K Mackway-Jones

A Delphi study to identify performance indicators for emergency medicine

Objectives: The aim of this study was to identify performance indicators thought to reflect the quality of patient care in the emergency department. Methods: A three round accelerated Expert Delphi study was conducted by email or fax. A panel of 33 experts drawn from the fields of emergency medicine, emergency nursing, professional service users, and patients were consulted. Participants were initially asked to propose performance indicators that reflected the quality of care given in the emergency department setting in the United Kingdom. In the second round these proposals were collated and scored using a 9 point Likert scale; those that had not reached consensus were returned for reconsideration in the light of group opinion. Those statements reaching a pre-defined consensus were identified. Results: 224 performance indicators were proposed. Altogether 36 indicators reached consensus reflecting good departmental performance after round three; 24 of these were process measures. Conclusions: 36 potential indicators of good quality of care in the emergency department in the UK have been identified.

Delphi based consensus study into planning for chemical incidents

Objective: To achieve consensus in all phases of chemical incident planning and response. Design: A three round Delphi study was conducted using a panel of 39 experts from specialties involved in the management of chemical incidents. Areas that did not reach consensus in the Delphi study were presented as synopsis statements for discussion in four syndicate groups at a conference hosted by the Department of Health Emergency Planning Co-ordination Unit. Results: A total of 183 of 322 statements had reached consensus upon completion of the Delphi study. This represented 56.8% of the total number of statements. Of these, 148 reached consensus at >94% and 35 reached consensus at >89%. The results of the process are presented as a series of synopsis consensus statements that cover all phases of chemical incident planning and response. Conclusions: The use of a Delphi study and subsequent syndicate group discussions achieved consensus in aspects of all phases of chemical incident planning and response that can be translated into practical guidance for use at regional prehospital and hospital level. Additionally, areas of non-consensus have been identified where further work is required.

Don't throw triage out with the bathwater

The concept of See and Treat has been heralded as something new and innovative that will ease the plight of emergency departments throughout England. However, anyone who has been in emergency care over the past 20 years will recognise this process as the norm during the early 1980s. Indeed triage was introduced to clinically risk manage this system of first come first serve and to re-direct the focus of scarce nursing and medical staff away from the most minor of presentations. For those who do remember these times there must have been a strong sense of deja vu during their See and Treat workshop. The Department of Health workshops focused on a series of exemplar hospitals who have introduced See and Treat. It is of note that they all appear to have a number of similarities, namely: It would be appropriate to put this information clearly into the public domain so that others can see how close the situation in these hospitals is to their own. Once this is done it will be easier to judge how much of the apparent benefit can be attributed to streaming as compared with See and Treat. We agree with Leaman who describes blocked beds and long trolley waits and questions the appropriateness of diverting senior clinical staff away from more complex cases …

Outpatient diagnosis of pulmonary embolism: the MIOPED (Manchester Investigation Of Pulmonary Embolism Diagnosis) study

Background and objectives: Pleuritic chest pain, a symptom of pulmonary embolism, is a common presenting symptom in the emergency department. The aim of this study was to validate an algorithm for the diagnosis of pulmonary embolism in emergency department patients with pleuritic chest pain. Methods: This was a prospective, diagnostic cohort study conducted in a large UK city centre emergency department. A total of 425 patients with pleuritic chest pain presenting to the emergency department between February 2002 and June 2003 were recruited. Patients scoring a low modified Wells clinical probability of pulmonary embolism, who had a normal latex agglutination D-dimer, were discharged. All others followed a diagnostic imaging protocol to exclude and diagnose pulmonary embolism using PIOPED interpreted ventilation-perfusion scanning, CT pulmonary angiography, and digital subtraction pulmonary angiography. All patients were followed up for three months for evidence of pulmonary embolism or deep vein thrombosis. An independent adjudication committee reviewed all deaths. Results: A total of 408 patients completed the diagnostic algorithm; 86.5% (353/408) were investigated as outpatients, 5.4% (22/408) were diagnosed as having pulmonary embolism, and 98.8% (403/408) were followed up for three months. Of the 381 patients without pulmonary embolism who completed follow up, the incidence of thromboembolic disease was 0.8% (95% CI 0.3% to 2.3%): two patients had pulmonary embolism and one had a deep vein thrombosis. Conclusions: The MIOPED (Manchester Investigation Of Pulmonary Embolism Diagnosis) diagnostic protocol can safely exclude pulmonary embolism in outpatients with pleuritic chest pain.

Planning for chemical incidents by implementing a Delphi based consensus study

This paper provides a practical approach to the difficulties surrounding planning for chemical incidents, based upon the results of a Delphi based consensus study. It is intended to offer advice, which can be implemented at regional and local prehospital and hospital level. The phases of the response that are covered include preparation, management of the incident, delivery of medical support during the incident, and recovery and support after the incident.

Treatment of uncomplicated subungual haematoma

A short cut review was carried out to establish whether nail removal and nail bed repair is better than simple trephining in patients with significant subungual haematoma. Altogether 312 papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Tetanus prophylaxis in superficial corneal abrasions

A short cut review was carried out to establish whether tetanus prophylaxis is indicated after non-penetrating corneal abrasion. Altogether 30 papers were found using the reported search, of which one presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of this best paper are tabulated. A clinical bottom line is stated.

Antibiotics in orbital floor fractures.

A short cut review was carried out to establish whether prophylactic antibiotics are indicated in patients with undisplaced maxillary or orbital floor fractures. Altogether 214 papers were found using the reported search, but none presented any evidence to answer the clinical question. More research is needed in this area and, in the mean time, local advice should be followed.

Reduction of pulled elbows

Report by David Lewis, East Anglian Trainees Checked by Jon Argall, Senior Clinical Fellow A short cut review was carried out to establish whether a pronation manoeuvre is better than a supination manoeuvre for first time reduction of pulled elbow. Altogether 57 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers …

Use of sterile gloves in the treatment of simple wounds

A short cut review was carried out to establish whether the use of sterile gloves during the treatment of simple wounds reduces infections. Altogether 48 papers were found using the reported search, but none presented any evidence to answer the clinical question. More research is needed in this area and, in the mean time, local advice should be followed.