Audit of patients with chest pain presenting to an accident and emergency department over a 6-month period.

The results of a 6-month retrospective audit of patients presenting with chest pain to an accident and emergency (A&E) department to which 46,000 new patients per year present are discussed. The computer diagnostic code assigned to the patients by the A&E doctor, referral rates for second opinion and disposal after assessment in the A&E department are examined, with particular reference to patients who may have had serious cardiac pathology, such as acute myocardial infarction (AMI) or unstable angina. Audit showed that overall 61% of patients with chest pain of all causes were assessed and discharged home by A&E doctors without recourse to second opinion. Of patients thought by the A&E doctors to have chest pain of cardiac origin, who were referred to the duty medical registrar or cardiologist, 88% were admitted. As a result of these findings a policy of more open referral for second opinion was instituted to reduce the likelihood of discharging patients home with serious cardiac pathology. In addition, the clinical problems of AMI and unstable angina are emphasized to all senior house officers early in their educational programme after joining A&E. Published literature on the diagnosis and misdiagnosis of AMI and unstable angina in the A&E department is reviewed. These studies are almost exclusively from North America, and a need for similar work in the U.K. is discussed.

Injuries due to falls as a result of uneven pavements.

At least one person per day attending the A&E department at King's College Hospital has sustained injuries from uneven pavements. The injuries have a significant morbidity as well as mortality of 1%. A&E records can be a source of useful information to aid local authorities in identifying areas associated with these injuries in order to reduce their frequency and subsequent claims for compensation.

A review of 7 years of complaints in an inner-city accident and emergency department.

In 7 years between 1982-88, 122 complaints were lodged against the Accident and Emergency department of King's College Hospital. A high percentage mentioned more than one aspect per complaint. Commonest were those regarding attitude (37.7%), missed diagnosis (36.6%), waiting time (32.8%), cursory examination (14.7%) and poor communication (11.5%). These causes of complaint are amenable to improvement. Training in interpersonal skills may reduce complaints of attitude. A high index of suspicion for the unusual and careful examination of patients would reduce complaints of missed diagnosis. Sufficient medical and nursing staff would reduce waiting time and improvements in communication with patients would keep this aspect to a minimum. Complaint investigation can be time consuming, when dissatisfaction is expressed explanations at the time of presentation by senior staff members may head-off a formal complaint.

Cost-effectiveness of investigations for invasive bladder cancer.

The results of diagnostic and staging investigations in consecutive cases of invasive transitional cell carcinoma of the bladder are reviewed. Urine culture, urine cytology and intravenous urography had positive results in a high percentage of cases. As diagnostic investigations they are cost-effective but certainly do not remove the obligation to perform cystoscopy and examination under anaesthetic. Isotopic bone scan and liver scan showed metastases in 4 and one cases respectively and only when there were clinical signs of disseminated disease. Chest X-ray showed metastases in one case. These investigations are not cost-effective. Lymphangiography was positive in 12 of the 94 cases and, although expensive (pounds 70), is still a staging investigation of value in planning treatment.