The AfJEM blog
Every quarter, the African Journal of Emergency Medicine, in partnership with several other regional emergency medicine journals, publishes abstracts from each respective journal. Abstracts are not necessarily linked to open access papers, but where green access is available it is linked to. Click 'Read More' to read further.
Structured Clinical Decision Aids Are Seldom Compared With Subjective Physician Judgment, and Are Seldom Superior
From: Schriger DL. Ann Emerg Med. 2017 doi: 10.1016/j.annemergmed.2016.12.004
We determine how often studies that evaluate the performance of an aid for decisionmaking, be it a simple laboratory or imaging test or a complex multielement decision instrument, compare the aid's performance to independent, unaided physician judgment.
This was a cross-sectional survey of all Original Research and Brief Research Report articles in Annals of Emergency Medicine from 1998 to 2015. We included all articles that evaluated the performance of an aid for decisionmaking in assisting a physician with a decision about testing, treatment, diagnosis, or disposition. Two authors independently characterized the intent and purpose of each aid for decisionmaking, determined whether each study had a comparison to unaided physician judgment within the article or in a separate article, and recorded the result of that comparison.
One hundred seventy-one (8.3%) of 2,060 research articles studied the performance characteristics of an aid for decisionmaking, 48 of which were formal clinical decision instruments. Forty of the 171 studies retrospectively analyzed existing databases and therefore could not assess physician judgment. Investigators compared the aid for decisionmaking to physician judgment in 11% (15/131) of the prospective studies, including 15% (6/41) of studies that evaluated a formal clinical decision instrument. For 9 articles that had no comparison to physician judgment, we found 6 unique external publications that compared that aid to physician clinical judgment. The decision aid was superior to clinical judgment in 2 of the 21 studies that contained a comparison.
Physician judgement is infrequently assessed when the performance of an aid for decision making is evaluated, and, when reported, the decision aid seldom outperformed physician judgement.
Ethyl chloride aerosol spray for local anesthesia before arterial puncture: randomized placebo-controlled trial
From: Ballesteros-Peña S. Emergencias. 2017;29:161-6
To compare the efficacy of an ethyl chloride aerosol spray to a placebo spray applied in the emergency department to the skin to reduce pain from arterial puncture for blood gas analysis.
Material and methods
Single-blind, randomized placebo-controlled trial in an emergency department of Hospital de Basurto in Bilbao, Spain. We included 126 patients for whom arterial blood gas analysis had been ordered. They were randomly assigned to receive application of the experimental ethyl chloride spray (n=66) or a placebo aerosol spray of a solution of alcohol in water (n=60). The assigned spray was applied just before arterial puncture. The main outcome variable was pain intensity reported on an 11-point numeric rating scale.
The median (interquartile range) pain level was 2 (1–5) in the experimental arm and 2 (1–4.5) in the placebo arm (P=.72).
Topical application of an ethyl chloride spray did not reduce pain caused by arterial puncture.
Clinical relevance of pharmacist intervention in an emergency department
From: Pérez-Moreno MA. Emerg Med J. 2017 Aug;34(8):495-501
To evaluate the clinical relevance of pharmacist intervention on patient care in emergencies, to determine the severity of detected errors. Second, to analyse the most frequent types of interventions and type of drugs involved and to evaluate the clinical pharmacist's activity.
A 6-month observational prospective study of pharmacist intervention in the Emergency Department (ED) at a 400-bed hospital in Spain was performed to record interventions carried out by the clinical pharmacists. We determined whether the intervention occurred in the process of medication reconciliation or another activity, and whether the drug involved belonged to the High-Alert Medications Institute for Safe Medication Practices (ISMP) list. To evaluate the severity of the errors detected and clinical relevance of the pharmacist intervention, a modified assessment scale of Overhage and Lukes was used. Relationship between clinical relevance of pharmacist intervention and the severity of medication errors was assessed using ORs and Spearman's correlation coefficient.
During the observation period, pharmacists reviewed the pharmacotherapy history and medication orders of 2984 patients. A total of 991 interventions were recorded in 557 patients; 67.2% of the errors were detected during medication reconciliation. Medication errors were considered severe in 57.2% of cases and 64.9% of pharmacist intervention were considered relevant. About 10.9% of the drugs involved are in the High-Alert Medications ISMP list. The severity of the medication error and the clinical significance of the pharmacist intervention were correlated (Spearman's ρ=0.728/p<0.001).
In this single centre study, the clinical pharmacists identified and intervened on a high number of severe medication errors. This suggests that emergency services will benefit from pharmacist-provided drug therapy services.