An analysis of telephone calls to an inner-city accident and emergency department.

The general public in the UK often telephone accident and emergency (A&E) departments for medical advice. Such calls are usually dealt with by nursing staff in an informal manner (often with no written record of the call being made). The specific questions addressed in this study are who was calling for advice, when did they call, what were their presenting complaints, and what was the outcome of the call? In addition, the study provided an opportunity to test the implementation of a new system of record-keeping for telephone consultation. A telephone consultation record (TCR) was developed and used to record details of each call made to the A&E department for medical/health advice. An analysis of 597 consecutive documented calls is presented in this paper. The majority of calls were dealt with by 'E' grade nursing staff (42.7%); only four calls (0.7%) were recorded by medical staff. Two hundred and six (43.5%) calls related to patients aged up to 15 years. In 57% of the cases the call was made by a third party. In all, 149 different presenting complaints were recorded on the TCRs. The three most common presenting complaints were dental problems (7.4%), fever (4.3%), and concerns about drug reactions (23%). Seventy-three per cent of callers were advised that a visit to the A&E department was not immediately necessary. The study identifies several important issues for development of a more formal and effective system of telephone advice. The majority of calls made to the A&E department appeared to be of a primary care nature but the extent to which nurses are trained to assess and advise on these problems needs to be questioned. A reluctance to document the calls to A&E was identified, one reason being a concern about accountability. Training and support are clearly required.     

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.     

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.     

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.     

Evaluation of an accident and emergency teleconsultation service for north-east Scotland

We evaluated an accident and emergency teleconsultation service provided to 14 community hospitals in north-east Scotland. Each community hospital was equipped with a videoconferencing system and a document camera to allow transmission of radiographs. The network used 384 kbit/s ISDN connections. A total of 1392 teleconsultations were recorded during a 12-month study period. Seventy-seven per cent of patients (n = 1072) were managed locally and 23% (n = 320) were transferred to Aberdeen. The majority (95%) of teleconsultations were conducted on weekdays, and 90% of these occurred between the hours of 09:00 and 16:00. The mean delay in contacting a doctor was 9 min and the mean consultation time was 10 min. The majority of patients were suffering from fractures or suspected fractures of the limbs. Radiograph transmission was used in 75% of all teleconsultations. A high degree of satisfaction was recorded by all users of the service.     

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.     

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.     

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.     

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 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.     

Assault patients attending a Scottish accident and emergency department.

Over 2 months in 1995, 235 assault patients attended the accident and emergency department of the Royal Alexandra Hospital, Paisley (2.4% of total new attendances). 80% were male and their mean age was 28 years (range 6-64); men were the assailants in over 90% of attacks. Alcohol had been consumed by 69% of the victims and 9% admitted to taking illicit drugs. The commonest place of assault was the street (44%) but women were more likely to be assaulted in their homes. Penetrating weapons were used in 23% of assaults. 60% of all injuries were to the head and neck. 27% of the victims were admitted to hospital. Paisley has an assault rate similar to that of other UK centres but the use of penetrating weapons is much higher than elsewhere.