Improving operational efficiency in an inner-city emergency department.

Saving lives in a high-volume, high-acuity inner-city trauma centre demands operational excellence. We conducted our research in an emergency department where treatment of Acute Coronary Syndrome is a critical operation. Our study results in a better understanding of patient flow, analysis of the waiting lines and an optimization model for labour cost minimization.     

Collapse in an accident and emergency department.

Collapse is a common presenting complaint to accident and emergency (A & E) departments. This retrospective study of 4180 new attendances at a district general hospital A & E showed that this accounted for 2.9%. A wide disease spectrum was implicated. This patient group has a high admission rate (47.8%) and a high mortality rate (31.3%). The deaths occurred largely in the elderly and it is suggested that elderly patients should either be admitted for observation, or a careful screening carried out for underlying pathology. The diversity of disease precludes a standard management protocol.     

Satisfaction with telephone advice from an accident and emergency department: identifying areas for service improvement.

OBJECTIVES: Members of the public often telephone general practice, accident and emergency departments, and other health services for advice. However, satisfaction related to telephone consultation has received relatively little attention. This study aimed to describe the views of callers to an accident and emergency department who expressed any element of dissatisfaction about their telephone consultation. This was part of a larger study intended to help identify areas for service improvement. METHODS: A telephone consultation record form was used to document details of advice calls made to the accident and emergency department over a three month period. Callers who provided a telephone number were followed up within 72 hours. The interviews were tape recorded, transcribed, and explored using content analysis for emerging themes related to dissatisfaction. RESULTS: 203 callers were contacted within 72 hours of their call, of which 197 (97%) agreed to participate. 11 (5.6%) expressed global dissatisfaction, and a further 34 (17%) callers expressed at least one element of dissatisfaction at some point during the interview. Sources of dissatisfaction fell into four broad categories, each of which included more specific aspects of dissatisfaction: 36 (80%) callers were dissatisfied with advice issues, 31 (69%) with process aspects, such as the interpersonal skills of the staff member who took the call, 23 (51%) due to lack of acknowledgement of physical or emotional needs, and 11 (24%) due to access problems. CONCLUSIONS: This study supports the findings of other work and identifies three issues for particular consideration in improving the practice of telephone consultation: (a) training of health professionals at both undergraduate and specialist levels should cover telephone communication skills, (b) specific attention needs to be given to ensuring that the information and advice given over the phone is reliable and consistent, and (c) organisational change is required, including the introduction of departmental policies for telephone advice which should become the subject of regular audit.     

The Football World Cup 1998: an analysis of related attendances to an accident and emergency department.

Throughout the Football World Cup Finals of France 1998, patients attended our inner city Accident and Emergency department with a variety of conditions related to the event. Analysis was made on the total of 151 patients who attended with World Cup related presentations during this five-week period. The majority were young men involved in alcohol related trauma. The workload of the department was only substantially affected after one match, that of the opening game between Brazil and Scotland.     

The management of dental problems presenting to an accident and emergency department.

Patients with dental diagnoses, not necessarily traumatic, often present to accident and emergency departments and general medical practitioners. Few doctors have received much, if any, education in the management of these patients. A 6 month prospective study revealed 107 patients (0.3% of new attenders) attending the accident and emergency department of Glasgow Royal Infirmary. Only 19 of these had suffered trauma. Medical staff in the department were only rarely able to make any diagnosis, and management of these patients took place on an empirical, symptomatic basis. Management could be improved by better education of medical students and doctors. Use of an algorithm may be appropriate.     

Audit of thrombolysis initiated in an accident and emergency department.

Early thrombolytic therapy after acute myocardial infarction is important in reducing mortality. To evaluate a system for reducing in-hospital delays to thrombolysis pain to needle and door to needle times to thrombolysis were audited in a major accident and emergency (A and E) department of a district general hospital and its coronary care unit (CCU), situated about 5 km away. Baseline performance over six months was assessed retrospectively from notes of 43 consecutive patients (group 1) transferred to the CCU before receiving thrombolysis. Subsequently, selected patients (23) were allowed to receive thrombolysis in the A and E department before transfer to the CCU. The agent was administered by medical staff in the department after receiving oral confirmation of myocardial infarction from the admitting medical officer in the CCU on receipt of fax transmission of the electrocardiogram. A second prospective audit during six months from the start of the new procedure established time intervals in 23 patients eligible to receive thrombolysis in the A and E department (group 2b) and 30 ineligible patients who received thrombolysis in the CCU (group 2a). The groups did not differ significantly in case mix, pre-hospital delay, or transfer time to the CCU. In group 2b door to needle time and pain to needle time were reduced significantly (geometric mean 38 min v 121 min (group 2a) and 128 min (group 1); 141 min v 237 min (group 2a) and 242 min (group 1) respectively, both p < 0.0001). The incidence of adverse effects was not significantly different. Nine deaths occurred (six in group 1, three in group 2b), an in-hospital mortality of 9.9%. Thrombolysis can be safely instituted in the A and E department in selected patients, significantly reducing delay to treatment.     

An evaluation of pre-hospital communication between ambulances and an accident and emergency department

We studied pre-hospital notification and the quality of data received from ambulance crews transporting seriously ill or injured patients to an accident and emergency department. During a two-month study period, pre-hospital notification was received for 54 patients. However, the department was notified about only 25 of 62 patients (40%) who, on arrival by ambulance, were triaged as emergencies. Despite developing a data protocol for emergency pre-hospital communication and being equipped to receive emergency ambulance calls directly, many such patients still arrived either unannounced or described in insufficient detail to allow appropriate preparations to be made for them.     

Two hundred school injuries presenting to an accident and emergency department

Two hundred children who had been injured at school and sought hospital treatment were studied. Younger children tended to be brought to the Accident and Emergency Department later after the injuries than the older children, and one in seven of those under 15 years attended alone or without a legally acceptable guardian. Sixteen per cent of the 204 injuries were fractures, of which 70% were to the upper limbs, and 18% facial. Eighteen per cent of the injuries were lacerations requiring sutures. Younger children sustained proportionately more lacerations and fewer minor injuries such as bruises, abrasions and sprains than older children. Over half of the injuries occurred in patients' free time at school, which had been unsupervised in 51% of cases.     

The general practitioner''s use and expectations of an accident and emergency department.

In an attempt to establish what the general practitioner expects from an accident and emergency department, and how closely the service provided correlates with that view, a 12-point questionnaire was sent to the general practitioners in the Glasgow Royal Infirmary catchment area. Out of the 61.2% of general practitioners who replied, the majority wish to have responsibility for their own patients for conditions which are neither accidents nor emergencies. There is less agreement as to how much should be done within an accident and emergency department and on the appropriate modes of referral and communication between the general practitioner and the hospital service. Further consultation and cooperation are necessary to interpret and resolve these differences.     

All day drinking--its impact on an accident and emergency department

In order to assess the impact of changes in the Licensing Laws in England, a prospective study was undertaken of patients attending the Accident and Emergency Department of the Newcastle General Hospital. Patients were breathalysed in October 1986, before the liberalisation of the Licensing Laws in England and Wales and again in October 1988, after this change. A blood alcohol level of greater than 50 mg/100 ml was detected in 13% of all attenders in 1986 and 14% in 1988. A comparison of the two years revealed no significant change in the number of patients who had ingested alcohol prior to attendance, although there was a trend towards increased frequency of alcohol ingestion in nighttime attenders.     

Sports injuries as seen at an accident and emergency department

We present certain characteristics of 1,000 consecutive patients who attended an Accident and Emergency Department (A&E) with an injury sustained as a result of sport. The majority of injuries occurred as a result of football. Sports injuries had a higher requirement of X-ray than general trauma patients. A minority were treated at the site of injury. A fifth of patients required no treatment or a simple dressing. Commonest treatment was a support bandage. Only 2% required immediate in-patient treatment. Those affected by sports injuries tend to be young and of working age and may lose work time as a result of their injuries and therefore appropriate treatment is justified.     

Adult asthma assessment in an accident & emergency department.

Poor initial assessment contributes to morbidity and mortality in acute severe asthma. We have audited this aspect of management in an A & E department over a single 6-month senior house officer employment cycle. The use of a cheap and simple stamp highlighting important clinical features of asthma was associated with a significant improvement in early assessment.     

Inaccurate communications in telephone calls to an antimicrobial stewardship program.

BACKGROUND: Antimicrobial stewardship programs (ASPs) decrease unnecessary antimicrobial use, decrease antimicrobial resistance, and improve patient outcomes. The effectiveness of a prior approval system--that is, the requirement that approval be obtained from ASP practitioners before certain antimicrobials can be used--depends on the accuracy of the patient data communicated from the primary service. OBJECTIVES: To determine the incidence of inaccurate communication of patient data during ASP interactions, describe examples of inaccurate communications, and identify risk factors for inaccurate communication. DESIGN: We used a retrospective cohort design. We evaluated the communicated patient data for clinically important inaccuracies, using the patients' medical records as the gold standard. SETTING: A tertiary care medical center that has a prior approval system for restricted antimicrobials. PATIENTS: Inpatients discussed in telephone ASP interactions. INTERVENTION: Observational study. RESULTS: Of telephone calls requesting prior approval from ASP practitioners, 39% (95% confidence interval [CI], 31%-48%) contained an inaccuracy in at least 1 type of patient data (eg, current antimicrobial therapy); the incidence varied widely between data types. Examples of inaccuracies are given to demonstrate their clinical relevance. In multivariable analysis, inaccurate communications were more common for telephone calls from surgical services (versus calls from nonsurgical services: odds ratio, 2.1 [95% CI, 1.1-3.9]) and for calls received by Infectious Diseases fellows (versus pharmacists: odds ratio, 2.0 [95% CI, 1.1-3.8]). CONCLUSIONS: A high proportion of ASP calls requesting prior approval included patient data inaccuracies, which have the potential to affect the prescribing of antimicrobials. Although risk factors were identified, these communication errors were common across the different types of ASP interactions. Inaccurate communications may compromise the utility of ASPs that use a prior approval system for optimizing antimicrobial use.     

Domestic violence experienced by women attending an accident and emergency department

Abstract: The aim of the study was to establish the extent and severity of domestic violence experienced by women attending the accident and emergency department of a large teaching hospital in Newcastle. The data were collected over a five-week period in 1992. All women between 17 and 80 years, attending the emergency or ambulatory areas between 8 a.m. and midnight, were asked to complete a confidential structured interview. A total of 401 women participated in the study, representing 82 per cent of eligible women approached. Each participant was asked if she had ever been physically hurt by someone close to her. Questions were asked to determine the relationship to the perpetrator, the type and cause of injury, treatment necessary and help sought Seven (1.7 per cent, 95 per cent confidence interval (CI) 0.46 to 3.02) of the women surveyed were attending the hospital as a direct result of an incident of domestic violence, and 100 women (25 per cent, CI 21 to 29) had experienced domestic violence at some time. Bruising, fractures and cuts were the most common forms of injury, with the most common locations being the head, face and chest. Weapons, such as guns and knives, were used in 20 per cent of the incidents. A considerable number of the women (68 per cent) did not seek help at the time of their injuries. As a substantial proportion of women have experienced domestic violence in their lives, accident and emergency workers should receive training in recognising and assisting victims of domestic violence.     

Patients attending an accident and emergency department for primary medical care

An increasing number of people seek primary care at casualtyor accident and emergency departments of hospitals. A questionnairewas completed by patients attending for primary care at an Australianhospital. The study aimed to determine why patients chose thehospital fortheir medical care, whether patients triaged tothe Primary Care Unit differed from patients triaged to theCasualty section of the Accident and Emergency Department, andwhether the characteristics of patients attending at daytimediffered from those attending out of hours. There were no significantdifferences between daytime and out-of-hours attenders accordingto sex or whether born in Australia or not. More children presentedat night or at the weekend; more older people presented by day.There were more single, divorced, separated and widowed patientsamong the daytime attenders. Daytime attenders had significantlylower incomes than out-of-hours attenders, were less likelyto have a local general practitioner or full health insurance:most had a health care card and cost may have been a factorin their attendance. Out-of-hours attenders who had a localgeneral practitioner appeared to be unaware of any deputizingservices or had rejected them in favour of the hospital service.