Appropriateness of healthdirect referrals to the emergency department compared with self-referrals and GP referrals.

OBJECTIVE: To assess the appropriateness of healthdirect referrals to the emergency department (ED) and compare these to self-referrals and general practitioner referrals. DESIGN AND SETTING: Prospective observational study conducted at the Royal Perth Hospital ED from August 2008 to April 2009, using the healthdirect database to cross check healthdirect advice with ED data. PATIENTS: Consecutive patients at triage, identified as healthdirect-referred, self-referred or GP-referred (720 patients per group). MAIN OUTCOME MEASURE: Appropriateness of referrals, using an a-priori definition. RESULTS: The healthdirect-referred patients were significantly younger than self-referred and GP-referred patients (mean age, 41.6 years v 45.5 years and 50.1 years, respectively; P < 0.01), more likely to be female (60.3% v 43.8% and 46.4%, respectively; P < 0.01) and more likely to attend the ED out of hours (64.0% v 45.8% and 21.0%, respectively; P < 0.01). Self-referred patients had the highest acuity profile (P < 0.01). The proportions of referrals that were assessed as being appropriate were: healthdirect-referred, 72.9% (95% CI, 69.7%-76.2%); self-referred, 73.8% (95% CI, 70.5%-77.0%); and GP-referred, 89.7% (95% CI, 87.5%-91.9%). Of the 534 calls that could be traced back to the healthdirect database, 280 (52.4%) represented patients who attended the ED despite a contrary recommendation. CONCLUSIONS: GP referrals had the highest level of appropriateness, and healthdirect- and self-referrals had similar levels of appropriateness. More than half the healthdirect-referred patients attended the ED despite a contrary recommendation, probably due to difficulty accessing after-hours health services.

The use of propofol for medium and long-term sedation in critically ill adult patients: a meta-analysis.

OBJECTIVE: To investigate the effects of using propofol for medium and long-term sedation on mortality and length of intensive care unit (ICU) stay of critically ill adult patients. DESIGN: Randomised controlled studies comparing propofol with an alternative sedative agent in critically ill adult patients were included without language restriction from the Cochrane Controlled Trial Register (2007 issue 3), EMBASE, and MEDLINE databases (1966 to 1 December 2007). Two reviewers reviewed the quality of the studies and performed data extraction independently. MEASUREMENTS AND RESULTS: Sixteen randomised controlled studies with a total of 1,386 critically ill adult patients were considered. Nine of the pooled studies (56%) limited the doses of propofol infusion to <6 mg/kg h(-1). Mortality was not significantly different between patients sedated with propofol, or an alternative sedative agent (odds ratio [OR] 1.05, 95% confidence interval [CI] 0.80-1.38, P = 0.74; I(2) = 0%). Using propofol for medium and long-term sedation was associated with a significant reduction in length of ICU stay (overall weighted-mean-difference [WMD] in days -0.99, 95%CI -1.51 to -0.47, P = 0.0002; I(2) = 82.26%) when compared to an alternative sedative agent; however, this benefit became insignificant (overall WMD in days -0.98, 95%CI -2.86 to 0.89, P = 0.30; I(2) = 78.8%) when the comparison was limited to between propofol and midazolam. CONCLUSIONS: Using propofol for prolonged sedation in critically ill patients appears to be safe and may reduce duration of mechanical ventilation. It reduces the length of ICU stay when compared to long acting benzodiazepines, but not when compared to midazolam.