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Saturday 19 October 2019
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Patient safety in emergency medicine

EMERGENCY CARE
The World Health Organization (WHO) defines patient safety as “the prevention of errors and adverse effects to patients associated with health care. While health care has become more effective it has also become more complex, with greater use of new technologies, medicines and treatments. Health services treat older and sicker patients who often present with significant comorbidities requiring more and more difficult decisions as to health care priorities”.1
 
To improve patient safety, the European Society of Anaesthesiology (ESA) and the European Board of Anaesthesiology (EBA) published the Helsinki Declaration on Patient Safety in Anaesthesiology in June 2010. This document, endorsed by all European National Societies of Anaesthesiology, the WHO, the World Federation of Societies of Anaesthesiologists (WFSA), and the European Patients’ Federation (EPF) stated that anaesthesiologists share responsibility for quality and safety in anaesthesia, intensive care, emergency medicine (EM) and pain medicine.
 
Accordingly, anaesthetists have a leading role in the multidisciplinary management of life-threatening emergencies regardless of the model of EM delivery adopted by different countries.2
 
Patient safety and vital function care specialty
Every anaesthetic procedure is a high-risk intervention. Anaesthesiology is, therefore, inseparably linked to patient safety; putting someone to sleep is relatively easy, keeping someone safe under, and after, anaesthesia is the great challenge. Consequently, anaesthesiology as a specialty is solely based around patient safety. This holds true from the very beginnings of modern anaesthesia; Hannah Greener’s death from chloroform in 1847 and the slowly growing understanding that giving an anaesthetic is not a risk-free undertaking stood at the beginning of the long and winding road towards modern resuscitation. Unexpected anaesthesia-related deaths have driven the development of resuscitation as a science, initially only targeting prevention and treatment of anaesthetic deaths but subsequently aiming at the full range of anaesthesia- and surgery-related morbidity.
 
In particular, these resuscitative aspects and the physiological insights into the human vital functions have shaped the specialty of anaesthesiology. This has resulted in an unrivalled accumulation of vital function care expertise within the specialty and to the development of modern sophisticated vital function monitoring routinely used in anaesthesiology. Over the past 150 years the controlled environment of the operating room has been the ‘motor of vital function care’ where anaesthetists have learned to treat the most critical vital function challenges safely and have laid the foundations for intensive care and critical emergency medicine (CREM). In addition to their unsurpassed technical skills, anaesthetists were the first medical specialists to embrace the importance of human factors and non-technical skills in patient safety; simulator training, adopted from the airline industry and the introduction of clinical governance have helped creating an environment that promotes patient safety as its first priority.
 
Moving the anaesthetist’s vital function expertise as critical EM into the emergency department (ED) and further afield is a logical extension of his/her role in the operating room. 
 
The generalist at the hospital’s front door
In EM, the concept of patient safety becomes more complex; this is due to the highly pressured and often overcrowded environment of an emergency department, the huge variety of conditions but also because of the rather broad and ambiguous definition of EM itself. The IFEM (International Federation for EM) defines EM as “a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of episodic undifferentiated physical and behavioural disorders; it further encompasses an understanding of the development of pre-hospital and in-hospital emergency medical systems and the skills necessary for this development”.3
 
The European Society for Emergency Medicine (EuSEM) has defined EM as a ‘specialty’ dealing with ‘urgent and emergency aspects of illness’.4
 
These definitions are wide, generic and somewhat confusing. There is no function differentiation between the acute care specialties and EM, which is essential for a seamless transition of care and there is also no differentiation between emergency and urgent patients; which is crucial to avoid under-prioritising of critical patients. To clarify the latter we suggest adopting the following definitions: 
  • Urgent conditions are acute medical conditions in which delays in treatment are well tolerated; 
  • Emergency conditions, on the contrary, may lead to irreversible damage of single organs or of the entire organism (death) if not immediately and effectively treated.
 
However, in almost all EDs the majority of patients are affected by diseases of low acuity, not needing immediate intervention; only a very small proportion are true emergency patients that are critically ill or injured and in need of immediate intervention (1.5%). To ascertain patient safety for this highly vulnerable patient group the immediate availability of advanced vital function care is essential.
 
Who manages patients in the ED?
We can summarise the different managements of EDs in two European models: 
  • The cross-sectional approach is based on EM as a single specialty taking care of all patients in the ED, regardless of the severity of their illness or injuries. In the UK, for example, this system apparently has reached its limits, with the Royal College of Emergency Medicine and the Royal College of Nursing calling, in their 2016 joint report, ‘The Medicine Needed for the Emergency Care Service’, on the specialties to return to the EDs, because they cannot cope with the workload and complexities under the current pressures;5 
  • The longitudinal approach, by contrast, requires the responsibility for the pathway of critical emergency patients to lie primarily with the corresponding medical specialty. In continental European care systems, this principle has facilitated a direct and seamless translation from specialty expertise (anaesthesiology/ICM, surgery, internal medicine/cardiology or neurology) right into the emergency department and further into the pre-hospital field.
A careful comparison between the two systems suggests that the cross-sectional approach has difficulties to keep pace with innovation. This is not surprising because the translation of expertise, as described above, is possibly hampered by inter-specialty barriers and the impossibility for one specialty to develop an in depth understanding of all conditions prevalent in an ED.
 
A safe emergency medical system is based on the effective interdisciplinary cooperation between specialties.6,7 From the anaesthesiologist’s perspective, the main priority is immediate access to expert vital function support (CREM) for critically unwell patients. This has been achieved by the longitudinal care systems, in which well-organised preset pathways for certain immediately life-threatening conditions are triggered by the pre-hospital emergency service. Multidisciplinary reception teams, immediate availability of massive transfusion, direct shock-room and theatre access, or immediate access to primary percutaneous coronary intervention have been standards of care for more than two decades in the central European and Scandinavian longitudinal care systems. In these well established, mature and high-performing longitudinal care systems, the introduction of EM as a cross-sectional specialty, without a clear function differentiation could jeopardise existing pathways and put patients at risk. Unfortunately there are no robust, evidence-based tools to rate the safety of an emergency system and to guide the executives of emergency care in the governance of patient safety, therefore further research considering established strategies from other high-risk sectors is necessary.8
 
Anaesthesiology is a medical speciality with defined areas of expertise including perioperative anaesthesia care, intensive care medicine and resuscitation, EM and pain medicine, and their organisational and management aspects.9 The necessary life-saving skill set is acquired and maintained under the controlled conditions of an operating room. Anaesthesiological expertise in this area has been recognised as CREM10 and is an integral part of the specialty.11 However, it is important to emphasise that anaesthetists are experts in dealing with life-threatening emergency conditions and not acute medicine. The acute care for non-life-threatening emergencies remains the task of EM, the corresponding specialty or the general practitioner. 
 
Why do anaesthetists have a central role in CREM?
Essential non-technical skills as a high degree of situational awareness and leadership combined with a unique set of technical skills, acquired and developed during routine activities in the operating room and in intensive care, enables the anaesthetist to manage almost all critical conditions safely. The postoperative period, critical care, pre- and in-hospital management of emergency situations have great similarities with the work in the operating room.12 Common principles include: airway management; stabilisation/ normalisation of vital physiologic parameters (respiration, circulation, metabolism, renal function and temperature); providing adequate sedation and analgesia; and maintaining an appropriate fluid balance.12
 
Advanced airway management and endotracheal intubation (ETI) may serve as example to illustrate the caveats non- anaesthetists face in providing vital function care; a practitioner needs to carry out approximately 150–200 ETIs before he can be apply this skill safely without supervision. This level of training is almost impossible to achieve for non-anaesthetists.13 Continued exposure is necessary to retain proficiency. Occasional practice on emergency patients and training on a manikin is not enough.14 An observational study on airway management in early trauma has reported that non-anaesthetists had a higher rate of failed intubation (0.7%) than anaesthetists (0.4%) and were twice as likely to have to perform a rescue airway intervention and this difference was statistically significant.15
 
In most countries, CREM is seen as a natural extension of the anaesthetist’s central role in the operating room and the intensive care unit. In some European countries, a supra-specialty in EM has been established; this supra-specialty is accessible to anaesthetists, surgeons, internal medicine doctors that can opt for two years of EM training following their primary specialisation. This concept combines the longitudinal approach with the cross-sectional requirements of overcrowded EDs and retains the multidisciplinary aspects of emergency care. These supra-specialists could be a bridge between the longitudinal system and the EM-led system.
 
In order to secure and develop immediate availability of vital function expertise for the sickest of our patients, ESA and EBA have approved and endorsed the concept of CREM and have spurred its diffusion in all European countries.
 
Conclusions
In conclusion, an appropriate emergency management system is a chain of care, with strong primary care preventing critical overcrowding of EDs. The system should distinguish between urgent and emergency care and also differentiate unambiguously between the functions of the participating specialties to ensure access to immediate vital function care if required. The latter patient group requires multidisciplinary treatment and participation or lead of an anaesthetist, who through his/her daily work in the operating room has the necessary technical and non-technical skills to coordinate and to carry out life-saving interventions in a timely fashion. 
 
References
1 World Health Organization. www.who.int. 
2 Petrini F et al. The Helsinki Declaration on Patient Safety in Anesthesiology: a way forward with the European Board and the European Society of Anesthesiology. Minerva Anestesiol 2010;76(11):971–7. 
3 International Federation for Emergency Medicine. www.ifem.cc/about/about.htm. 
4 European Society for Emergency Medicine. http://eusem.org/about-us/policy-statement/ (accessed February 2017). 
5 The Royal College of Emergency Medicine. The medicine needed for the emergency care service. www.rcem.ac.uk/RCEM/News/News_2016/The_Medicine_Needed_for_the_Emergency... (accessed February 2017).
6 Devita MA et al. Findings of the First Consensus Conference on Medical Emergency Teams. Crit Care Med 2006;349:2463–78. 
7 Ramlakhan S et al. The safety of emergency medicine. Emerg Med J 2016;33(4):293–9. 
8 Hesselink G et al. Improving the governance of patient safety in emergency care: a systematic review of interventions. BMJ Open 2016 29;6(1):e009837. 
9 De Robertis E et al. Core curriculum in emergency medicine integrated in the specialty of anaesthesiology. Eur J Anaesthesiol 2007;24(12):987–90. 
10 Søreide E et al; Position Paper Task Force. Shaping the future of Scandinavian anaesthesiology: a position paper by the SSAI. Acta Anaesthesiol Scand 2010;54:1062–70. 
11 The Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Pre-hospital and emergency critical care. www.ssai.info/education/critical-emergency-medicine/ (accessed February 2017). 
12 De Robertis E, Tomins P, Knape H. Anaesthesiologists in emergency medicine: the desirable manpower. Eur J Anaesthesiology 2010;27:223–5. 
13 Bernhard M et al. Developing the skill of endotracheal intubation: implication for emergency medicine. Acta Anaesthesiol Scand 2012;56(2):164–71.  
14 Deakin CD et al. Does an advanced life support course give non-anaesthetists adequate skills to manage an airway? Resuscitation 2010;81(5):539–43. 
15 Lockey D et al. Observational study of the success rates of intubation and failed intubation airway rescue techniques in 7256 attempted intubations of trauma patients by pre-hospital physicians. Br J Anaesth 2014;113(2):220–5.