Re: seniority of doctors I presume you are aware of Jonathon Wyatt's paper
from last year ?
The Association between seniority of A&E doctor and outcome following
trauma
Wyatt JP, Henry J, Beard D
Injury, 1999 30: 165-168
Here are a few others though I know some of them are trauma related. Are
you specifically looking for early 'medical' interventions by senior
people ?
1) Implementation of a two-tier trauma response.
Injury 1998 Nov;29(9):677-83
Ryan JM, Gaudry PL, McDougall PA, McGrath PJ
Department of Emergency Medicine, Westmead Hospital, NSW, Australia.
In this paper in Injury we showed how effective an ED consultant led trauma
team could be in the management of patients with stable trauma protecting
the rest of the hospital and allowing it to continue in patient work
uninterrupted.
OBJECTIVE: To apply a triage tool to patients on their arrival in the
emergency department and determine the efficacy and safety of a two-tier
trauma response. DESIGN: Descriptive prospective audit. SETTING: Principal
urban referral hospital that provides a major trauma service. MATERIALS AND
METHODS: The triage tool designated a major trauma or stable trauma
response. A major trauma designation mobilised a multidisciplinary team and
a stable trauma designation an expedited evaluation by emergency department
staff. Chi-square test and Mann-Whitney U test were used to compare major
and stable trauma designations. Triage accuracy was evaluated using outcome
variables. MAIN RESULTS: 78% of 58 major trauma responses and 30% of 180
stable trauma responses were admitted. The median injury severity score
(and interquartile range) of admitted patients was 9.0 (5.0-19.5) for major
responses and 5.0 (2.0-9.0) for stable responses. The triage tool had a
sensitivity of 65%, specificity of 87%, accuracy (appropriate triage rate)
of 82%, undertriage rate of 8% and overtriage rate of 10%. CONCLUSION: The
triage tool adequately distinguished between patients with and without
major trauma. Undertriaged patients had timely and appropriate referral for
definitive surgical care and had no adverse outcomes.
2) This weeks Lancet also has replies to Fiona Leckeys paper from a few
months ago and are worth reading. She showed improvement in trauma care
over the last 10 years associated with an increase in the seniority of
doctor attending to the patient as a first responder. (validation for the
A&E based trauma team)
Lancet 2000 May 20;355(9217):1771-5
Trends in trauma care in England and Wales 1989-97.
UK Trauma Audit
and Research Network.
Lecky F, Woodford M, Yates DW r
http://www.thelancet.com/newlancet/sub/issues/vol355no9217/article1771.html
3) Here is another example of how good audit supervised by A&E consultants
makes for improved service. Peter Freeland published this letter in the BMJ
recently as a follow up to their recent series about critical incident
monitoring. I guess it demonstrates what would currently be considered as
basic good practice within A&E departments in the UK.:
http://www.bmj.com/cgi/content/full/321/7259/505#resp9
Safety of systems can often be improved
EDITOR We agree with the findings of Espinosa and Nolan's study on reducing
errors made by emergency physicians in reporting radiographs.1 We work at a
district general hospital's accident and emergency department that has
operated an almost identical system for over 10 years, in accordance with
the British Association of Accident and Emergency's guidelines.2
Key points in our department are the rapid return of all radiographs to the
requesting physician; the reporting of the radiographs by consultant
radiologists within 24 hours; the recall of any patients with errors made
in interpreting radiographs by telephone;
and the use of any such radiographs as a teaching exercise for all staff.
Differences in the systems include reporting of plain radiographs within 24
hours in our institution rather than 12 hours, and an additional level of
input in the marking of radiographs as abnormal by radiographers.
Using the experience of the radiographers adds another tier of safety to
the system. The radiographer marks all abnormal radiographs with a red dot.
This part of the system is audited regularly (last audit: sensitivity 93%,
specificity 97%; audit period two weeks, 449 radiographs; true positive
results 80, false positive results 6, false negative results 9, true
negative results 354).
Having such a fail safe system has several effects: patient satisfaction is
subjectively better, with the knowledge that all radiographs are reported;
few complaints are made about misinterpretation; and a culture of learning
and cooperation exists
among junior staff.
Continuous audit data show a remarkably low rate of clinically important
misinterpretation: 0.64% of plain radiographs per month (mean 6.84 events
per month, mean 1069 radiographs per month; range 0% (0/1049) to 1.4%
(16/1151) per month, data from 90 consecutive months). This compares with
the rate of false negative errors of 0.3% (0.26% to 0.34%) in Espinosa and
Nolan's study.
This is an excellent systematic approach to what is an error prone
activity, reducing mistakes by accident and emergency staff (often junior),
increasing patient satisfaction, and reducing long term patient morbidity
and litigation. We think that this is the type of approach alluded to in
another article in the same issue, by Barach and Small, applied in a
medical context.3
Peter Freeland, consultant in accident and emergency medicine.
St John's Hospital at Howden, Livingston, West Lothian EH54 6PP
1.
Espinosa J, Nolan T. Reducing errors made by emergency physicians in
interpreting radiographs: longitudinal study. BMJ
2000; 320: 737-740[Abstract/Full Text]. (18 March.)
2.
Clinical Services Committee, British Association for Accident and
Emergency Medicine. X-ray reporting for accident
and emergency departments. London: BAEM, 1983. (Currently under
revision.)
3.
Barach P, Small S. Reporting and preventing medical mishaps: lessons
from non-medical near miss reporting systems. BMJ
2000; 320: 759-763[Full Text]. (18 March.)
I hope some of these are helpful but we do need to perform more research
that shows what we are doing in A&E at a senior level is reflected in good
outcomes for patients.
John Ryan
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