How evidence based are therapeutic decisions taken on a medical admissions unit?

OBJECTIVES: To audit the proportion of drug treatments started on a medical admissions unit that is justified by published evidence, and the proportion for which no justification could be found. METHODS: Retrospective review of randomly selected case notes to identify drug treatments started and the problem(s) for which they were prescribed, followed by literature searches. RESULTS: A total of 132 treatment-problem pairs were found, comprising 85 unique treatment-problem pairs. An evidence base was found in support of 78 of the treatments started (59.1%). A further 41 treatment-problem pairs could be argued to be reasonable practice (sometimes included in guidelines), even though no published trial data support them. Ninety per cent of drug treatments started on the medical admissions unit have either an evidence base or are accepted practice. CONCLUSIONS: Regular audit of this nature could be carried out on units admitting acute medical patients. Similar audits in internal medicine have delivered consistent results (50%-60%); there is a baseline level against which units can compare themselves. Clinical audit is an integral feature of clinical governance; all wards admitting acute medial patients could conduct similar audits on a random sample of patients.

Emergency management of diabetic ketoacidosis in adults.

The authors propose a regimen for managing diabetic ketoacidosis in adults based on available evidence and their experience in the emergency department.

Decision making by emergency physicians when assessing cardiac arrest patients on arrival at hospital.

OBJECTIVE: To investigate the factors which influence decision making by experienced emergency physicians when they decide whether to (a) pronounce 'life extinct' in adult patients with non traumatic cardiac arrest while in the ambulance, or (b) bring them into the resuscitation room in the Emergency Department for further assessment/management. DESIGN: Qualitative study involving semi structured interviews and a focus group. SETTING: Accident & Emergency (A&E) departments in the Yorkshire region. PARTICIPANTS: Fifteen emergency physicians (two clinical fellows, nine specialist registrars and four consultants) working in the Yorkshire region. RESULTS: Six main themes were identified that impacted upon the decision making process: the doctor's past experience, ambulance service issues, prehospital care, patient characteristics, presence and views of relatives, and organisational issues. CONCLUSION: The reasoning behind decisions made when a patient arrives at the Emergency Department in cardiac arrest is multifactorial. Strict guidelines would be difficult to construct since individuals vary in the importance they attach to different factors.

Critical appraisal of papers describing triage systems.

This article seeks to provide readers with a framework to enable them to assess the quality of the published description or evaluation of a triage system. Similarities between the triage process and the process of diagnosis and the nature of clinical decision rules are noted. Criteria that triage evaluations should meet are recommended, based on methodology suggested from evidence-based medicine, the development of clinical decision rules, and evaluation of diagnostic tests.

Flow diagram or prose: does the format of practice guidelines matter?

The aim of this study was to compare the performance of two formats (prose and flow diagram) of the guidelines for management of paracetamol poisoning, and to assess the likely performance without access to the guidelines. A prospective questionnaire study of the management of seven hypothetical cases of paracetamol ingestion was carried out by accident and emergency senior house officers at a regional induction course. No differences were found between the two formats. The proportion of correct answers was 37% in the flow diagram and 31% in the prose group (95% confidence interval for the difference -8% to 20%). In the group with neither format of the guideline the proportion of correct answers was lower: 19% (95% confidence interval for the difference between this group and the group with flow charts 6.9% to 30.6%, for the difference between this group and the group with the prose format 0.4% to 24.8%). The time taken to answer the questions did not vary between the groups. These data do not support the exclusive use of either format. They suggest that management of paracetamol poisoning is less likely to be correct if staff do not have access to the guidelines.

What do accident and emergency medical staff think of practice guidelines?

The objective of this paper was to determine the views of accident and emergency consultants and trainees towards practice guidelines and their experiences using guidelines. A postal questionnaire survey of consultants, senior registrars and registrars in accident and emergency medicine was carried out in Yorkshire. The results of this survey show that the potential benefits of practice guidelines are appreciated, and that evidence-based and 'user-friendly' guidelines are wanted. It is concluded that unless rigorously developed and clear and easy to use, guidelines are unlikely to be implemented in accident and emergency departments in the UK.

Reviews in accident and emergency medicine: the past and the future.

OBJECTIVE: To determine whether reviews published in the past 10 years are as helpful as they could be to their readers, and to explain why future reviews should meet certain methodological criteria. METHODS: The quality of 16 reviews published in two journals dealing with accident and emergency medicine over 10 years was objectively assessed using 11 currently recommended criteria. RESULTS: The median number of methodological criteria satisfied was two. Only five of the reviews posed a specific question or problem and then answered this with conclusions based on evidence presented. CONCLUSIONS: If reviews are to enhance patient care, the way in which they are performed, written and used must change.

Do accident and emergency senior house officers know the British guidelines on the management of acute asthma?

Avoidable deaths from asthma continue, even in hospital. Since the management of acute severe asthma is often initiated in the Accident and Emergency department, it is crucial that staff there have adequate knowledge. An anonymous questionnaire, containing items based on chart 6 of the UK guidelines, was completed by 66 Accident and Emergency Senior House Officers from the Yorkshire region. The study aim was to establish these doctors' levels of knowledge about the recommended management of acute asthma in Accident and Emergency. The median score was 10 (out of a possible 24) and the interquartile range 8-13. Further efforts are required to implement these guidelines so that the best patient outcomes can be achieved.