediate interest to us:
Hospital consultants at Stafford were not at the forefront of promoting change. Clinicians did not pursue management with any vigour with the concerns they may have had. Many kept their heads down. A degree of passivity about difficult personnel issues is all too common in the NHS as, perhaps, elsewhere.
The national general acceptance of the importance...
Tension gastrothorax: a rare cause of breathlessness
A 67-year-old lady presented to the emergency department with a 4 day history of breathlessness for which she had started clarithromycin. She had a history of a hiatal hernia repair in 1996 and had recently started inhalers for presumed chronic obstructive pulmonary disease (COPD). Her pulse was 101 bpm, blood pressure 174/120 mm Hg, respiratory rate 36 and O2 saturations 88% on air. She was clammy, dyspnoeic and auscultation of her chest revealed global wheeze. She was treated for an exacerbation of COPD.
A chest radiograph showed a massive gastrothorax with mediastinal shift (figure 1). Attempts to pass a nasogastric tube were unsuccessful and she rapidly deteriorated, becoming drowsy, dropping her blood pressure to 108/60 mm Hg and O2 saturations to 86% on 60% O2. Some clinical improvement was seen after intubation. A CT chest was performed which demonstrated a volvulus of the stomach with mediastinal shift (figure 2). An emergency...
An alternative way ahead
We had a visit from the Intensive Support Team recently. In common with other Emergency Departments (ED), we have struggled a little to achieve the national 4 h throughput target. The response of our health authority was to send in the IST.
The team, which did not contain an emergency physician, spent about an hour in the department, and of course we were interested to see what they had discovered in an hour which had not been apparent to us over many years. We hoped that their report would recognise that the main causes of our failure to meet the target were the increasing numbers of major cases being brought to the ED, and the inability of our hospital to find accommodation for these patients in a timely fashion.
We were therefore disappointed by the ED section of the report which suggested that senior emergency medicine (EM) physicians should...
BET 2: Immobilisation of stable ankle fractures: plaster cast or functional brace?
Report by: Anna J Thackray, CT3 EM and Jonathan Taylor, CT3 EM
Search checked by: Charlotte E Cross, ST4 Trauma & Orthopaedics
Institution: Manchester Royal Infirmary Abstract
A short-cut review of the literature was carried out to establish whether a functional brace was as good as a traditional plaster of Paris to immobilise a stable ankle fracture in terms of functionality and recovery speed. A total of 260 papers was found using the below outlined search method, of which five were thought to represent the best evidence to answer the specific clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these are shown in table 2. The clinical bottom line is that the limited evidence seems to suggest that a functional brace appears to give more favourable outcomes. Good quality studies involving large populations are, however, needed...
Isolated analysis of one time measure: only seeing part of the picture
Woodcock et al1 highlight that changing the 4 h standard from 98% to 95% resulted in processes adjusting accordingly. But they fail to address the key issue of whether it benefits patients. Their conclusion that this shows that more patients are waiting for care is imprecise and possibly wrong. The 4 h standard relates to the total time spent in the emergency department until discharge or admission to a ward. Care starts much earlier; figures for January 2012 show that the median wait for ambulance cases to be assessed by a healthcare professional (triage) was 3 min (95% seen in 47 min) and the median time for all cases to be seen by a decision making clinician is 49 min (95% in 85 min).2 This has only been collected nationally since April 2011 and so we cannot assess change over the last few years.
The 240 min total time in England stills...
Alcohol: signs of improvement. The 2nd national Emergency Department survey of alcohol identification and intervention activity
To conduct a survey of current alcohol identification and brief advice activity in English Emergency Departments, and to compare the results with the previous survey conducted in 2007.
Cross-sectional survey of all 187 Emergency Departments in England.
Significant increases (p<0.001) in the proportion of departments routinely asking about alcohol, using a screening questionnaire, offering help/advice for alcohol problems, and having access to Alcohol Health Workers or Clinical Nurse Specialists. More than half of all departments indicated that they had an ‘alcohol champion’, and this was significantly associated with access to training on both identification and provision of brief advice (p<0.001). Departments that routinely asked questions were the most likely to use a formal screening tool (p<0.05), and the Paddington Alcohol Test was the most frequently used measure (40.5%).
There have been significant improvements in ED alcohol identification and brief advice activity since 2007 in line with the recommendations of the Royal College of Physicians, Department of Health and NICE guidelines. English EDs are beginning to maximise the likelihood of identifying patients who may benefit from further help or advice about their alcohol consumption, and are able to offer access to specialist staff who can provide appropriate interventions.
A multicentre observational study to evaluate a new tool to assess emergency physicians' non-technical skills
To evaluate a new tool to assess emergency physicians' non-technical skills.
This was a multicentre observational study using data collected at four emergency departments in England. A proportion of observations used paired observers to obtain data for inter-rater reliability. Data were also collected for test-retest reliability, observability of skills, mean ratings and dispersion of ratings for each skill, as well as a comparison of skill level between hospitals. Qualitative data described the range of non-technical skills exhibited by trainees and identified sources of rater error.
96 assessments of 43 senior trainees were completed. At a scale level, intra-class coefficients were 0.575, 0.532 and 0.419 and using mean scores were 0.824, 0.702 and 0.519. Spearman's for calculating test-retest reliability was 0.70 using mean scores. All skills were observed more than 60% of the time. The skill Maintenance of Standards received the lowest mean rating (4.8 on a nine-point scale) and the highest mean was calculated for Team Building (6.0). Two skills, Supervision & Feedback and Situational Awareness-Gathering Information, had significantly different distributions of ratings across the four hospitals (p<0.04 and 0.007, respectively), and this appeared to be related to the leadership roles of trainees.
This study shows the performance of the assessment tool is acceptable and provides valuable information to structure the assessment and training of non-technical skills, especially in relation to leadership. The framework of skills may be used to identify areas for development in individual trainees, as well as guide other patient safety interventions.
Tissue oxygen saturation measurement in prehospital trauma patients: a pilot, feasibility study
This study evaluated the feasibility of prehospital tissue oxygen saturation (StO2) in major trauma patients.
A prospective, pilot feasibility study carried out in a physician based prehospital trauma service.
Prehospital StO2 was recorded on 13 patients. Continuous StO2 monitoring was achieved on all patients, despite intermittent failure of pulse oximetry and non-invasive blood pressure monitoring in six patients. No adverse outcomes of StO2 monitoring were reported. The specific equipment used was reported to be inconveniently bulky and heavy for use in the prehospital setting.
Prehospital measurement and monitoring of StO2 is feasible in trauma patients undergoing prehospital anaesthesia and may be useful in the early identification of shock, triggering of transfusion protocols and guiding fluid resuscitation.