Quarterly EJEM Research Round-up

Welcome to the quarterly European Journal of Emergency Medicine (EJEM) research round-up, where we present our top picks from the last three months of EJEM editions.

by Youri Yordanov, Associate Editor

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In a recently published study, Coisy et al[1], explored whether emergency medicine healthcare workers rate the triage level of patients with chest pain differently based on gender and ethnic appearance. Conducted as an international cross-sectional survey, the study involved 1,563 emergency department physicians, residents, and nurses from France, Belgium, Switzerland, and Monaco. The participants were presented with a standardized clinical case of a 50-year-old patient reporting chest pain and were asked to assign a triage priority level from 1 (requiring immediate treatment) to 5 (able to wait up to 2 hours). This unique clinical scenario was paired with one of eight randomized images depicting patients of different genders (male/female) and ethnic appearances (White, Black, North African, Southeast Asian).

The study’s key findings revealed that male patients were more likely to be classified as higher priority than female patients, with 62% of males versus 49% of females being rated as requiring immediate emergency care. When comparing ethnic appearances, Black patients were less likely to be classified as high priority compared to White patients (47% vs 58%). North African patients were rated the highest priority at 61%, followed by White (58%), Southeast Asian (55%), and Black patients (47%). Additionally, the perceived pain intensity was rated lower for female patients compared to males, with scores of 5.4 versus 6.0 out of 10, respectively. The study also found that physicians and residents, as well as those with more clinical experience, were more likely to rate cases as higher priority.

The researchers concluded that the images of patients with different characteristics significantly influenced the prioritization decisions for what was otherwise an identical clinical case. These findings suggest the presence of potential gender and ethnic biases in emergency triage assessments. The study’s strengths include its large sample size, randomized design, use of standardized cases, and statistical corrections for multiple comparisons. However, the study also had limitations, such as the potential lack of representativeness of the sample, the differences in AI-generated patient images beyond just gender and ethnicity, and the absence of data on the ethnicity of the respondents.

These findings align with previous research that shows longer emergency department wait times for non-White patients and a tendency to consider women's cases as less serious than men’s, even when their clinical presentations are similar. These results might reflect biases rooted in clinical experience or medical education, where certain groups may be overrepresented in case studies.

The study underscores the importance of addressing potential disparities in emergency care to enhance equity. The authors also emphasize that while initial triage differences were observed, this does not necessarily translate into worse overall outcomes, as previous studies have shown mixed results regarding the impact of implicit biases on clinical decision-making.

The researchers suggest several implications from their findings. These include the need to carefully address ethnic discrimination in medical education, the importance of recruiting more ethnic minority practitioners in emergency departments, the development of standardized triage competencies in medical and nursing education, and the improvement of pain assessment and treatment equity in emergency departments.

In conclusion, the visualization of simulated patients with different characteristics modified healthcare workers' prioritization decisions for chest pain cases. Compared to White patients, Black patients were less likely to be prioritized for emergency treatment, and women were rated as less urgent compared to men. This study advocates for healthcare professionals to acknowledge the potential for assessment bias based on gender and ethnicity.

The EUSEM Syncope Group's just published a paper titled "The Syncope Core Management Process in the Emergency Department: A Consensus Statement of the EUSEM Syncope Group"[2]. In this paper they emphasize the need for a standardized approach to managing syncope in European emergency departments. Syncope, which is a temporary loss of consciousness caused by a sudden drop in blood pressure, accounts for about 1-5% of ED visits. However, managing syncope effectively is challenging due to the wide range of potential causes for transient loss of consciousness (TLOC), of which syncope is just one subset.

The paper underlines the importance of distinguishing syncope from other non-syncopal causes of TLOC to ensure that patients receive appropriate care. Although the European Society of Cardiology issued guidelines in 2018 for managing syncope in EDs, these guidelines lack the detailed, process-oriented instructions needed to guide clinical practice effectively.

The manuscript primary objective was to establish a European consensus on the management of syncope in emergency departments, focusing on the creation of a universal process pathway. This pathway aims to standardize the initial evaluation and care of patients presenting with TLOC, ensuring that life-threatening conditions are ruled out and that patients are appropriately risk stratified. The study also developed a practical flowchart algorithm that can be adapted for use in various emergency departments settings across Europe.

To develop this consensus, the researchers used a modified Delphi process, which involved multiple rounds of feedback from European experts in emergency medicine and cardiology. This process resulted in the creation of an extended event process chain (eEPC), which was then translated into a practice-based flowchart algorithm.

The study successfully developed a universal process pathway, encapsulated in the eEPC, to ensure that all patients presenting with TLOC are systematically evaluated to determine whether they experienced syncope or another form of TLOC. The pathway prioritizes ruling out life-threatening conditions, categorizing patients into low, intermediate, or high-risk groups, and guiding further management based on this stratification. It also emphasizes the importance of distinguishing syncope from other causes of TLOC, such as seizures or psychogenic events. The eEPC serves as a blueprint that can be adapted to the specific resources and protocols of various emergency departments.

?This consensus statement and the resulting process pathway represent a significant advancement toward standardizing syncope management in European emergency departments.

?The study by Duclos et al. [3] investigates the impact of adherence to regional trauma management guidelines on mortality rates among trauma patients. Trauma is a major cause of death, particularly within the first 24 hours post-injury, and accounts for a significant proportion of deaths in Europe. In 2017, trauma caused 39,869 deaths in Europe, representing 8% of total deaths. In France, an epidemiological study reported approximately 140,000 trauma admissions in 2016, with a mortality rate of 6%.

The primary objective of the study is to evaluate the association between guideline adherence and survival rates at 28 days post-injury. Secondary objectives include examining the impact of compliance on mortality at 6 months, especially in patients with severe injuries. The study hypothesizes that higher compliance with regional trauma management guidelines will lead to lower mortality rates.

The researchers conducted a retrospective observational study in two urban regional trauma centers in Marseille, France, throughout 2019. The study followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines and included adult trauma patients who required pre-hospital management and were subsequently admitted to the emergency department or to an intensive care unit. Patients under 18, those without pre-hospital medical team contact, those who died before hospital admission, and those with incomplete medical records were excluded from the study. Data were collected from electronic medical records, and compliance with regional guidelines was evaluated using a list of 30 items, which included aspects such as global assessment, treatment, imaging, and care timelines. The overall compliance rate for each patient was calculated based on the number of compliant items out of the total applicable items.

Out of 7,269 patients screened, 494 met the inclusion criteria for the study. The median age of patients was 35 years, with 80% being male. Blunt trauma was the most common type of injury, and nearly half of the patients suffered from traumatic brain injury. The overall compliance with the regional guidelines was 63%. The study found that higher compliance was associated with reduced mortality at 28 days, particularly among patients with an Injury Severity Score (ISS) above 23. The mortality rate for the entire cohort at 28 days was 6.7%, and at 6 months, it was 7.5%.

The study suggest a significant association between adherence to guidelines and reduced mortality at 28 days for severely injured patients, with a similar trend observed at 6 months. These findings align with previous research showing that guideline adherence improves survival rates. The study also highlighted challenges in achieving high compliance, especially when multiple guidelines must be followed simultaneously. It suggested that tools such as electronic checklists could improve compliance rates, as seen in other medical contexts.

In conclusion, the study by Duclos et al. [3] underscores the importance of strict adherence to regional trauma management guidelines in improving survival rates, particularly for severely injured patients. The findings suggest that enhancing compliance through tools like electronic checklists could further reduce mortality rates, contributing to better trauma care in regional healthcare networks.

1 Coisy F, Olivier G, Ageron F-X, Guillermou H, Roussel M, Balen F, et al. Do emergency medicine health care workers rate triage level of chest pain differently based upon appearance in simulated patients? European Journal of Emergency Medicine 2024;31:188.

2 M?ckel M, Catherine Janssens KA, Pudasaini S, Garcia-Castrillo Riesgo L, Moya Torrecilla F, Golea A, et al. The syncope core management process in the emergency department: a consensus statement of the EUSEM syncope group. European Journal of Emergency Medicine 2024;31:250.

3 Duclos G, Heireche F, Siroutot M, Delamarre L, Sartorius M-A, Mergueditchian C, et al. The association between regional guidelines compliance and mortality in severe trauma patients: an observational, retrospective study. European Journal of Emergency Medicine 2024;31:208.

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