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212
LETTERS TO THE EDITOR
nal study found that the number exceeding the 50% threshold on any single medication fell from 339 of 400 to 257 of 400. Furthermore, those meeting the 50% threshold for all 10 medications fell from 12 of 40 doctors (30%) to only 4 (10%). This means that even if only a 50% pass mark was considered acceptable 96% of the doctors still blind prescribed at least one medication. If we define an essential factor to be one with a mean below 1.5, then five factors were considered to be essential: generic name, indications, contraindications, dose and route. Analysis of the original answers provided by the 40 doctors in the original study found that 16 (40%) failed to get all five essential factors correct on any single medication. The greatest number of the 10 medications that any single doctor got all five
essential factors correct was four. Consequently, every single junior doctor blind prescribed at least six of the 10 medications. The results emphasise that although consultants demonstrate considerable variability in their opinion of absolute importance of factors, there is remarkable consistency in which aspects of medication knowledge is expected. The data indicate that training, especially in the area of contraindications of medications, is required. Furthermore, junior doctors need to understand the limitations of their knowledge base and build in robust personal practices to check the critical information, such as contraindications, before prescribing medications to patients.
Competing interests
Reference 1. Starmer K, Sinnott M, Shaban R, Donegan E, Kapitzke D. Blind prescribing: a mixed-methods study of junior doctors’ prescribing preparedness in an Australian emergency department. Emerg. Med. Australas. 2013; 25: 147–53.
Robert ELEY,1 Lyndall SPENCER,2 Katrina STARMER3 and Michael SINNOTT1,2 1 School of Medicine, The University of Queensland, Brisbane, Queensland, Australia, 2Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia, and 3Emergency Department, Cairns Base Hospital, Cairns, Queensland, Australia doi: 10.1111/1742-6723.12198
None declared.
How many emergency departments? Dear Editor, How many ‘EDs’ does Australia have: 122, 1 126, 2 162, 3 181 4 or 203 2 (Table 1)? How many rural hospitals have an emergency area that fails to make the grade: 483 or 406?2 We do not know because national organisations cannot agree when a rural hospital’s emergency service meets the criteria to be called an ‘ED’. How can we decide what rural emergency fa-
TABLE 1.
cilities should do when we cannot even decide what they are? The definition of ‘ED’ and ‘other emergency service’ varies by organisation. The ACEM defines EDs as hospital-based facilities providing round the clock emergency care.5 This statement mandates minimum staffing and resources, but it does not suggest a term for the many rural facilities that lack them.
The Independent Health Pricing Authority’s3 (IHPA) role delineation statement describes roles and required resources for three levels of emergency service and four levels of ED. However, the concept that only patients appropriate to the given role will arrive at small services is unrealistic. IHPA’s own figures show that critically ill patients still present to small rural emergency services.3
Australian sources of emergency department statistics
Source
EDs Other emergency services
Australian Institute of Health and Welfare2 – method 1 Australian Institute of Health and Welfare2 – method 2 National Health Performance Authority1
126
483
203
406
Independent Hospital Pricing Authority3
162
122
Australasian Society for Emergency Medicine4 181
Decision rule for classifying as an ‘Emergency Department’ An emergency facility attached to a large, medium or specialty hospital (peer groups A and B) An emergency facility that submits episode-level data on every presentation AIHW method 1, excluding specialist hospitals and hospitals seeing fewer than 20 000 presentations annually Classification by Emergency Care Advisory Working Group delineation statement Not stated
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
213
LETTERS TO THE EDITOR
The Australian Institute of Health and Welfare 2 (AIHW) classifies facilities as EDs if they submit detailed data about every patient they see. Large, medium and specialty hospitals are mandated to provide these data. However, AIHW classifications become murky because some jurisdictions voluntarily provide data from much smaller services. It is important to note that no patient-level data is submitted for the other 406 Australian emergency facilities (which combined manage 16% of Australia’s emergency presentations2). How many EDs does Australia have? The answer should be 609. That is the number of hospital-based facilities providing their community with an around-the-clock entry point to the wider emergency care system. Resource-based levels are still important. They allow fair discussion
about performance, funding and appropriate models of care. However, there is no clear distinction between EDs and other services. They are a spectrum of facilities engaged in the same task.
Competing interests None declared.
References 1. National Health Performance Authority. Technical Supplement: time patients spent in emergency departments in 2011-12. NHPA; 2012. 2. Australian Institute of Health and Welfare. Australian Hospital Statistics 2011-12. Health services series no. 50. Cat. no. HSE 134. Canberra: AIHW, 2013. 3. Health Policy Analysis. Investigative Review of Classification Systems for
Emergency Care – Literature Review. Sydney: Independent Hospital Pricing Authority, 2013. 4. Lowen R. Directory of Emergency Departments of Australia and New Zealand 2009. Melbourne: Australasian Society for Emergency Medicine, 2009. 5. Australasian College for Emergency Medicine. Statement on the delineation of Emergency Departments. 2012. [Cited 19 Feb 2014.] Available from URL: https://www.acem.org.au/ getattachment/541e19cd-6e5e-48b2 -93f6-7416c43ac13a/Statement-on -the-Delineation-of-Emergency -Departme.aspx
Tim BAKER and Samantha DAWSON Centre for Rural Emergency Medicine, Deakin University, Warrnambool, Victoria, Australia doi: 10.1111/1742-6723.12199
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
212
LETTERS TO THE EDITOR
nal study found that the number exceeding the 50% threshold on any single medication fell from 339 of 400 to 257 of 400. Furthermore, those meeting the 50% threshold for all 10 medications fell from 12 of 40 doctors (30%) to only 4 (10%). This means that even if only a 50% pass mark was considered acceptable 96% of the doctors still blind prescribed at least one medication. If we define an essential factor to be one with a mean below 1.5, then five factors were considered to be essential: generic name, indications, contraindications, dose and route. Analysis of the original answers provided by the 40 doctors in the original study found that 16 (40%) failed to get all five essential factors correct on any single medication. The greatest number of the 10 medications that any single doctor got all five
essential factors correct was four. Consequently, every single junior doctor blind prescribed at least six of the 10 medications. The results emphasise that although consultants demonstrate considerable variability in their opinion of absolute importance of factors, there is remarkable consistency in which aspects of medication knowledge is expected. The data indicate that training, especially in the area of contraindications of medications, is required. Furthermore, junior doctors need to understand the limitations of their knowledge base and build in robust personal practices to check the critical information, such as contraindications, before prescribing medications to patients.
Competing interests
Reference 1. Starmer K, Sinnott M, Shaban R, Donegan E, Kapitzke D. Blind prescribing: a mixed-methods study of junior doctors’ prescribing preparedness in an Australian emergency department. Emerg. Med. Australas. 2013; 25: 147–53.
Robert ELEY,1 Lyndall SPENCER,2 Katrina STARMER3 and Michael SINNOTT1,2 1 School of Medicine, The University of Queensland, Brisbane, Queensland, Australia, 2Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia, and 3Emergency Department, Cairns Base Hospital, Cairns, Queensland, Australia doi: 10.1111/1742-6723.12198
None declared.
How many emergency departments? Dear Editor, How many ‘EDs’ does Australia have: 122, 1 126, 2 162, 3 181 4 or 203 2 (Table 1)? How many rural hospitals have an emergency area that fails to make the grade: 483 or 406?2 We do not know because national organisations cannot agree when a rural hospital’s emergency service meets the criteria to be called an ‘ED’. How can we decide what rural emergency fa-
TABLE 1.
cilities should do when we cannot even decide what they are? The definition of ‘ED’ and ‘other emergency service’ varies by organisation. The ACEM defines EDs as hospital-based facilities providing round the clock emergency care.5 This statement mandates minimum staffing and resources, but it does not suggest a term for the many rural facilities that lack them.
The Independent Health Pricing Authority’s3 (IHPA) role delineation statement describes roles and required resources for three levels of emergency service and four levels of ED. However, the concept that only patients appropriate to the given role will arrive at small services is unrealistic. IHPA’s own figures show that critically ill patients still present to small rural emergency services.3
Australian sources of emergency department statistics
Source
EDs Other emergency services
Australian Institute of Health and Welfare2 – method 1 Australian Institute of Health and Welfare2 – method 2 National Health Performance Authority1
126
483
203
406
Independent Hospital Pricing Authority3
162
122
Australasian Society for Emergency Medicine4 181
Decision rule for classifying as an ‘Emergency Department’ An emergency facility attached to a large, medium or specialty hospital (peer groups A and B) An emergency facility that submits episode-level data on every presentation AIHW method 1, excluding specialist hospitals and hospitals seeing fewer than 20 000 presentations annually Classification by Emergency Care Advisory Working Group delineation statement Not stated
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
213
LETTERS TO THE EDITOR
The Australian Institute of Health and Welfare 2 (AIHW) classifies facilities as EDs if they submit detailed data about every patient they see. Large, medium and specialty hospitals are mandated to provide these data. However, AIHW classifications become murky because some jurisdictions voluntarily provide data from much smaller services. It is important to note that no patient-level data is submitted for the other 406 Australian emergency facilities (which combined manage 16% of Australia’s emergency presentations2). How many EDs does Australia have? The answer should be 609. That is the number of hospital-based facilities providing their community with an around-the-clock entry point to the wider emergency care system. Resource-based levels are still important. They allow fair discussion
about performance, funding and appropriate models of care. However, there is no clear distinction between EDs and other services. They are a spectrum of facilities engaged in the same task.
Competing interests None declared.
References 1. National Health Performance Authority. Technical Supplement: time patients spent in emergency departments in 2011-12. NHPA; 2012. 2. Australian Institute of Health and Welfare. Australian Hospital Statistics 2011-12. Health services series no. 50. Cat. no. HSE 134. Canberra: AIHW, 2013. 3. Health Policy Analysis. Investigative Review of Classification Systems for
Emergency Care – Literature Review. Sydney: Independent Hospital Pricing Authority, 2013. 4. Lowen R. Directory of Emergency Departments of Australia and New Zealand 2009. Melbourne: Australasian Society for Emergency Medicine, 2009. 5. Australasian College for Emergency Medicine. Statement on the delineation of Emergency Departments. 2012. [Cited 19 Feb 2014.] Available from URL: https://www.acem.org.au/ getattachment/541e19cd-6e5e-48b2 -93f6-7416c43ac13a/Statement-on -the-Delineation-of-Emergency -Departme.aspx
Tim BAKER and Samantha DAWSON Centre for Rural Emergency Medicine, Deakin University, Warrnambool, Victoria, Australia doi: 10.1111/1742-6723.12199
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
