Value of serum prolactin in the management of syncope.

OBJECTIVE: A meta-analysis of studies of the usefulness of raised serum prolactin in diagnosing generalised tonic-clonic seizures (GTCS) in patients presenting to the accident and emergency (A&E) department after a single episode of syncope. METHODS: A three part question was defined. Medline, EMBASE, PubMed, the Cochrane Library were searched to identify relevant studies. Studies were evaluated for eligibility and quality and data extracted to calculate sensitivity (SN), specificity (SP), and likelihood ratios (LR). RESULTS: Of 13 relevant studies only three met the criteria for evaluation. If a serum prolactin concentration is greater than three times the baseline when taken within one hour of syncope, then in the absence of test "modifiers": (1) the patient is nine times more likely to have suffered a GTCS as compared with a pseudoseizure positive LR = 8.92 (95% CI (1.31 to 60.91)), SN = 0.62 (95% CI (0.40 to 0.83)), SP = 0.89 (95% CI (0.60 to 0.98)) and (2) five times more likely to have suffered a GTCS as compared with non-convulsive syncope positive LR 4.60 (95% CI (1.25 to 16.90)), SN = 0.71 (95% CI (0.49 to 0.87)), SP = 0.85 (95% CI (0.55 to 0.98)). CONCLUSION: A positive test result is highly predictive of a GTCS, however a negative test result does not necessarily exclude a seizure. Serum prolactin should be measured in patients presenting to the A&E department within an hour of a syncopal episode, unless the cause is immediately obvious.

Improving the delivery of analgesia to children in pain.

OBJECTIVES: To improve the time taken for children arriving to the accident and emergency (A&E) department in pain to receive analgesia. Delivery within 30 minutes of triage was taken as an achievable goal. METHODS: 262 children who had received analgesia in the "minor injuries" area of West Middlesex University Hospital A&E department were studied over a four month period. Current practice was indicated over the first two months by retrospectively looking at data from 129 children's A&E cards. A Paediatric Pain Protocol was then introduced and another 133 children's cards studied to see if this had made an improvement. The protocol for those children aged over 4 years differed to that for children aged 4 years and under. RESULTS: For children aged 4 years and over, the introduction of the protocol significantly increased the number that received analgesia within 30 minutes of triage: 55.3% (n=54) post-protocol versus 34.0% (n=33) pre-protocol (p=0.003). However, for children aged 4 years and under there was no change in the proportion that received analgesia within 30 minutes of triage: 56.7% (n=17) postprotocol versus 59.4% (n=19) pre-protocol (p=0.829). CONCLUSIONS: The introduction of a simple Paediatric Pain Protocol has improved the time taken to deliver analgesia to children arriving in this A&E department.

An audit of litigation costs in four accident and emergency departments.

OBJECTIVE: To carry out an audit of cases of litigation relating to accident and emergency departments to determine the outcome and costs to the hospitals involved. METHODS: The experience of four similar hospitals was examined over a three year period. All cases which required at least an exchange of solicitors' letters were included. RESULTS: In total 32 claims were made, of which 17 were settled by solicitors' letters, six cases proceeded to court and were lost by the hospital involved, and in nine cases an out-of-court settlement was reached. The costs to the hospitals ranged from 180 pounds to 30,000 pounds, with an average cost of 4080 pounds. Over the course of the audit the number of cases of litigation remained constant at three per year, while the number of complaints rose threefold to 150. The majority of successful claims concerned missed fractures. CONCLUSIONS: Litigation is uncommon and litigation costs reasonable. Given the frequency of missed fractures as a reason for a successful claim, early x ray reporting probably reduces the risk of litigation.

Audit of unexpected return visits to an accident and emergency department.

Unscheduled re-attendances of patients to the A&E Department were examined over 50 days. A re-attendance rate of 1.9 per 100 new patients was found. Of 102 return visits, only 35 resulted in no change in the diagnosis or treatment. Common faults in the initial consultation were failure to explain the condition and prognosis adequately and failure to provide adequate analgesia. Review of patients reattending unexpectedly by a more senior member of staff is a means of identifying faults in management and advising and educating junior staff.

Successful transcutaneous external pacing for asystole following cardiac arrest.

We report a case of successful transcutaneous external pacing for out of hospital cardiac arrest causing asystole.

Deaths in three accident and emergency departments.

A survey of three London hospitals found that approximately 0.45 patients per thousand new attenders die in the accident and emergency department and that there is evidence of poor management in about 10% of these deaths. The commonest faults were excessive delay before starting appropriate treatment and neglect of the basic principles of emergency medicine. These points need to be emphasized in the training of accident and emergency staff.

The vagrant in the accident and emergency department.

Those of no fixed abode constituted only 0.3% of all new patients seen in one year. The majority presented with a disorder due to acute medical illness or trauma. This group has poor access to general practitioners, and turns to the accident and emergency department for medical care. However, the number of investigations performed and the number admitted to hospital indicate a substantial amount of serious pathology. The proportion of homeless attenders abusing the accident and emergency facilities is small.