Debate continues on the use of tPA in acute ischaemic stroke (AIS). Editorial by Klening et al, address previous (October 2012) criticisms in editorials by Hoffmann & Cooper and Fatovich, arguing that, despite its acknowledged flaws, the Third International Stroke Trial (IST-3) strengthens the evidence for the benefits of thrombolysis within up to 6 hours of AIS and also shows a corresponding benefit for elderly patients. They call on emergency physicians to collaborate on shortening onset to thrombolysis delivery time, and examining further improvements to this therapy. Bladin et al in their letter, also dispute these previous criticisms contending that the IST-3 methodology, inclusion criteria and analysis were appropriate and recognised the strengths of the trial, with updated systematic reviews and meta-analysis supporting IST-3 and confirming the benefit of early treatment with tPA in AIS. In response a letter from Hoffmann & Cooper, reiterates that the primary outcome measure for IST-3 strongly demonstrated not only an absence of benefit, but probable harm. Fatovich responds, by questioning the reliance on meta-analyses to support stroke thrombolysis, particularly as the integrity of one of the only two positive stroke lysis studies in this evidence base has been recently challenged. Fatovich reiterates the ACEM position statement: “There is insufficient evidence for stroke thrombolysis to be considered a standard of care.”
If high-risk patients could be identified it may be possible to avert MET calls, ICU admission or even deaths soon after admission from the ED. Loekito and colleagues in a first of its kind, retrospective observational study focused on a comprehensive evaluation of laboratory tests in undifferentiated ED patients. They provide proof-of-concept evidence that combinations of 9 common laboratory measurements – including full blood count, urea, electrolytes and creatinine, liver function and blood gases – can assist in identifying high-risk ED patients. Nickson in a FOAMededitorial review of this study, notes that while the thresholds used by Loekito et al for optimal diagnosis rates result in very high negative predictive values, that positive combined laboratory measurements are limited by high false positive rates reducing the predictive value. Nickson suggests including lactate into the suite of laboratory measurements, and combining physiological parameters with the laboratory markers to improve the predictive value. Appropriate clinical responses to these measurement alerts and impact on patient care also needs further study.
Pain is the most common presenting symptom to EDs. Implementation of the National Pain Management Initiative to improve analgesic practice in EDs was analysed by Doherty et al across 45 Australian hospitals. Clinically important improvements in documentation of pain scores and reducing time to analgesia (TTA) were reported as a result of this initiative. Ducharme’s editorial (FOAMed), criticises this study for focusing on surrogate makers for pain management – TTA and pain score documentation – noting that, while these markers were improved by the study intervention, there was no improvement in patient pain relief when assessed at one hour after arrival. Ducharme argues that there is too much focus on pain scales and that a change in mindset to a more patient-centred approach is required. Thus clinicians should pay closer attention to actual patient outcomes, titrating opioid dose in order to achieve adequate pain relief to the satisfaction of the patient.
Patients with advanced cancer regularly present to EDs. Jelinek and co-workers, in an exploratory study of issues in managing advanced cancer patients in EDs, describe emergency clinicians being ‘caught in the middle’ in caring for cancer patients with complex needs and conflicting priorities. However, there is broad support for the important role that EDs play, despite the limitations in the care environment and resources in providing access and care to patients with advanced cancer. Ieraci editorial (FOAMed) extends the themes from this study , to consider broader issues of end of life care that are becoming a more common component of emergency medicine practice. Ieraci argues that a “good death” requires planning and preparedness from all involved in the care chain – including the patient, family and carers, nursing, and community and subspeciality clinicians – with emergency physicians being prepared to take leadership in initiating the management of the dying process
Operational management of the ED clinical setting is essential to ensure timely and high quality care. Traditionally trainee emergency physicians learn this skill, in a somewhat ad hoc manner, through ‘in charge overnight’ rostering. Craig and Dowling evaluate a pilot study , undertaken in an adult tertiary ED of an innovative educational program of FACEM-supervised daytime ‘registrar in charge’ (RIC) shifts. Feedback from registrars and senior (FACEM) clinicians was positive, with little negative impact on departmental function reported. RIC shifts are feasible and acceptable, enabling the registrar to experience ED management, with opportunity for useful feedback, under the supervision of an experienced emergency physician. Further the editorial by Celenza, likens clinical decisions-making in emergency medicine – spanning from fuzzy logic to the Gestalt recognition of emergent patterns in the diagnosis of the undifferentiated patient – to ED operational management. While experience is essential, guidance, supervision and feedback are required to ensure trainees develop ED operational expertise.