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Crilly, Julia; Johnston, Amy NB; Wallis, Marianne; Polong‐Brown, Josea; Heffernan, Ed; Fitzgerald, Gerard; Young, Jesse T; Kinner, Stuart
doi: 10.1111/1742-6723.13300pmid: 31115191
People brought in by police (BIBP) to the ED are a potentially vulnerable group. This narrative scoping review aimed to identify, evaluate and summarise current literature regarding the frequency of presentation, demographic and clinical profile of patients (including reason for presentation), care delivery, and outcomes for people BIBP to the ED, and identify current gaps in knowledge. The review involved searching EMBASE, CINAHL and PubMed using a combination of terms: emergency/ED coupled with police custody/watch house or police presentation, for papers published in English language from January 2006 to November 2017. A total of 20 studies met the inclusion criteria. These included 17 observational (non‐randomised controlled trials) quantitative studies and three descriptive case reports. The proportion of presentations to ED that were BIBP varied depending on the study design and sampling frame. People BIBP often presented with mental health problems, substance use problems, aggressive behaviour and injury caused by self or others. Of studies focused specifically on patients arriving to the ED in mental health crisis (i.e. suicidal ideation or self‐harm), 18–27% were BIBP. ED presentations BIBP were mostly male and typically younger than people arriving by other means. The nature of care provided in the ED and outcomes of the acute episode of care were typically not well described. Limited research regarding people BIBP to the ED limits the ability to comprehensively understand their demographic and clinical profile and outcomes of emergency care. Further research is required to inform if and where in the patient’s journey further improvements may be targeted.
Long, Elliot; Craig, Simon; Babl, Franz E; Tavender, Emma; Lunny, Carole
doi: 10.1111/1742-6723.13298pmid: 30989835
In this series we address important topics for emergency clinicians who either participate in research as part of their work, or use the knowledge generated by research studies. Emergency clinicians are routinely in the position of applying new evidence in clinical practice. With an ever‐increasing volume of evidence generated, this can be problematic when studies are conducted in different settings, and include different patient groups, different interventions and different outcomes. This is made even more difficult when the results of primary research studies do not agree. Systematic reviews are becoming increasingly valuable as they appraise and synthesise research findings using a clear methodology, and summarise the results of primary studies. As such, systematic reviews help translate research findings into clinical practice. This paper provides a practical starting point for understanding the steps involved in conducting a systematic review in emergency medicine and will help readers appraise the findings of systematic reviews.
Hanning, Jennifer; Walker, Katherine J; Horrigan, Diane; Levinson, Michele; Mills, Amber
doi: 10.1111/1742-6723.13303pmid: 31044525
Goals‐of‐care discussions at end‐of‐life are associated with increased patient satisfaction and reduced treatment burdens, reduced family and healthcare worker distress and healthcare costs, while achieving equal life‐expectancy. It is unclear how goals‐of‐care discussions should occur. The objective of the study was to determine which patients could benefit, requirements, content, documentation, and harms and benefits of emergency medicine goals‐of‐care discussions. We sought primary evidence on goals‐of‐care discussions in EDs with adult patients nearing end‐of‐life, published in English after 1989. Data sources included Medline, Embase, PsycINFO, CINAHL, Web of Science and reference lists of included articles. One thousand nine hundred and twenty abstracts were screened, five articles selected. There was no consensus on the meaning of goals‐of‐care, which is often confused with advanced care planning and treatment limitation. Emergency clinicians can identify most patients needing discussions following training. There was no evidence for how to involve stakeholders, nor how to adapt conversations to meet cultural and linguistically diverse needs. Expert panels have suggested requirements and content for conversations with little supporting evidence. There was no evidence for how emergency conversations differ to those in other settings, nor for harms or benefits for holding goals‐of‐care conversations in EDs. Increased ED goals‐of‐care conversations increased hospice referral and reduced in‐patient admissions. Most studies were of moderate quality only, outcomes were not standardised and sample sizes were small. ‘Goals‐of‐care’ is used inconsistently across the literature. This is the first systematic review regarding goals‐of‐care discussions in EDs. Further research is needed on all aspects of these conversations.
Fouche, Pieter F; Stein, Christopher; Jennings, Paul A; Boyle, Malcolm; Bernard, Stephen; Smith, Karen
doi: 10.1111/1742-6723.13304pmid: 31041848
Endotracheal intubation is an advanced airway procedure performed in the ED and the out‐of‐hospital setting for acquired brain injuries that include non‐traumatic brain pathologies such as stroke, encephalopathies, seizures and toxidromes. Controlled trial evidence supports intubation in traumatic brain injuries, but it is not clear that this evidence can be applied to non‐traumatic brain pathologies. We sought to analyse the impact of emergency intubation on survival in non‐traumatic brain pathologies and also to quantify the prevalence of intubation in these pathologies. We conducted a systematic literature search of Medline, Embase and the Cochrane Library. Eligibility, data extraction and assessment of risk of bias were assessed independently by two reviewers. A bias‐adjusted meta‐analysis using a quality‐effects model pooled prevalence of intubation in non‐traumatic brain pathologies. Forty‐six studies were included in this systematic review. No studies were suitable for meta‐analysis the primary outcome of survival. Thirty‐nine studies reported the prevalence of intubation in non‐traumatic brain pathologies and a meta‐analysis showed that emergency intubation was used in 12% (95% CI 0–33) of pathologies. Endotracheal intubation was used commonly in haemorrhagic stroke 79% (95% CI 47–100) and to a lesser extent for seizures 18% (95% CI 10–27) and toxidromes 25% (95% CI 6–48). This systematic review shows that there is no high‐quality clinical evidence to support or refute emergency intubation in non‐traumatic brain pathologies. Our analysis shows that intubation is commonly used in non‐traumatic brain pathologies, and the need for rigorous evidence is apparent.
Turner, Damian; Winter, Suzanne; Winkel, Kenneth; MacIsaac, Christopher; Padula, Andrew; Braitberg, George
doi: 10.1111/1742-6723.13327pmid: 31207174
We want to discuss antivenom use in snakebite clinical practice guidelines. Coronial reviews in Victoria of two cases of snakebite envenomation, one described in detail below, prompted us to submit this paper for a wider audience and debate. Venom and antivenom levels were measured in the case detailed below, but not in the other. The coroner received conflicting and varied advice from experts regarding the dose of antivenom. The Victorian Department of Health and Human Services and the Australasian College for Emergency Medicine were instructed to review snakebite management guidelines, particularly with respect to antivenom dosage. The discussion that took place among medical experts led to considerable media attention. We discuss the potential fallout when there is no consensus among medical experts.
Babl, Franz E; Pfeiffer, Helena; Dalziel, Stuart R; Oakley, Ed; Anderson, Vicki; Borland, Meredith L; Phillips, Natalie; Kochar, Amit; Dalton, Sarah; Cheek, John A; Gilhotra, Yuri; Furyk, Jeremy; Neutze, Jocelyn; Lyttle, Mark D; Bressan, Silvia;
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doi: 10.1111/1742-6723.13202pmid: 30477046