A survey of new attenders at a paediatric accident and emergency department

A prospective study of one week’s new attendances (sampled over three consecutive weeks) at the A&E Department of the National Children’s Hospital (NCH) was undertaken. A total of 310 children attended over the composite week. Of these, 307 took part in the study, all but three of which were accompanied by an adult. Almost three-quarters (72%) of the children attended without medical referral. Most children (80%) resided within two miles of the hospital. While 46% of respondents claimed they had used the hospital at least once during the previous twelve months, frequent attendance did not appear to be a problem. The majority of children (83%) were seen by a casualty officer within one hour of arrival. Injuries accounted for over half (53 %) of the conditions presented. A fifth (21 %) of the attenders were admitted, half (54 %) of whom were discharged within 24 hours. The study provides baseline data on paediatric A&E services in Dublin and should assist planning of future services.     

Patient consultation survey in an ophthalmic outpatient department

INTRODUCTION: Consultation methods differ between medical practitioners depending on the individual setting. However, the central tenet to the doctor-patient relationship is the issue of confidentiality. This prospective survey highlights patient attitudes towards consultation methods in the setting of an ophthalmic outpatient department. METHOD: Questionnaires were completed by 100 consecutive patients, who had been seen by an ophthalmologist in a single room, which had a joint doctor-patient consultation occurring simultaneously. RESULTS: Each question of all 100 questionnaires was completed. 58% of patients were not concerned about sharing a consultation room with another patient or doctor. However, this did not equate to the 49% of patients who were indifferent to discussing issues in the joint consultation room. The most common factor was the general issue of confidentiality. DISCUSSION: Ensuring total patient confidentiality may be deemed more necessary for certain medical specialties than for others, as seen in the practice of separate medical records in genitourinary medicine, for instance. However, with regard to patient consultations, the same level of confidentiality should be afforded across all specialties, and such factors should be borne in mind when planning outpatient clinics.     

Alcohol-related attendances at an accident and emergency department.

Using a self-administered alcohol-related questionnaire and the clinical records a survey was made of the prevalence and severity of alcohol-related problems in the accident and emergency department at the Belfast City Hospital. Of 10,410 consecutive attendances during three months, 6,625 completed a questionnaire: 4,349 admitted they took alcohol at some time, 906 men exceeded 21 units weekly, and 490 women exceeded 14 units weekly. The majority of those who drank were under the age of 35 years. Only 182 considered that they might have an alcohol-related problem. Possible health promotion initiatives for these at-risk patients are considered which might be used specifically in an accident and emergency department.     

Coping with occupational stress in an accident and emergency department

Kingston Regional Hospital's Accident and Emergency Department (A&E), located in a volatile area of Kingston, Jamaica, treats 90-170 patients daily. It does so with limited staff and a potentially stressful work environment. This study explores the factors associated with occupational stress in the Department, and the coping strategies used by the doctors and nurses working there. A pre-tested self-administered questionnaire was completed by 28 (84.8%) of the total population (n = 33) of health personnel working in the A&E. The participants were 15 (53.6%) doctors, eight (28.6%) registered nurses and five (17.8%) enrolled assistant nurses. The data were analyzed using Statistical Package for the Social Sciences (SPSS) Version 7.5. Qualitative data were analyzed by sorting texts into related themes and describing the ideas of the subjects. The median age was 32 years, range 23-50 years. Median duration of employment in the A&E was three years, range 0.5-22 years. Eighteen (60%) rated the A&E as "stressful". The major sources of stress were the external environment and the amount and quality of the workload. Ninety-six per cent reported experiencing one to seven emotional and physical symptoms. Forty-six per cent also reported behavioural symptoms. The emotional, physical and behavioural symptoms of stress were associated (p < 0.05). The number of behavioural symptoms experienced was associated with age (p < 0.05). The majority (89.2%) of doctors and nurses reported that they were satisfied with their jobs and had no intention of leaving their jobs within a year. This suggested the effectiveness of the reported humour, teamwork and "extracurricular" activities in buffering the effects of stress. Nurses were more likely to be "burned out" than doctors (p = 0.03). The respondents suggested increased monetary compensation, more staff and positive feedback from managers as factors which may relieve work stress. They suggested that organized counselling and stress management programmes would be useful.     

Training and supervision needs and experience: a longitudinal, cross-sectional survey of accident and emergency department senior house officers

The aim of this study was to investigate senior house officers'' (SHOs) perceptions about their training needs, satisfaction with teaching and supervision, and the relationship this has with psychological distress levels. All 171 SHOs employed within 27 accident and emergency (A&;E) departments in the South Thames region were sent questionnaires at the start of their attachments in A&;E, at the end of months four and six. The questionnaires asked SHOs to rate on visual analogue scales their perceived need for further training for 23 clinical and practical activities relevant to A&;E practice. At the end of the fourth month SHOs were asked to indicate who had provided them with the most valuable teaching and supervision, indicate their satisfaction levels with training received, and suggest ways to improve teaching and supervision. SHOs'' psychological distress levels were measured in all three questionnaires.  Overall, satisfaction with supervision and training was mixed. SHOs perceived greatest need for further training in areas encountered less frequently in A&;E. Registrars were the most valued providers of supervision and teaching. Increased numbers of middle grade staff and protected study time were suggested as ways to improve supervision and teaching. SHOs with higher scores for training need at the end of their attachment in A&;E expressed significantly less satisfaction with training and higher psychological distress levels. The variation between SHOs'' perceptions of training needs indicates the importance of tailoring training and supervision to individual requirements.     

Improving the interpretation of electrocardiographs in an accident and emergency department.

In this study we have examined the ability of senior house officers in the Accident and Emergency (A&E) Department to interpret electrocardiographs (ECGs) and tested the value of a single seminar and guidelines on interpretation. We prospectively audited ECG interpretation taken from notes over a two-month period and repeated this audit following a single seminar by a consultant cardiologist and after the issue of guidelines. A formal test of interpretation of a set of 20 ECGs by senior house officers in A&E was also carried out. 245 case notes were reviewed and in one third the ECG was interpreted incorrectly by senior house officers in A&E but incorrect clinical management followed in only 3.2% of cases. Following the intervention, 242 case notes were reviewed and serious misinterpretations were halved as was the number of patients mismanaged as a result (1.7%). In conclusion, formal training in ECG interpretation can reduce serious errors.     

Letters to go: general practitioners' referral letters to an accident and emergency department

OBJECTIVE: To investigate the content of general practitioners' referral letters to the Accident and Emergency (A&E) Department of a large regional hospital. METHOD: Two hundred and fourteen consecutive identifiable letters from general practitioners presented by patients over a four week period were reviewed. The accuracy and content of the letters was measured by the presence of 10 key items, and checked against the A&E notes when necessary. A further nine items were examined to discover whether the context of the referral had any influence on letter content. RESULTS: Information that was relatively poorly represented in the letters included social and personal background details, vital signs, regional examination findings, a management plan, and investigation results. The presence in the letter of a management plan or a clear presenting problem was found to be significantly associated with appropriate referrals. CONCLUSIONS: Poor referral letters may reflect a professional distance between the general practitioner and A&E staff that is stretched by the anonymity of the relationship, increasing A&E specialisation, or lack of feedback to the general practitioner. Specific information standards for A&E referrals should be developed to ease contact and to establish criteria for referral.     

Evaluation of a point-of-care transcutaneous bilirubinometer in Chinese neonates at an accident and emergency department

OBJECTIVE: To evaluate the use of a point-of-care transcutaneous bilirubinometer, JM-103 Minolta, for estimation of the serum bilirubin level in the management of neonatal jaundice in term or near-term Chinese neonates. DESIGN: Prospective correlation study. SETTING: Accident and Emergency Department of a regional hospital in Hong Kong. PATIENTS: All term or near-term Chinese neonates aged 3 to 7 days, who attended the Accident and Emergency Department because of jaundice between September and November 2007. MAIN OUTCOME MEASURES: Paired transcutaneous bilirubin measurements by the JM-103 Minolta and the total serum bilirubin measurement by a direct spectrophotometric method in the laboratory. RESULTS: The mean age of the 113 neonates at the time of data collection was 5 days (range, 3-7 days). Transcutaneous bilirubin showed a good correlation with total serum bilirubin; the highest correlation coefficient was 0.83 (P < 0.001). Transcutaneous bilirubin cutoff values of 230 micromoles per litre and 298 micromoles per litre could have 100% sensitivity and specificity respectively, to predict a total serum bilirubin level of higher than 250 micromoles per litre (the accepted threshold for treatment). The mean difference between transcutaneous and total serum bilirubin was 14 micromoles per litre (standard deviation, 28 micromoles per litre; P < 0.001); the JM-103 tended to overestimate total serum bilirubin. The 95% limits of agreement were between -40 and 69 micromoles per litre. CONCLUSION: The new point-of-care transcutaneous bilirubinometer, JM-103 Minolta, demonstrated good correlation with the serum bilirubin measurement in Chinese neonates aged 3 to 7 days. Thus, it is a useful screening device to facilitate quick decisions on disposal of jaundiced neonates presenting to accident and emergency departments or in out-patient clinic settings.     

Non-admitted elderly in the accident and emergency department

The aim of the study was to identify the functional disabilities and support needs of elderly people who presented but were not admitted to a Dublin Accident & Emergency (A & E) department within a 1 month period. Semi-structured interviews were conducted with 19 per cent (100/532) of the non-admitted elderly within 2 weeks of the A & E visit. Injury related complaints were apparent in 51 per cent of the patients with 3 per cent requiring hospital admission within 2 weeks of the A & E visit. Increased dependency in 1 or more Activities of Daily Living (ADL) occurred in 10 per cent while 28 per cent had increased dependency in 1 or more Instrumental Activities of Daily Living (IADL). Increased family support following discharge was received by 45 per cent of the elderly. The most commonly needed statutory service which was not provided was the home-help service. This study provides baseline data on the non-admitted elderly in one Dublin A & E department and should assist planning of future services.     

Medical patients aged 65 and over admitted to an accident and emergency department

A study of 100 consecutive emergency medical admissions to Oldchurch Hospital was made to establish if the mode of referral--either by the general practitioner or self referral--influenced the presentation and severity of illness and the eventual outcome. Of the 94 cases analysed, 55 were self referred and 39 were sent in by their general practitioners. No significant differences were found between the two groups of patients, which suggests that the patient (or the patient's family or companion) is as discriminating as the general practitioner in deciding when emergency referral to hospital is necessary.     

Primary medical care in a paediatric accident and emergency department.

The characteristics of a random sample of 853 children who attended the accident and emergency department of the Royal Belfast Hospital for Sick Children were studied prospectively to determine the extent to which the department was being used to provide primary medical care. Direct parent referrals accounted for 69% of all attendances with a further 21% referred by the family doctor. Parental preference and accessibility were the main reasons given for choosing to attend the department with the latter significantly higher among out-of-hours attendances. However, only 37 of the 585 parent referrals had made an attempt to contact the family doctor. Overall, 33.9% of children were felt to be inappropriate attenders, i.e. were neither accident nor emergency cases, and the proportion was highest among the parent-referred groups. The present financial restraints facing the National Health Service make it uneconomical to provide primary medical care at both hospital and community level. However, the level of demand for the accident and emergency department, together with the attitudes of those who attend, make it unlikely that a more rational use of resources will be achieved in the foreseeable future.     

Bicycle-related injuries: a survey in a pediatric emergency department.

The number of bicycle-related injuries has risen significantly with the increased popularity of bicycle riding in Canada. The risk of injury is highest among children. To assess the magnitude of the problem and to identify the contributing factors we used a questionnaire, injury reports and patient charts to survey bicycle-related injuries among children brought to the emergency department of the Children's Hospital of Eastern Ontario, Ottawa, between May 1 and Sept. 30, 1988. The questionnaire was completed for 517 (91%) of the 568 children; 70% were boys, and the mean age was 9.4 years. Only 2% of the patients had been wearing a helmet at the time of injury, although 13% claimed to own one for cycling. Over 60% of the accidents were attributable to carelessness or poor bicycle control; mechanical failure and environmental hazards were minor factors. Over 80% of the injuries occurred within a kilometre of the child's home. Of the 97 children admitted to hospital 49% had head and skull injuries and 40% had limb fractures. Bicycle-related injuries represented 14.8% of all nonwinter (Apr. 1 to Oct. 31) trauma admissions among children 5 years or older. Our results further document bicycle-related injuries as an important childhood problem and underscore the need for improved safety measures.     

Which patients are likely to die in an accident and emergency department?

Four hundred and eighty-eight deaths occurring in an accident and emergency department over five years were analysed. Their causes were categorised as medical, surgical, or traumatic. Medical causes accounted for 87% of the deaths, of which 60% were from cardiac conditions. Blood loss was an important factor in over half the deaths from surgical and traumatic causes. Lives might have been saved by considering infectious disease in patients with medical conditions and by undertaking more rapid blood transfusion, earlier chest drainage, and lateral cervical spine x rays in appropriate surgical or traumatic cases. The admission to casualty departments of people with terminal neoplasms should be discouraged. The management of medical emergencies should be emphasised when training accident and emergency department staff.     

尼日利亚某城市医院急诊科死亡病例特点

目的：医院的急诊科通常能够反映当地公共卫生的服务质嚣。哈科特港大学教学医院是尼日利亚南部地区重要的卫生服务机构，以其为中心辐射的服务人门约5000000。本文研究死亡病例的人口统计学特点、死亡之前在急诊科的时间。方法：研究对象为2000年4月-2003年3月的3年中在哈科特港大学教学医院急诊科就诊的患者，回顾分析就诊记录、护理报告和死亡证明。找出其中的人口统计学特征、死亡原因，以及从到达急诊科到死亡的时间，建立复合频率表用于分析。     

Violence in the emergency department: a survey of health care workers

BACKGROUND: Violence in the workplace is an ill-defined and underreported concern for health care workers. The objectives of this study were to examine perceived levels of violence in the emergency department, to obtain health care workers' definitions of violence, to determine the effect of violence on health care workers and to determine coping mechanisms and potential preventive strategies. METHODS: A retrospective written survey of all 163 emergency department employees working in 1996 at an urban inner-city tertiary care centre in Vancouver. The survey elicited demographic information, personal definition of violence, severity of violence, degree of stress as a result of violence and estimate of the number of encounters with violence in the workplace in 1996. The authors examined the effects of violence on job performance and job satisfaction, and reviewed coping and potential preventive strategies. RESULTS: Of the 163 staff, 106 (65%) completed the survey. A total of 68% (70/103) reported an increased frequency of violence over time, and 60% (64/106) reported an increased severity. Most of the respondents felt that violence included witnessing verbal abuse (76%) and witnessing physical threats or assaults (86%). Sixty respondents (57%) were physically assaulted in 1996. Overall, 51 respondents (48%) reported impaired job performance for the rest of the shift or the rest of the week after an incident of violence. Seventy-seven respondents (73%) were afraid of patients as a result of violence, almost half (49%) hid their identities from patients, and 78 (74%) had reduced job satisfaction. Over one-fourth of the respondents (27/101) took days off because of violence. Of the 18 respondents no longer working in the emergency department, 12 (67%) reported that they had left the job at least partly owing to violence. Twenty-four-hour security and a workshop on violence prevention strategies were felt to be the most useful potential interventions. Physical exercise, sleep and the company of family and friends were the most frequent coping strategies. INTERPRETATION: Violence in the emergency department is frequent and has a substantial effect on staff well-being and job satisfaction.