Julia Harris Consultant Emergency Medicine Associate Dean HEE

1. A view from the Emergency Department – Misdiagnosis and delays to treatment in acute abdominal pain Julia Harris Consultant Emergency Medicine Associate Dean HEE

2. Agenda • Decision making in the ED • Abdominal pain in unselected patients presenting to the ED • Commonest diagnoses • Barriers to diagnosis • access to imaging • Delays to diagnosis and treatment • other clinical priorities • The 4 hour target! l

3. Decision making in EM • Triage/streaming • Rapid Assessment • Detailed assessment • Investigations • Referral

4. Triage • Nurse led • Sets the context within which a clinician sees the patient (Framing) • May direct to a non-ED setting • May include fresh observations or “borrow” those from the Ambulance service for decision making • Analgesia/antipyretic administration • Pattern recognition and investigation protocols here

5. Streaming • Very minimal history • Experienced EM nurse • Minimal observations (often take ambulance obs) • Decision outcomes • RESUS • Majors/Pitstop • Minors/UCC/GP

6. Rapid assessment/Pitstop • Encouraged by NHSE • Nurse of doctor led • can be focus for “rule in/out worse scenario” - ROWS • can mislead junior clinicians (“my consultant thinks its x”) • limited information - clinical gestalt • request investigations • Can place patient on incorrect pathway • Direct admit to specialties

7. Detailed assessment • Best/gold standard • TIME • review of ambulance sheets and other information sources • review of investigations • 4 hour target will not allow assessment of impact of interventions hence use of CDU or other clock-stop areas

9. Standards of care • Basic clinical assessment review of vital signs and ambulance/carer/witness information • Supervision • Range of clinical experience and competence • appropriate referral to a specialty team is an acceptable outcome in some cases • Referral decision • referral “viva” vs policies for admission • Safe discharge and safety netting • advice sheets, discharge summaries, specialist/hot clinics

10. Abdominal pain in the ED • 5-10% of patients will have abdominal pain (UK) • causes may be medical, surgical, intra-abdominal or extra-abdominal • “undifferentiated abdominal pain” is the diagnosis at discharge in approx 25% of patients from the ED (and 35-41% of patients admitted!) • of whom 80% are symptom-free at 2 weeks • Older patients have 6-8x increased mortality compared younger patients

11. Italian study 2016 >93 000 ED admissions, admission rate 5.67%

12. Differential diagnosis in unselected patients in ED

14. Junior doctors struggle with.. • Multiple symptoms • Multiple injury • “unexplained” symptoms • recurrent attenders, chronic pain • mental health • rude/aggressive patients • “difficult’ - drugs, domestic violence, police custody, emotionally unstable personality, homeless, language barrier • young children

15. Case 1 23yo woman central colicky abdo pain 8 weeks pregnant vomiting Surgeons in theatre No gynae on-site

16. Case 2 80 yo man woke in night with abdominal pain did not settle with Rennies Comfortable after simple analgesia bloods normal central abdominal tenderness

17. Case 3 67yo man severe back pain alcoholic attendances for pancreatitis direct admit surgery

18. Case 4 45 yr old renal transplant patient Rheumatoid arthritis generalised abdominal pain short of breath

19. Specific diagnoses • Appendicitis • Perforated Duodenal ulcer • Ectopic pregnancy • Cholecystitis • Renal Colic • Abdominal Aortic Aneurysm

20. Appendicitis • Children and younger adults • classically fever, central abdominal pain (midgut) followed by vomiting and then RIF pain, tenderness, guarding and then rebound tenderness (peritonitis), anorexia • retro-caecal and pelvic appendix variations • older patients ay present atypically • A CLINICAL DIAGNOSIS • WCC increased, CRP may be increased • Management of RIF pain but no tenderness

21. Perforated DU • much less common since PPI • upper abdo pain, often radiating to back, vomiting (+/- bile) • aseptic peritonitis early - rigid abdomen, no bowel sounds • shock, tachycardia, low BP • Air under diaphragm on erect CXR

22. Cholecystitis • Constant upper abdo pain, radiating to RUQ and R shoulder (late) • Tender RUQ on deep inspiration (Murphy’s sign) • fever, nausea, vomiting, high WCC • pain after fatty meals (Gallstones) • Biliary colic • colicky right upper abdo pain • may develop jaundice • fever, jaundice and colicky pain, urgent iv antibiotics

23. Renal colic • Loin to groin pain (unilateral) • colicky (can’t keep still) with nausea and vomiting • blood in urine (95%) • may have loin tenderness • care in men (testicular torsion) • CTKUB pathways

24. Abdominal Aortic aneurysm • Older patient, arteriopathic • back pain and shocked • pain may radiate to legs • pulsatile mass in epigastrium • ED USS • divert pathways in vascular networks

25. Abdominal pain in the older patient • Much higher risk • Many departments have a policy to discuss all with ST4+ • Lower threshold for CT scan and admission • Additional diagnoses • ischaemic gut (AF) • diverticulitis • volvulus • bowel obstruction from obstructed hernia, cancer • non- abdominal causes eg MI, pneumonia, sepsis

26. Barriers to diagnosis • Many symptoms and signs are not specific • older patient will appear less unwell in the early stages - mild abdominal tenderness etc • access to CT scans can be limited • surgical specialist in theatre when on call • junior surgical registrars unwilling to admit to observe • RIF pain in women (gynae/surgery debates)

27. Supervision • Senior medical staff share/take responsibility for all clinical decisions taken • Senior nursing staff cannot take clinical responsibility for a doctor’s clinical decisions • Specialties must write in the notes • EM juniors must document specialty discussions and named medical staff

28. Why things go wrong • unselected case mix • inexperienced junior staff • time-critical interventions • insufficient SCDM capacity • some pejorative decision making

29. High risk times • Handover patients • End of shift • Night shifts (weekends) • fatigue increases error • less supervision capacity • End of rotation • familiarity, breach of protocols • Just before holidays • tired, protocol breach

30. Delays to diagnostic imaging • Clinical priorities • stroke, trauma • reluctance to CT scan in younger women (esp) - USS first • risk to renal function with contrast if pre-existing impairment • Regional organisation of services - by-pass policies • Lack of 24/7 imaging

31. How things go wrong • incomplete basic assessment - cutting corners, workload related, inexperienced personal judgement, not wishing to perform “that PR exam” • Pressure to discharge - unsafe clinical decisions made by someone who has not seen the patient, “knowledge” hierarchy • Dismissing symptoms that cannot easily be explained • Not listening to parents, carers, nursing staff • Burnout - loss of empathy, not sleeping

32. SOPs help • Major trauma, sepsis teams • Senior review of high risk conditions • CDU/Observation wards • SOPs for specialty reviews (30-60 minutes) and in person • Checklists - transfers, discharge esp vulnerable patients • Safety netting policies and advice sheets

33. That 4 hour target! • Challenging • Hospitals run at very high capacity • Not geared up for bolus attendances • Sick patients may (appropriately) take most/all of your resources for some time • ..and it happens all day, every day for years!

34. Dodgy curry Re-attended obstructed hernia Pericarditis Collapsed on surgical ward AAA