Whilst all EDs are consultant led there is no doubt that for the most part they are not consultant based in that senior doctors are rarely present overnight and during all ‘out of hours’ periods. Perhaps ‘out of hours’ is an anachronism for our specialty as the patients still come, and still need help. Traditionally the night and late shifts are not led by consultants, but are there really any advantages to basing a service with consultants on the shop floor overnight? Perhaps it makes little difference? Aruni Sen and colleagues in Wrexham have a service delivery model that does put consultants on overnight and they have clearly shown the advantages of senior presence in the department (see page
The report says that ‘in spite of the significant challenge of beginning to deliver on local quality, innovation, productivity and prevention (QIPP) plans, standards of safety and quality have been maintained or improved’.
It's dry, dreary and turgid stuff to read. It is 64 pages long and covers many facets of the NHS. Here are a few messages, some of which are relevant to this journal:
MRSA infections were 33% lower than in the same quarter last year and...]]>
Major trauma remains the leading cause of death among children over the age of 1 year,
Compared with the adult population, the absolute number of cases of major trauma in children is small, which has implications for how their trauma care should best be structured. Data are incomplete, but this may account for as few as 300 cases per year in the UK.
Currently, children suffering major trauma are delivered from the scene of injury to the nearest emergency department and subsequently transferred to...]]>
To develop and validate models to predict emergency department (ED) presentations and hospital admissions for time and day of the year.
Initial model development and validation was based on 5 years of historical data from two dissimilar hospitals, followed by subsequent validation on 27 hospitals representing 95% of the ED presentations across the state. Forecast accuracy was assessed using the mean average percentage error (MAPE) between forecasts and observed data. The study also determined a daily sample size threshold for forecasting subgroups within the data.
Presentations to the ED and subsequent admissions to hospital beds are not random and can be predicted. Forecast accuracy worsened as the forecast time intervals became smaller: when forecasting monthly admissions, the best MAPE was approximately 2%, for daily admissions, 11%; for 4-hourly admissions, 38%; and for hourly admissions, 50%. Presentations were more easily forecast than admissions (daily MAPE ~7%). When validating accuracy at additional hospitals, forecasts for urban facilities were generally more accurate than regional forecasts (accuracy is related to sample size). Subgroups within the data with more than 10 admissions or presentations per day had forecast errors statistically similar to the entire dataset. The study also included a software implementation of the models, resulting in a data dashboard for bed managers.
Valid ED prediction tools can be generated from access to de-identified historic data, which may be used to assist elective surgery scheduling and bed management. The paper provides forecasting performance levels to guide similar studies.
Consultant based delivery of emergency service is perceived to add value. This study aims to demonstrate the impact of such a service model based on consultant working in a UK emergency department.
This retrospective study was based on the emergency department of a district general hospital. Activity data was analysed for 2009. Workload and admission rates were compared between consultants, middle grade doctors and senior house officers (SHOs). Admission rates were compared against two similar departments. Data from night shifts allowed consultant activity to be contrasted with middle grades and SHOs. Time spent in the department, admission rates, patients who left without treatment, discharged outright and clinic returns were used for comparison.
Consultants often saw more patients than SHOs or middle grade doctors. This was on top of their traditional duties of senior opinion. On comparison of activity at night shifts, they admitted fewer (25.2% vs 30.3%, p=0.026), had fewer leaving without treatment (1.6% vs 5.1%, p<0.001), discharged more outright (59.8% vs 47.5%, p<0.001), referred fewer to clinic (5.7% vs 6.6%, p=0.49) and had a faster turnaround time (p<0.001: Priority 2, 3 and 4) for every triage category. Some of the comparisons were clinically but not statistically significant.
A consultant based service delivery offers many advantages. These cannot be matched by either junior or middle grades. This would be in addition to the consultants' supervisory role. Consultant expansion is urgently required to achieve this sustainably. A further study evaluating the cost benefits of this service model is now underway.
To evaluate the effectiveness of a rapid assessment zone (RAZ) to mitigate emergency department (ED) overcrowding.
Electronic databases, controlled trial registries, conference proceedings, study references, experts in the field and correspondence with authors were used to identify potentially relevant studies. Intervention studies, in which a RAZ was used to influence length of stay, physician initial assessment and patients left without being seen, were included. Mean differences were calculated and reported with corresponding 95% CIs; individual statistics are presented as RR with associated 95% CI.
From 14 446 potentially relevant studies, four studies were included in the review. The quality of one study was appraised as moderately high; others were rated as weak. Two studies showed that a RAZ was associated with a reduction of 20 min (95% CI: –47.2 to 7.2) in the ED length of stay; in one non-randomised clinical trial (RCT), a 192 min reduction was reported (95% CI: –211.6 to –172.4). Physician initial assessment showed a reduction of 8.0 min; 95% CI: –13.8 to –2.2 in the RCT and a reduction of 33 min (95% CI: –42.3 to –23.6) and 18 min (95% CI: –22.2 to –13.8) respectively were found in two non-RCTs. There was a reduction in the risk of patient leaving without being seen (RCT: RR=0.93, 95% CI: 0.77 to 1.12; non-RCT: RR =0.68, 95% CI: 0.63 to 0.73).
Although the results are consistent, and low acuity patients seem to benefit the most from a RAZ, the available evidence to support its implementation is limited.
To describe the common medical presenting problems of children attending a paediatric emergency department (ED) compared with 10 years previously.
A retrospective review of electronic patient record and comparison with previous cohort.
A UK university hospital ED.
A cohort of children and young people aged 0–15 years who attended the ED between 7 February 2007 and 6 February 2008 (n=39 394) compared with a historical cohort from 10 years earlier.
Information on presenting problem, demographic data and source of referral were collected. Presenting problems were ranked and comparisons made with previous data using the difference between proportions analysis and the significance test for a difference in two proportions. A total of 39 394 children (57% boys) were seen with 14 724 medical attendances compared with 10 369 attendances from the 1997 cohort, an increase of 42%. Most (85%) ED attendances can be accounted for by the 10 most common presenting problems, including breathing difficulty (2494, 20.1%), febrile illness (1752, 14.1%), diarrhoea with or without vomiting (1731, 14.0%), rash (1066, 8.6%) and cough (835, 6.7%). Similar proportions are described to a decade earlier; however, there were fewer patients attending with breathing difficulty (–10.9%, p<0.001).
Over a 10-year period, there has been a rise in the number of people attending the ED with medical conditions. The 10 most common presenting problems account for 85% of medical attendees. These results suggest the increasing utilisation of ED services for children with common medical presenting problems and should inform further research exploring the pathways for attendance and the thresholds in seeking medical advice in order to inform the commissioning of paediatric emergency and urgent care services.
Prepandemic projections anticipated huge excess attendances and mortality in an influenza pandemic. A number of tools had been suggested for triaging patients with influenza for inpatient and critical care admission, but none had been validated in these patients. The authors aimed to evaluate three potential triage tools—CURB-65, PMEWS and the Department of Health community assessment tool (CAT)—in patients in the first waves of the 2009 H1N1 pandemic.
Prospective cohort study in three urban emergency departments (one adult, one paediatric, one mixed) in two cities.
All patients presenting to the three emergency departments fulfilling the national definition of suspected pandemic influenza.
30-day follow-up identified patients who had died or had required advanced respiratory, cardiovascular or renal support.
The pandemic was much less severe than expected. A total of 481 patients (347 children) were recruited, of which only five adults fulfilled the outcome criteria for severe illness. The c-statistics for CURB-65, PMEWS and CAT in adults in terms of discriminating between those admitted and discharged were 0.65 (95% CI 0.54 to 0.76), 0.76 (95% CI 0.66 to 0.86) and 0.62 (95% CI 0.51 to 0.72), respectively. In detecting adverse outcome, sensitivities were 20% (95% CI 4% to 62%), 80% (95% CI 38% to 96%) and 60% (95% CI 23% to 88%), and specificities were 94% (95% CI 88% to 97%), 40% (95% CI 32% to 49%) and 81% (95% CI 73% to 87%) for CURB-65, PMEWS and CAT, respectively.
Although limited by a paucity of cases, this research shows that current triage methods for suspected pandemic influenza did not reliably discriminate between patients with good and poor outcomes.
Emergency doctors must make decisions for many patients in a limited time. Various emergency cases are not compatible with routine conditions as described in textbooks, so doctors use clinical decision making (CDM) processes to act in the best possible way. In the present work, these processes and some of the related factors were assessed.
Decisions made by doctors were studied via patient medical records, doctors' notes and interviews with decision-making doctors from the Emergency Department of Rasul-Akram Hospital, Tehran, Iran. All doctors were unaware of this research, and they had previously studied CDM processes as part of their training curriculum. A total of 10 day and 10 night shifts (240 h) between 1 March 2010 and 30 May 2010 were considered for the study.
Rule-based, event-driven, knowledge-based and skill-based decisions, respectively, were the most frequent processes used by doctors in 726 first visits. It was also found that 7% of decisions were not made on a known CDM basis, that all of them were for non-urgent and ‘standard’ patients, and that most patients who were non-urgent were referred to first-year postgraduates. Skill-based decisions were not applied in very urgent cases; 107 out of 726 decisions on first visits had shifted to knowledge-based process by the time of final treatment decisions. For final treatment decisions, rule-based and knowledge-based processes were more frequently used than other CDM processes.
The rule-based process is the most common CDM process used by emergency doctors, perhaps because of the minimisation of human error in this process. CDM choice may be influenced by triage level, treatment room and doctors' educational levels. Revealing and studying these factors may help shift decisions to the best possible decision making levels, defining a model in future research.
This is the first study of suicide attempts and completions in the emergency department (ED) in a large national medical system.
All root cause analysis (RCA) reports completed of suicides and suicide attempts that occurred in ED in the Veterans Health Administration between 1 December 1999 and 31 December 2009 were reviewed. The method, location, anchor point for hanging and implement for cutting as well as the root causes were categorised.
Ten per cent of all RCA reports of suicides and suicide attempts that occur within the hospital occur in the ED. Hanging, cutting and strangulation were the most common methods. The most common anchor point for hanging was doors, and the most common implement for cutting was a razor blade. In eight of the 10 cases of cutting, the implement was brought into the ED. The most common root causes were problems communicating risk and being short-staffed.
Based on these results the following recommendations are made for helping to reduce suicide attempts in the ED: (1) use a systematic protocol and checklist to review mental health holding areas periodically in the ED for suicidal hazards; (2) develop and implement specialised protocols for suicidal patients that include continuous observation when possible; (3) conduct thorough contraband searches with suicidal patients; (4) designate specialised holding areas, when practically possible, for suicidal patients that are free of anchor points for hanging, sharps and medications, and medical equipment; and are isolated from exits to reduce the risk of elopement.
Recent initiatives in the Care of the Trauma patient in the UK have led to the establishment of Major Trauma Centres (MTCs), supporting a Trauma Network. It is envisaged that any person suffering from major trauma will be taken directly to one of these centres, with an expectant increase in survivability and decrease in morbidity. This will have an impact on the Ambulance Service in terms of journey times, and the MTCs in terms of bed days. Whilst these are not ‘new’ patients to the NHS, they may require a redistribution of funds. Most of the modelling into the effects of this has been carried out in London, which may not be applicable to more rural areas. We therefore determined to gain data on how a similar policy would affect trauma services in our rural region.
A retrospective study of all trauma patients conveyed by a regional ambulance service. The London Trauma Divert Criteria were applied to the patient report forms, and the number of patients who may have transported directly (or by secondary transfer) to MTCs identified.
We found that between 28 and 58 additional patients a month would be transferred.
As this is more than 1 patient a day, there may be considerable strain on the MTCs and Ambulance Services. We believe service commissioners in rural areas need to consider the funding and organisational arrangements for major trauma in light of this.
To assess in patients with acute respiratory failure (ARF) whether out-of-hospital (OOH) non-invasive ventilation (NIV) is feasible, safe and more effective compared with standard medical therapy (SMT).
Patients with OOH ARF were randomly assigned to receive either SMT or NIV.
Fifty-one patients were enrolled, 26 of whom were randomly assigned to SMT and 25 of whom received NIV. Two patients were excluded because of protocol violations. OOH NIV was safe and effective in all patients. In the SMT group, treatment was not effective in five of 25 patients who required OOH mechanical ventilation (p=0.05). Patients in the SMT group were admitted to an intensive care unit (ICU) more frequently (n=17) (p<0.05) and for longer periods (3.7±6.4 days) (p=0.03) compared with patients in the NIV group (n=9, 1.3±2.6 days). Six patients in the SMT group required subsequent inhospital intubation and invasive ventilation during their hospital stays; only one patient in the NIV group required intubation (p=0.10). In contrast, patients in the NIV group received NIV more frequently (n=14) in hospital compared with patients in the SMT group (n=5) (p<0.01).
OOH NIV proved to be feasible, safe and more effective for the treatment of ARF compared with SMT. OOH NIV promotes inhospital treatment with NIV and may reduce the frequency and length of ICU stays. Because the risks of OOH emergency intubation can be avoided, NIV should be the first-line treatment in OOH ARF if no contraindications are present.
The x-ray demonstrated a widened mediastinum consistent with aneurysmal dilation of the thoracic aorta. A subsequent CT angiogram demonstrated a tortuous and calcified aneurysmal thoracic aorta. The maximum diameter of the ascending and descending aorta was 7.1 cm and 8 cm, respectively. There was no clear demonstration of a dissection process or dissection flap nor was there any clinical or radiographic suggestion of acute aneurysmal rupture (
The incidence of such a finding is estimated to be 5.9 per 100 000 person-years
To determine whether there are prehospital differences between blacks and whites experiencing out-of-hospital cardiac arrest and to ascertain which factors are responsible for any such differences.
Cohort study of 3869 adult patients (353 blacks and 3516 whites) in the Illinois Prehospital Database with out-of-hospital cardiac arrest as a primary or secondary indication for emergency medical service (EMS) dispatch between 1 January 1996 and 31 December 2004.
Return of spontaneous circulation was lower for black patients (19.8%) than for white patients (26.3%) (unadjusted OR 0.69, 95% CI 0.53 to 0.91). After adjusting for age, sex, prior medical history, prehospital event factors, patient zip code characteristics and EMS agency characteristics, the no difference line was suggestive of a trend, with a CI just transposing 1.00 (adjusted OR 0.71, 95% CI 0.50 to 1.01, p=0.053).
Blacks were less likely to experience a return of spontaneous circulation than whites, less likely to receive defibrillation or cardiopulmonary resuscitation from EMS and more likely to receive medications from EMS. Differences in underlying health, care prior to the arrival of EMS, and delays in the notification of EMS personnel may contribute to racial disparities in prehospital survival after out-of-hospital cardiac arrest.
Best Evidence Topic reports (BETs) summarise the evidence pertaining to particular clinical questions. They are not systematic reviews, but rather contain the best (highest level) evidence that can be practically obtained by busy practicing clinicians. The search strategies used to find the best evidence are reported in detail in order to allow clinicians to update searches whenever necessary. Each BET is based on a clinical scenario and ends with a clinical bottom line, which indicates, in the light of the evidence found, what the reporting clinician would do if faced with the same scenario again.
The BETs published below were first reported at the Critical Appraisal Journal Club at the Manchester Royal Infirmary1 or placed on the BestBETs website. Each BET has been constructed in the four stages that have been described elsewhere.2 The BETs shown here together with those published previously and those currently under construction can be...]]>
They report on a study in which pain assessments at triage were conducted among 94% of the patients who indicated having pain. Furthermore, pain assessments were associated with Manchester triage system (MTS) urgency categories. They conclude that, compared with our study, the reported rate of pain assessments is substantially higher. However, it is questionable whether these comparisons can be validly made.
In our study it was determined that in 86% of the presenting patients, the pain assessments should have been conducted according to the MTS guidelines. In 32% of these presentations, nurses actually assessed the pain. The 94% reported by Martin-Sanchez et al represents a different number. In their study, 45% of the emergency department patients referred to pain. It is...]]>
To determine the pain assessment at triage in a Spanish ED and the association of the pain categories with the complaint and urgency categories, we designed a transversal study that included all non-trauma stable patients ≥16 years triaged using the MTS during 6 months (June–December 2009) excluding cases from psychiatry, obstetrics and gynaecology specialities in the Hospital Clinico San Carlos. The total number of patients triaged was 18 101, of which 8115 (45%) were referred for pain. The pain assessment was registered in those with referred pain in 7630 (94%). The most common complaints were: abdominal pain 1827 (22%), limb problems 996 (12%), unwell adult 926 (11%) and...]]>
However, having spent some time with the text I now think I understand and believe that this text has a place. This is not ‘radiology-lite’; it is truly rooted...]]>
Cervical epidural abscess is an uncommon disease with a high risk of neurologic deficit, and even death.
The physician should...]]>
A 30-year-old man with a history of alcoholic cardiomyopathy, congestive heart failure, cirrhosis and chronic liver disease presents to the emergency department with intermittent right upper quadrant (RUQ) pain that becomes worse after eating fatty fried foods. He reports some associated nausea with pain episodes but no vomiting or diarrhoea. He denies any fever; however, vital signs taken on presentation reveal a temperature of 38.0°C. On examination the patient demonstrates tenderness of the RUQ with a palpable liver edge and a positive Murphy's sign. No pedal oedema or gross ascites was present. The patient underwent an ultrasound with the results shown in
None.
Obtained.
Institutional review board.
JBK drafted the article. CBP prepared and edited the manuscript.
Not commissioned; internally peer reviewed.
(A) Chest CT showing the ruptured aneurysm of non-coronary sinus of...]]>
On examination, there was a voluminous swelling (20x15 cm) over the lumbar area, overlying segments L2–S4; the swelling was soft, elastic, immobile, painful to palpate, with moderate bruising (
X-rays showed spondylolisthesis of L5 on S1 and diffuse soft tissue thickening over the posterior and lateral aspects of the lumbar vertebral column (
Morel-Lavallée lesion (haematoma or seroma) occurs after close blunt trauma, direct or tangential, with a degloving mechanism that separates the hypodermis from the fascia beneath, causing a shearing injury.
Hospitals in England are under pressure to ban advertisements by ‘no win, no fee’ lawyers that many National Health Service (NHS) trusts have been using to boost their revenue and offset the cost of producing information leaflets for patients. One company has agreements with 170 hospitals and has produced £9.2 million of savings for the NHS in the past decade. Since the NHS is spending more and more each year on cases brought by aggressive ‘no win, no fee’ lawyers and with the intention of spending more on patient care, there is a campaign urging the Department of Health to take action against any law firms that breach advertising guidelines (BMJ 2012;344:e635).
Following the public inquiry into the high number of deaths at Mid-Staffordshire NHS Trust, it is expected that recommendations will be made in order to protect...]]>