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.

Epidemiological findings and medical, legal, and public health challenges of an investigation of severe soft tissue infections and deaths among injecting drug users -- Ireland, 2000.

In May 2000, public health authorities in Dublin, Ireland, identified a cluster of unexplained severe illness among injecting drug users (IDUs). Similar clusters were also reported in Scotland and England. Concurrent investigations were undertaken to identify the aetiology and source of the illnesses. In Dublin, 22 IDUs were identified with injection-site inflammation resulting in hospitalization or death; eight (36%) died. Common clinical findings among patients with severe systemic symptoms included leukaemoid reaction and cardiogenic shock. Seventeen (77%) patients reported injecting heroin intramuscularly in the 2 weeks before illness. Of 11 patients with adequate specimens available for testing, two (18%) were positive by 16S rDNA PCR for Clostridium novyi. Clinical and laboratory findings suggested that histotoxic Clostridia caused a subset of infections in these related clusters. Empiric treatment for infections among IDUs was optimized for anaerobic organisms, and outreach led to increased enrolment in methadone treatment in Dublin. Many unique legal, medical, and public health challenges were encountered during the investigation of this outbreak.

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.

A & E services in Ireland: the potential role of general practice in accident and emergency services.

BACKGROUND: In 1996, Irish accident and emergency (A&E) departments had approximately 1.2 million visits. General practitioners (GPs) have been shown to work efficiently in A&E. AIM: This study aimed to describe the current A&E structures in Ireland and the potential contribution of general practice. METHOD: Questionnaires were sent to all 43 Irish A&E departments seeking information on staffing levels, training posts and interest in the role of GPs within the department. RESULTS: Thirty-four (79%) hospitals responded, representing at least 71% of all A&E visits. Eleven (32%) had A&E consultants. In 16 (47%) hospitals the A&E department was supervised by other consultants; in 14 supervision was for five hours per week or less. Seven hospitals had no consultant supervision. Twenty-six (76%) had NCHDs assigned to the department. Only 11% of NCHDs were in training in A&E medicine. Six departments employed GPs but 28 said they would like to do so. Most wished GPs to see non-urgent cases but one-third wished them to see all cases. Current staffing levels had little relationship with departmental workload. CONCLUSIONS: The limited consultant supervision and small numbers of NCHDs in training for A&E medicine raise concerns about staffing. Most hospitals want GPs to work in their A&E departments. This has implications for training and for the interface between general practice and the A & E department.

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.

Antithrombin III in cardiac surgery: an outcome study.

A retrospective study examined the impact, in heparin resistant patients (HRP), of lyophilized antithrombin III (ATIII) upon five patient outcomes: intensive care unit stay (ICU-S), 24 hour chest tube drainage (CTD in ml), blood and blood product usage (BPU), development of postoperative coagulopathy (PO-Coag), and reoperation for bleeding (Re-Op). Data was collected from the medical records of 311 patients admitted to the hospital between 12/15/95 and 10/24/96. Subjects were divided into three groups based upon heparin resistance and hemostasis medication. Group 1 (n = 109) were HRP treated with increased heparin, Group 2 (n = 100) were HRP receiving ATIII, and Group 3 (n = 102) were non-HRP and served as controls. Group 2 was also subdivided by use of aminocaproic acid and time of ATIII administration. No significant differences were found between the groups for PO-Coag. and Re-Op. However, significant reduction in CTD (p = 0.05) was seen in the aminocaproic acid patients who were treated with ATIII pre-CPB or within the first 20 minutes of CPB. The CTD in this group was (419.37, +/- 72.96) as compared to Group 1 (782.88, +/- 360.94) and Group 3 (766.67, +/- 407.56). Other Group 2 subgroups showed significant differences in BPU, ICU-S and CTD. The results of this study support the notion that early identification and treatment of HRP with ATIII and aminocaproic acid may decrease postoperative blood loss.

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.

The impact of perfusionist education programme characteristics on programme directors' responsibilities.

The purpose of this study was to measure the effect of four programme characteristics (curriculum design, type of degree offered, length of programme and number of students per class) on perfusionist education programme directors (PDs) in the USA in terms of the number of hours worked per week, number of cases pumped per year and workload mix. Descriptive and statistical analyses were performed on the responses to questionnaires sent to all perfusionist programmes between March 1993 and April 1994. PDs reported working an average of 51.8 h/week and pumping an average of 68.8 cases per year. All but one respondent reported spending more than 50% of his/her time (mean 74.5% +/- 19%) on programme-related issues such as administration, classroom teaching and clinical instruction. This level of commitment, as well as the total number of hours worked per week, were not found to be influenced by the programme's length, duration, class size or type of degree awarded. However, PDs of baccalaureate programmes, and programmes with more than nine students spent a significantly greater proportion of their time on administrative issues than their colleagues in other types of programmes. The bureaucratic demands of baccalaureate and large programmes require PDs to devote an average of 39.5% of their time to administration, compared to 27.2% in the other programmes. The results of this study show that the operation of all perfusionist education programmes requires a major commitment of time on the part of the individual designated as PD.

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.