I think that we should probably not even be asking for such evidence.
As an example. Our Department sees about 90,000 patients a year.
Of these I estimate that about 5% (4500) are 'sick' (ie. outcome
lived/died can be influenced by treatment seniority). Of these 4500 I
estimate that 150 die in the first 48 hours (the time in which
seniority of A&E doc will have most effect). As a proportion of the
'sick' this is 0.0334.
Imagine that having a senior A&E Doc present prevents 20% of
deaths!!!!! If so the number of deaths per year would be 120 (0.0267
as a proportion).
A sample size calculation on this (unrealistically large) difference
tells us that with a Power (Beta value) of 80% and an Alpha value of
5% we would need 10500 'sick' patients to be seen by a consultant
and 10500 'sick' patients to be seen by a junior to find this
difference.
As 'sick' patients are 5% of the workload, this study would require
the randomisation of about half a million patients.
If the ability of a senior A&E doctor to prevent death is less than
20%, then the number of patients required would go up substantially.
My advice would be that we should not require Level 1 evidence in
the debate about the effect of seniority of A&E care on mortality
unless we are prepared to do this study!!
Tim.
> I'm not aware of any study looking at the benefits of having Senior
> A&E doctors seeing acute medical patients. I would have thought it was
> self evident that there would be an improvement, because you wouldn't
> have the most inexperienced doctors seeing the sickest patients.
> Probably preferable to saying the "thickest seeing the sickest".
>
Timothy J Coats MD FRCS FFAEM
Senior Lecturer in Accident and Emergency / Pre-Hospital Care
Royal London Hospital, UK.
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