Resource utilisation for syncope presenting to an acute hospital Emergency Department.

BACKGROUND: Syncope is a common clinical problem accounting for up to 6% of hospital admissions. Little is known about resource utilisation for patients admitted for syncope management in Ireland. AIM: To determine the utilisation of resources for patients admitted for syncope management. METHODS: Single centre observational case series of consecutive adult patients presenting to an acute hospital Emergency Department with syncope over a 5-month period. RESULTS: Two-hundred and fourteen of 18,898 patients (1.1%) had a syncopal episode, 110 (51.4%) of whom were admitted. Mean length of stay was 6.9 days. Sixty-four of these admissions were deemed unnecessary by retrospective review when compared to ESC guidelines. Eighty-five (77.3%) admitted patients had cardiac investigations and 56 (51%) had brain imaging performed. CONCLUSIONS: Syncope places a large demand on overstretched hospital resources. Most cases can be managed safely as an outpatient and to facilitate this, hospitals should develop outpatient Syncope Management Units.

Validation of the use of the ROSIER stroke recognition instrument in an Irish emergency department.

BACKGROUND: A study was performed to determine the utility of the 8-point recognition of stroke in the emergency room (ROSIER) instrument as a diagnostic tool in a large Irish emergency department. METHODS: Fifty patients had ROSIER scores completed by doctors. Diagnoses achieved using the score were compared with discharge diagnoses. Relations between ROSIER score, impairment and length of stay were assessed. RESULTS: Forty-seven patients (94%) had a ROSIER Score > or =1 indicating a stroke, 44 (94%) of these had stroke confirmed on investigation. Two patients with stroke were missed and three were wrongly identified. Positive predictive value for the ROSIER was 94%. ROSIER correlated with Scandinavian neurological stroke score. (r = -0.414, p = 0.003) and was associated with increasing length of stay in survivors (p = 0.16, one-way ANOVA. F = 3.116, df = 6). CONCLUSION: The ROSIER is a suitable and useful adjunct in the assessment of stroke patients in Ireland.

Stab to second intercostal space: a bubbling extrapleural wound.

A 37 year old man was found collapsed at the roadside and taken to the emergency department. Communication was difficult, as the patient could not speak English. There was a wound in the left second intercostal space on the midclavicular line, which was bleeding and was bubbling air. A drain was inserted, bleeding controlled, and his wounds sutured. Chest x ray later confirmed satisfactory placement of the drain. The following day, swelling and discharge indicated oesophageal damage, which was later confirmed by gastrografin swallow. With conservative management in hospital for 2 weeks, he made a full recovery and was discharged.

Characteristics of attenders and their attendances at an urban accident and emergency department over a one year period.

OBJECTIVES: To describe (1) the characteristics of attenders to an urban accident and emergency (A&E) department over a one year period according to the frequency of their attendance and (2) the features of their attendances according to the frequency which the patient attended the department during the study period. METHODS: A dataset containing information on all new attendances to an urban A&E department in 1995 was formed. For each attendance the following information was recorded: day of the week, hour of attendance, referral source, triage category, and disposal. A second dataset, consisting of the individuals ("attenders") who made the A&E visits ("attendances") during 1995 was also produced. For each attender the following information was recorded: age, sex, postal code of residence, socioeconomic status, marital status, and number of attendances during 1995. A methodology reviewing the trends of frequency of attendance was utilised, as opposed to the use of an arbitrary cut off point. RESULTS: 34,908 patients made 46,735 visits in 1995. Increasing frequency of attendance was significantly associated with increasing age (Kruskal-Wallis < 0.001), being male (chi 2 for linear trend 14.06, p < 0.001), having a local postal address (chi 2 279.79, p < 0.0001), general medical services eligibility (chi 2 781.67, p < 0.0001), and inversely associated with being married (chi 2 33.91, p < 0.0001). Increasing frequency of attendance was significantly associated with attendance between the hours of 1700 and 0900 (chi 2 295.62, p < 0.001), being triaged as a non-emergency (chi 2 1254.33, p < 0.0001), and self referral (chi 2 141.4, p < 0.0001). CONCLUSIONS: A small group of A&E attenders accounts for a disproportionately large percentage of the total number of departmental attendances. The characteristics of frequent A&E attenders suggest that they may represent a vulnerable group of patients. A follow up study of the utilisation of all primary care services by such patients is suggested.

Randomized controlled trial of general practitioner versus usual medical care in a suburban accident and emergency department using an informal triage system.

We determined if care provided by general practitioners (GPs) to non-emergency patients, in a suburban accident and emergency (A&E) department using an informal triage system, differs significantly from care provided by usual A&E staff. One thousand eight hundred and seventy-eight patients participated. By comparison with usual A&E staff, GPs prescribed significantly more often (percentage relative difference [% RD] = 12 [95% confidence interval = 1-23]) and referred more patients to hospital (% RD = 21 [95% CI = 9-33]). This is the first study to report that sessional GPs working in an A&E department utilize similar or more resources than usual A&E staff. It emphasizes the need for the continued audit of initiatives that have been introduced into new settings.

Regional intravenous calcium--an effective method of treating hydrofluoric acid burns to limb peripheries.

An effective method of providing pain relief in hydrofluoric acid burns is reported, using a Bier's block type technique and regional intravenous calcium gluconate. This method allows satisfactory analgesia and prevents further tissue destruction, without the risk and added discomfort of increased tissue tensions associated with local infiltration of calcium.

Effect of the introduction of a financial incentive for fee-paying A&E attenders to consult their general practitioner before attending the A&E department.

BACKGROUND: The Health (Out-Patient Charges) Regulations 1994 were designed to encourage those Irish patients liable for their own health care costs to attend their GP before their local Accident and Emergency (A&E) department. Such patients are referred to as General Medical Services (GMS)-ineligible. Prior to the introduction of the regulations in March 1994, there was a perverse financial incentive for these patients to attend directly A&E departments instead of their GP. OBJECTIVE: The aim was to compare the number of GMS-ineligible patients referred by a GP during the year before and the year after the implementation of the Regulations. METHOD: This study involved the audit of all new attendances to a large A&E department, for 1 year before and after the introduction of the new regulations. The main outcome measures were the number of new attenders in the subsequent year, the proportion of GMS-ineligible attenders, the proportion of GMS-ineligible attenders referred by a GP and the proportion of GMS-ineligible attenders referred by a GP and categorized as having neither critical nor urgent complaints. RESULTS: The total number of new attenders in the year subsequent to the introduction of the regulations was 45,302, an increase of 4.9% on the previous year's total. The proportion of GMS-ineligible attenders decreased from 45.3 to 44% (-1.3%; 95% confidence interval (CI) -0.6 to -1.9). The proportion of GMS-ineligible attenders who were referred by a GP increased by 2.4% (95%; CI 1.7-3.1). The proportion of GMS-ineligible attenders, referred by a GP with complaints categorized as neither critical nor urgent, increased by 2.5% (95%; CI 1.8-3.2). CONCLUSIONS: The introduction of the regulations was associated with a small, but statistically significant, reduction in the number of GMS-ineligible patients who attended with non-emergency conditions. The proportion of GMS-ineligible attenders who were referred by a GP increased by 2.4% (95%; CI 1.7-3.1). The overall workload of the A&E department was, however, unaffected. Further evaluation of the effects of this reduction on the health status of patients is required.

Randomised controlled trial of general practitioner versus usual medical care in an urban accident and emergency department: process, outcome, and comparative cost.

OBJECTIVE: To see whether care provided by general practitioners to non-emergency patients in an accident and emergency department differs significantly from care by usual accident and emergency staff in terms of process, outcome, and comparative cost. DESIGN: A randomised controlled trial. SETTING: A busy inner city hospital's accident and emergency department which employed three local general practitioners on a sessional basis. PATIENTS: All new attenders categorised by the triage system as "semiurgent" or "delay acceptable." 66% of all attenders were eligible for inclusion. MAIN OUTCOME MEASURES: Numbers of patients undergoing investigation, referral, or prescription; types of disposal; consultation satisfaction scores; reattendance to accident and emergency department within 30 days of index visit; health status at one month; comparative cost differences. RESULTS: 4684 patients participated. For semiurgent patients, by comparison with usual accident and emergency staff, general practitioners investigated fewer patients (relative difference 20%; 95% confidence interval 16% to 25%), referred to other hospital services less often (39%; 28% to 47%), admitted fewer patients (45%; 32% to 56%), and prescribed more often (41%; 30% to 54%). A similar trend was found for patients categorised as delay acceptable and (in a separate analysis) by presenting complaint category. 393 (17%) patients who had been seen by general practitioner staff reattended the department within 30 days of the index visit; 418 patients (18%) seen by accident and emergency staff similarly reattended, 435 patients (72% of those eligible) completed the consultation satisfaction questionnaire and 258 (59% of those eligible) provided health status information one month after consultation. There were no differences between patients managed by general practitioners and those managed by usual staff regarding consultation satisfaction questionnaire scores or health status. For all patients seen by general practitioners during the study, estimated marginal and total savings were Ir1427 pounds and Ir117,005 pounds respectively. CONCLUSION: General practitioners working as an integral part of an accident and emergency department manage non-emergency accident and emergency attenders safely and use fewer resources than do usual accident and emergency staff.

Attitudes of Dublin accident and emergency department doctors and nurses towards the services offered by local general practitioners.

Good communication at the accident and emergency (A&E)-general practice interface is important. Such communication will be affected by the attitudes of A&E staff towards local general practitioners (GPs). The objectives of this study were to establish and compare, using a questionnaire, the attitudes of Dublin A&E doctors and nurses towards the services offered by local GPs. A questionnaire was sent to all nurses and non-consultant doctors working in four of the six Dublin A&E departments. Completed questionnaires were received from 57 (61%) nurses and 35 (81%) doctors. Only two activities (being accessible to patients during normal surgery hours and providing family planning services) were rated by more than one-fifth of doctors and nurses as being performed 'well'. Six activities (being accessible to patients outside surgery hours, providing long-term care for the chronically ill and debilitated, providing appropriate care for 'difficult' patients, advising patients about the appropriate use of services and performing first aid) were rated by more than 40% of both doctors and nurses as being performed 'badly'. For all activities the nurses consistently rated the performance of the 'average GP' more critically than the doctors. These results must be interpreted cautiously. The implications of these findings and how best they can be addressed are discussed.

Review of a mobile accident and emergency unit at a rock concert.

On Saturday 16th May 1992, an outdoor Rock concert was held at a rural location located between two hospitals which are fourteen miles apart. It was attended by over 50,000 people. A mobile accident and emergency unit (MAEU), was staffed by two doctors and five nurses. The facilities, demands and injury pattern are reviewed, and recommendations for future events are made.

Bilateral rotatory subluxation of the scaphoid.

We describe the case of a 17-year-old girl, who presented to our Accident and Emergency (A&E) department following minor trauma to her forearm. Initial x-rays were misread as normal. Radiographs demonstrated classical features of rotatory subluxation of the scaphoid, which was found to be bilateral.

Sports injuries and the accident and emergency department--ten years on.

A six month prospective survey in 1990 of sports injuries presenting to the A+E department of St James and the Mater hospitals revealed 1594 patients, accounting for 3.8% of the total number of new patients seen in that period. These results were compared to a similar study conducted in the Mater in 1980. Comparison with the 1980 study showed similar patterns with respect to sex, sport and site of injury. There was an increase of the age at which sport was played as evidence by the age of those injured. Whilst delay in presentation has improved somewhat, 57% of patients stil waited more than 12 hours before attending. Management of the total spectrum of injury has changed. More X-Rays were taken and on-site physiotherapy has been established in both A+E departments. Despite such an accessible facility the use of physiotherapy in sports injuries could be improved. There was also variation in the treatment of non-orthopaedic injury. We recommend that education of sport participants continue, especially in the areas of protective equipment and early presentation for medical assessment. We further propose that A+E staff be educated in the special needs of sports men and women, and that as recommended previously in the 1980 study, a Central Sports Injury Clinic for the six Dublin hospitals be established.

The significance of random breath alcohol sampling in the accident and emergency department.

Using a detailed questionnaire, 126 patients attending an accident and emergency department were screened for drinking problems. Eleven per cent (14) were identified as having established drinking problems, but only two of these had received help from professional agencies. In all, 39% (50) were identified as being adversely affected by their drinking habits. A breath alcohol test (BT) alone, on the same patients failed as a screening device for hidden drinking problems in these circumstances, and we do not recommend its use. The simple 'CAGE' questionnaire was a little more sensitive, but asking more questions identified more problems. A positive BT in the presence of a positive CAGE occurred in three patients and although insensitive it was absolutely specific for a serious drinking problem. A significant number of patients who attend an accident and emergency department have a drinking problem. The most effective method of detecting this is to ask patients about their drinking habits.