Diagnostic errors in an accident and emergency department

Objectives—To describe the diagnostic errors occurring in a busy district general hospital accident and emergency (A&E) department over four years.

Method—All diagnostic errors discovered by or notified to one A&E consultant were noted on a computerised database.

Results—953 diagnostic errors were noted in 934 patients. Altogether 79.7% were missed fractures. The most common reasons for error were misreading radiographs (77.8%) and failure to perform radiography (13.4%). The majority of errors were made by SHOs. Twenty two diagnostic errors resulted in complaints and legal actions and three patients who had a diagnostic error made, later died.

Conclusions—Good clinical skills are essential. Most abnormalities missed on radiograph were not difficult to diagnose. Junior doctors in A&E should receive specific training and be tested on their ability to interpret radiographs correctly before being allowed to work unsupervised.

     

A scale for measuring the severity of diagnostic errors in accident and emergency departments.

OBJECTIVE: To design and test a simple scale for measuring the severity of diagnostic errors occurring in accident and emergency (A&E) departments. METHODS: Empirical design of a scale which indicates the severity of errors on a scale of 1 to 7. It is obtained by adding two scores which indicate the additional treatment which a patient would have received and the follow up which would have been organised if the correct diagnosis had been made initially. RESULTS: The misdiagnosis severity score (MSS) revealed 166 diagnostic errors in injuries treated in an A&E department over one years. The scoring system allowed the more significant errors to be separated from the less significant ones. CONCLUSIONS: The MSS proved useful in describing the errors made in an A&E department.     

Alcohol and radiographs in the accident and emergency department

Objective—To investigate the contribution of alcohol ingestion to the radiological workload of an inner city accident and emergency (A&E) department.

Methods—A prospective survey of patients presenting to A&E who required radiographs was performed over a seven day period. The A&E clinician questioned patients about alcohol intake during the six hours before the onset of the presenting complaint or injury, and made an objective assessment of signs of alcohol ingestion or intoxication. An assessment was made also of the relative contribution of alcohol as a cause of patients' injuries.

Results—A total of 419 patients who had radiography fulfilled the inclusion criteria, and a questionnaire was completed for 351 (84%). Forty (11%) of 351 were found to have ingested alcohol. Thirty five (87%) of 40 patients who had ingested alcohol were radiographed for trauma, as compared with 171 (55%) of the 311 who had not (p<0.001). Alcohol was considered to have been causative of injury in 30% and a contributory factor in an additional 58%. Radiographs of the skull, face and jaw accounted for 18 (33%) of 55 radiographs from trauma patients who had ingested alcohol compared with 20 (9%) of 212 radiographs from those who had not (p<0.001). There was no significant difference in the proportion of abnormal radiographs between these two groups (27% of radiographs from trauma patients who had ingested alcohol compared with 23% of radiographs from those who had not, p>0.2).

Conclusion—Patients with alcohol related injuries requiring radiography have a significant impact on the radiological workload of an A&E department, although the prevalence of alcohol ingestion detected in this study was less than expected from previous studies.

     

The sprained ankle

The sprained ankle is the most common musculoskeletal injury seen by physicians caring for active youngsters and adults. It accounts for approximately one fourth of all sports-related injuries and is commonly seen in athletes participating in basketball, soccer, or football. It has been shown that one third of West Point cadets suffer an ankle sprain during their 4 years at the military academy. While diagnosis and management of the sprained ankle is usually straightforward, several serious injuries can masquerade as an ankle sprain, and it is important for the clinician to recognize these to prevent long-term morbidity. In this article the basic anatomy of the ankle, mechanisms by which the ankle is injured, and the differential diagnosis of the acutely injured ankle are reviewed. Appropriate evaluation of the injured ankle and the criteria that should be utilized for determining the necessity of radiographs are discussed as well as management of the acutely sprained ankle and the role of prevention in reducing the risk of ankle injury.     

Patients who attend two accident and emergency departments.

Forty-six patients were identified who attended an accident and emergency (A&E) department having previously attended a different A&E department in the same city for the same problem. Of these patients, 20% had been referred to the second department by the general practitioner (GP) or practice nurse. A diagnostic error had been made in 17.5% of patients at their first visit and some management errors were discovered. Eleven per cent of patients had an unnecessary second set of radiographs taken. A review of unplanned reattenders to an A&E department is an important opportunity for audit and normally an error will not be discovered if a patient attends a different department. We recommend that in cities where there is more than one A&E department a system should be set up whereby if a patient attends one department having previously attended another, the first department should be informed of the patients reattendance, especially if any diagnostic or management error has been discovered. Patients should be educated that if they have sought medical help for any problem and the condition does not improve, then they should return to see the same doctor or A&E department for continuity of care and avoidance of unnecessary duplication of investigations including exposure to X-rays.     

Sports medicine and the accident and emergency medicine specialist

Background: Sport and exercise related injuries are responsible for about 5% of the workload in the accident and emergency (A&E) department, yet training in sports medicine is not a compulsory part of the curriculum for Higher Specialist Training.

Aim: To determine how A&E medicine consultants and specialist trainees view their role and skill requirements in relation to sports medicine.

Method: A modified Delphi study, consisting of two rounds of a postal questionnaire. Participants were invited to rate the importance of statements relating to the role and training of the A&E specialist in relation to sports injuries (six statements) and the need for knowledge and understanding of defined skills of importance in sports medicine (16 statements).

Value of research: This provides a consensus of opinion on issues in sport and exercise medicine that have educational implications for A&E specialists, and should be considered in the curriculum for Higher Specialist Training. There is also the potential for improving the health care provision of A&E departments, to the exercising and sporting population.

     

The effect of a Picture Archiving and Communications System (PACS) on diagnostic performance in the accident and emergency department

Objective—A study has been conducted to identify the benefits to the accident and emergency (A&E) department of a hospital wide Picture Archiving and Communications System (PACS).

Methods—The study was conducted in two parts: firstly while the hospital was using conventional radiographic films, and secondly when the PACS was in operation. For each part of the study, the diagnoses of radiographic images made by A&E clinicians were compared with those made by radiologists. This resulted in the estimation of the incidence of false negative findings by the A&E staff. The management of patients with such findings was studied to identify those for whom a change of treatment was required. Such data for the two periods, when film and when PACS was used, were compared.

Results—It was found that the overall rate of misdiagnoses across all A&E patients who had radiography was low in both periods and there was a significant reduction when PACS was used (1.5% for film and 0.7% for PACS, 95% CI for difference between proportions: -0.014 to -0.0034), but the rate of serious misdiagnoses involving patient recall did not change significantly (95% CI for difference between proportions: -0.0059 to +0.0001).

Conclusions—When PACS was used the diagnostic performance by A&E staff improved by reducing false negative interpretations but the rate of serious misdiagnosis did not change.

     

Management of soft tissue knee injuries in an accident and emergency department: the effect of the introduction of a physiotherapy practitioner

Objective: To assess the effect of the introduction of a physiotherapist with an extended scope of practice in the management of acute soft tissue knee injuries in an accident and emergency (A&E) department.

Methods: The A&E department established an Acute Knee Screening Service (AKSS) in 1998. An experienced physiotherapist was appointed to run the AKSS after additional training. Local guidelines and protocols were developed in conjunction with trauma knee surgeons, radiologists, physiotherapists, and A&E doctors. This study describes 100 consecutive patients managed by the AKSS over a three month period and comparisons are made over a similar period before the introduction of the AKSS.

Results: The initial diagnosis of patients with acute knee injuries referred to the service showed meniscal injuries (38%), cruciate ligament injuries (18%), fractures (2%), patellofemoral joint injuries (10%), and others (32%). Ninety five per cent of patients referred to AKSS were seen within one week. Medical time was saved in both A&E and trauma clinic. Fifty nine per cent of patients were treated and discharged from the service without further medical review. Thirty nine per cent (39) were referred to trauma clinic and of these 44% (17) had MRI scans performed as requested by the physiotherapist. Eighty eight per cent (15) of these scans showed significant abnormality: (nine, anterior cruciate ligament tears, one, posterior cruciate ligament tears, and nine meniscal tears).

Conclusions: A physiotherapy practitioner working with an extended role is a valuable addition to an A&E department. The AKSS improves the quality of care of acute knee injuries, saves medical time, and fosters cooperation across services within the NHS.

     

The Sheffield experiment: the effects of centralising accident and emergency services in a large urban setting

Objectives—To assess the effects of centralisation of accident and emergency (A&E) services in a large urban setting. The end points were the quality of patient care judged by time to see a doctor or nurse practitioner, time to admission and the cost of the A&E service as a whole.

Methods—Sheffield is a large industrial city with a population of 471 000. In 1994 Sheffield health authority took a decision to centralise a number of services including the A&E services. This study presents data collected over a three year period before, during and after the centralisation of adult A&E services from two sites to one site and the centralisation of children's A&E services to a separate site. A minor injury unit was also established along with an emergency admissions unit. The study used information from the A&E departments' computer system and routinely available financial data.

Results—There has been a small decrease in the number of new patient attendances using the Sheffield A&E system. Most patients go to the correct department. The numbers of acute admissions through the adult A&E have doubled. Measures of process efficiency show some improvement in times to admission. There has been measurable deterioration in the time to be seen for minor injuries in the A&E departments. This is partly offset by the very good waiting time to be seen in the minor injuries unit. The costs of providing the service within Sheffield have increased.

Conclusion—Centralisation of A&E services in Sheffield has led to concentration of the most ill patients in a single adult department and separate paediatric A&E department. Despite a greatly increased number of admissions at the adult site this change has not resulted in increased waiting times for admission because of the transfer of adequate beds to support the changes. There has however been a deterioration in the time to see a clinician, especially in the A&E departments. The waiting times at the minor injury unit are very short.

     

Prehospital use of paracetamol among children attending the accident and emergency department

Methods: A prospective cohort study of carers of children attending a paediatric accident and emergency (A&E) department. Carers of children completed a questionnaire to identify domestic patterns of paracetamol use. Data were collected on temperature of the child in the A&E department, administration of antipyretics in the A&E department, diagnosis, and disposal from the A&E department.

Results: Seventy five adults attending the A&E department consented to involvement. Sixty five of the children were feverish on arrival in the A&E department. Twenty one children (32.3%) had not received paracetamol before attending. There was a significant relation between knowledge of the antipyretic properties of paracetamol and administration (χ²=5.0, p<0.05). There was a significant correlation between fever and administration of paracetamol in the A&E department (χ²=23.7, p<0.01), however, 15 feverish patients (24.6%) were not treated.

Conclusions: Most carers administer paracetamol appropriately in the prehospital setting. Administration correlates significantly with knowledge of its benefits. There is scope for education of carers and A&E department staff in the in the appropriate use of antipyretics such as paracetamol.

     

Use of out of hours services: a comparison between two organisations

Background: Increasing numbers of self referrals at the accident and emergency (A&E) department cause overcrowding, while a substantial number of these patients exhibit minor injuries that can be treated by a general practitioner (GP).

Methods: Two different organisations of out of hours care in two Dutch cities (Heerlen and Maastricht) were investigated. Important differences between the two organisations are the accessibility and the location of primary care facility (GP cooperative). The Heerlen GP cooperative is situated in the centre of the city and is respectively 5 km and 9 km away from the two A&E departments situated in the area of Heerlen. This GP cooperative can only be visited by appointment. The Maastricht GP cooperative has free access and is located within the local A&E department. During a three week period all registration forms of patient contacts with out of hours care (GP cooperative and A&E department) were collected and with respect to the primary care patients a random sample of one third was analysed.

Results: For the Heerlen and Maastricht GP cooperative the annual contact rate, as extrapolated from our data, per 1000 inhabitants per year is 238 and 279 respectively (χ²_(1df)=4.385, p=0.036). The contact rate at the A&E departments of Heerlen (n=66) and Maastricht (n=52) is not different (χ²_(1df)=1.765, p=0.184). Some 51.7% of the patients attending the A&E department in Heerlen during out of hours were self referred, compared with 15.9% in Maastricht (χ²_(1df)=203.13, p<0.001).

Conclusions: The organisation of out of hours care in Maastricht has optimised the GP's gatekeeper function and thereby led to fewer self referrals at the A&E department, compared with Heerlen.

     

Referral to the accident and emergency department following the use of community alarms

Objectives—To assess the degree of appropriate referral to the accident and emergency (A&E) department following the use of a community alarm where a mobile warden works in conjunction with the community alarm control centre.

Methods—611 consecutive calls using community alarms underwent assessment and the appropriateness of referral to the A&E department was considered.

Results—Of 542 requests for help 44 patients were transported to the A&E department (8.1%). Twenty nine patients were admitted (5.3%) and 15 patients (2.8%) discharged home from the A&E department after assessment or treatment, or both. Only three patients (0.55%) had been referred to the A&E department inappropriately.

Conclusions—This study shows that where a mobile warden works in conjunction with the community alarm control centre the number of inappropriate referrals to the A&E department should be minimal.

     

A review of telemedicine in accident and emergency: the story so far

Recent developments in information and communications technology have the potential to revolutionise health care. This has been recognised at government level, and plays a significant part in the new information strategy for the NHS "Information For Health". Telemedicine (literally, medicine at a distance) is one of the most successful techniques in this rapidly expanding field, and in preliminary studies has proved to be both successful and popular with patients and health care professionals. In the UK telemedicine has been mainly applied to two major areas of accident and emergency (A&E) practice. These are the transmission of computed tomography scans for urgent neurosurgical opinion and the ongoing support of minor injuries units. The latter also involves transmission and interpretation of radiographs, usually peripheral limb films.

Telemedicine is not a medical sub-specialty in itself, but a facilitator of all medical and surgical specialties. While recent modernisation initiatives have permitted A&E departments to purchase a range of telemedical equipment, overall progress is hampered by a lack of large or scientifically rigorous studies, and a complete absence of data on the economic implications of this new technique. This review introduces A&E telemedicine in terms that avoid jargon and complex technical details. After a brief consideration of the origins of the subject, attention is given to recent publications relating to minor injuries support and A&E teleradiology. The technical and clinical feasibility of A&E telemedicine are demonstrated, and a case is made for the transmission and interpretation of minor injuries radiographs using a relatively simple and inexpensive system, supported by timely radiological reporting. After a brief study of various legal and ethical issues, the likely developments of the future are discussed.

     

Children with seizures presenting to accident and emergency.

OBJECTIVE: To analyse the diagnoses made in children presenting to an accident and emergency (A&E) department with seizures. METHODS: All children who presented to a district general hospital A&E department with seizures over a 1 year period were identified. A retrospective review of A&E and hospital records was performed one year after they were first seen. The types of seizure, investigations performed, treatment given, and the range of associated diagnoses were ascertained. RESULTS: 199 children (of 21,795 attending A&E in the year) had 254 visits with seizures, which represented 1.2% of the child attendances at A&E. Self referral occurred in 87%, and 52 patients had established epilepsy. Febrile seizures were far the commonest type of first seizure (n = 75), but there were also 13 cases of symptomatic seizures resulting from various metabolic and neurological causes. CONCLUSIONS: The children studied had a very different spectrum of problems from adults. A&E staff should be aware of the range of problems in children who present with seizures. Experienced paediatric staff should be available to assist all A&E departments where children are seen.     

Use of,and outputs from,an assault patient questionnaire within accident and emergency departments on Merseyside

Objectives: To describe the implementation, use of, and outputs from an assault patient questionnaire (APQ) introduced in accident and emergency (A&E) departments to determine Crime & Disorder and Community Safety priorities on Merseyside, a metropolitan county in north west England, UK.

Methods: Why and how the APQ was implemented, data collected, and information obtained. The subsequent incorporation of the APQ into the Torex Patient Administration System (PAS) at the Royal Liverpool University Hospital A&E department and its routine completion by trained reception staff.

Results: Analysis is based upon anonymised data—for example, patient ID and date of birth information is suppressed. A summary of "baseline" information obtained from the data collected is provided.

Conclusions: It is possible for the APQ to be implemented at no extra cost in a large A&E department in an acute general teaching hospital. Valuable intelligence can be obtained for Crime & Disorder Act and Community Safety processes. The APQ forms part of a medium to long term strategy to prevent and reduce violent assaults in the community that subsequently require treatment in an A&E department. Such incidents include assaults both inside and outside licensed premises, attacks by strangers on the street, and domestic violence. Emphasis is also placed upon the feedback of results to staff in A&E departments.

     

Rollerblading in children: the Edinburgh experience.

OBJECTIVE: To determine the incidence and severity of injuries sustained by children who present to an accident and emergency (A&E) department following rollerblading accidents. DESIGN: A prospective case-control study. SETTING: The A&E department of a city centre paediatric teaching hospital. METHODS: Data were collected on a specially designed proforma on each child presenting with an injury sustained while rollerblading. The injury severity score was calculated for each patient and details were taken of the length of admission or outpatient follow up where appropriate. RESULTS: Seventy four children (37 male; 37 female) presented with injuries over a three month period. The age range was 6-13 years in both groups. Half the injuries occurred at weekends. Fractures (n = 37) and soft tissue injuries (n = 28) were the most prevalent; 89% of injuries involved the limbs. Sixty eight children (92%) required treatment in A&E. Four (3%) were admitted to hospital and required operative procedures under general anaesthetic. The injury severity score ranged from 1 to 9 with a mean of 2.8. The length of hospital stay for admissions was 1-3 days; 47 children required follow up in the outpatient department (1-3 visits). Average length of outpatient contact was 18 days. CONCLUSIONS: This study shows a greater incidence of rollerblading injuries than has been reported elsewhere. No figures are at present available for the United Kingdom as a whole.     

Monteggia fracture-dislocation in children.

Monteggia fracture-dislocations are uncommon in childhood. Correct early diagnosis is essential to avoid elbow dysfunction and the necessity for open reduction of the radial head. This retrospective analysis of 220 forearm fractures in children shows that 50% of Monteggia fractures were misdiagnosed by accident and emergency (A&E) department senior house officers (SHOs) and 25% were misdiagnosed by senior radiologists. Instruction in correct clinical and radiological examination of the elbow joint in children to junior A&E doctors, with early review of suspicious cases by senior medical staff, may help to reduce the incidence of missed Monteggia fractures.     

Trends in community violence in England and Wales 1995-1998: an accident and emergency department perspective

Objectives—To identify overall, seasonal, sex and age specific national trends in community violence from an accident and emergency (A&E) department perspective.

Design and Setting—Prospective collection of national violence data from a stratified random sample of 33 A&E departments in England and Wales.

Methods—Data were analysed for the three years from May 1995 to April 1998. Time series statistical methods were used to detect trends among those aged 0–10, 11–17, 18–30, 31–50 and 51 + years.

Results—121 475 assaults were identified: 89 533 (74%) men sustained injury. Forty five per cent were aged 18–30. The significant trends were an increase in injured women and those aged 31–50. Significant seasonal trends were identified for both sexes and all age groups: peaks were found in July to September and troughs in February to April.

Conclusions—There was no overall significant change in levels of violence between 1995–1998 from an A&E department perspective. Numbers of women injured and those aged 31–50 increased significantly. The incidence of injury sustained in community violence is biphasic: is highest during July to September and lowest during February to April. National A&E department violence surveillance provides a unique perspective.

     

Unnecessary delays in accident and emergency departments: do medical and surgical senior house officers need to vet admissions?

Work was carried out to determine whether patients requiring emergency medical or surgical admission to hospital via accident and emergency (A&E) departments benefit from initial assessment by the ward senior house officer (SHO) as well as the A&E SHO. Two comparable consultant-led A&E departments sharing the same catchment population and receiving similar numbers of new patients each year were studied. A panel of four consultants audited the A&E notes and in-patient records of consecutive emergency medical and surgical patients admitted to two hospitals over the same 6 month period. In one hospital patients were seen and admitted by the A&E SHO alone. In the other hospital patients were seen by the A&E SHO and the medical or surgical SHO from the admitting unit. Diagnostic errors, inappropriate admissions to hospital and admission of patients to inappropriate wards were used as outcome measures. There was no significant difference in the rates of diagnostic error or inappropriate admissions between those patients seen by an A&E SHO only, and those seen in A&E by the A&E and ward SHOs. Detaining emergency medical and surgical patients in the A&E department for further assessment by ward SHOs does not alter inappropriate admission rate or improve diagnostic accuracy.     

Implementation of the Ottawa Ankle Rules by nurses working in an accident and emergency department.

OBJECTIVE: To assess whether accident and emergency (A&E) nurses using the Ottawa Ankle Rules could detect all ankle fractures. DESIGN: Prospective observational study. SETTING: A&E department of a university teaching hospital. SUBJECTS: All patients who presented with ankle injuries who were initially assessed by a nurse taught the Ottawa Ankle Rules. OUTCOME MEASURES: (1) The numbers of patients referred by the nurse for ankle radiography; (2) of these, the number with ankle fractures; (3) of those not sent for radiography initially by the nurse, the number who subsequently had x rays (ordered by the doctor) and had a fracture; (4) of those having no x rays, the number who reattended later. RESULTS: 324 patients were eligible; 238 had x rays at the request of the nurse (73%); 48 of these (20%) were diagnosed as having a fracture. Of those 86 patients not sent for radiography by the nurse, 19 subsequently had x ray examinations at the request of a doctor and no fracture was detected. Of the 67 not sent for radiography, none returned within the subsequent eight weeks. CONCLUSIONS: Nurses can apply the Ottawa Ankle Rules safely without missing acute fractures; that is, of those who were not sent for radiography by nurses, none subsequently reattended the A&E department or the trauma service of the Bristol Royal Infirmary during the following two months.