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.

     

The Effect of Picture Archiving and Communications Systems on the Accuracy of Diagnostic Interpretation of Pediatric Emergency Physicians

Objectives: To compare the accuracy of diagnostic interpretation of radiographs by pediatric emergency physicians (EPs) before and after the introduction of a Picture Archiving and Communications System (PACS). Methods: The pre‐PACS study period included results from September 2001, when patients were evaluated by using only conventional radiographs. The post‐PACS study period consisted of results from September 2002, when patients were evaluated by using only digital radiographic studies. During these periods, consecutive medical records of all patients who underwent radiological studies when attending the pediatric emergency department (ED) were reviewed. The radiographic interpretation by the pediatric EP, documented at the time of the ED visit, was compared with that made by the pediatric radiologist. Results: Data were available from 1,644/1,651 sets of conventional radiographs ordered for the pre‐PACS study period and from 1,430/1,431 sets of digital radiographic studies for the post‐PACS study period. The prevalence of positive radiological studies as per the radiologists was 32.2% (pre‐PACS study period) vs. 28.7% (post‐PACS study period). Diagnostic performance of the pediatric EPs for the two time periods was as follows: overall accuracy, 98.1% (95% confidence interval [CI] = 94.5% to 100%) vs. 98.5% (95% CI = 87.5% to 100%); sensitivity, 96.4% (95% CI = 94.5% to 97.8%) vs. 98.1% (95% CI = 96.2% to 99.2%); specificity, 98.9% (95% CI = 98.1% to 99.4%) vs. 98.6% (95% CI = 97.7% to 99.3%); negative predictive value, 98.3% (95% CI = 97.4% to 99.0%) vs. 99.2% (95% CI = 98.5% to 99.7%); and positive predictive value, 97.7% (95% CI = 96.0% to 98.8%) vs. 96.6% (95% CI = 94.4% to 98.2%). The proportion of false negatives (FN) was 1.2% (19/1,644) vs. 0.6% (8/1,430). Only one FN patient for each time period required immediate follow‐up for a missed diagnosis. Conclusions: Radiograph interpretations by pediatric EPs with digital studies remain as accurate in comparison with assessments performed by using conventional radiographs.     

Survey of the use of rapid sequence induction in the accident and emergency department

OBJECTIVES: To determine the current position regarding the use of rapid sequence induction (RSI) by accident and emergency (A&E) medical staff and the attitudes of consultants in A&E and anaesthetics towards this. METHODS: A questionnaire was designed that was distributed to consultant anaesthetists and A&E physicians in hospitals receiving over 50,000 new A&E patients per year. RESULTS: A total of 140 replies were received (a response rate of 72%). The breakdown of results is shown. There was wide difference of opinion between anaesthetists and A&E consultants as to who performs RSI at present in their A&E departments, however two thirds of anaesthetists thought A&E staff with appropriate training and support should attempt RSI either routinely or in certain circumstances. CONCLUSIONS: A&E staff in several hospitals routinely undertake RSI and the majority of A&E consultants thought that RSI would be undertaken by A&E staff if an anaesthetist were unavailable. There is disagreement regarding the length of anaesthetic training required before A&E medical staff should undertake RSI.     

Can additional experienced staff reduce emergency medical admissions?

Background: Increases in emergency medical admissions are placing a strain upon hospitals throughout the world. The aim of the study was to evaluate the effect of a new post, the "A&E physician", upon emergency medical admissions to a hospital.

Methods: For six months the A&E physician workload was audited and a randomised controlled comparison undertaken. Days were randomised to "A&E physician present" or "A&E physician absent". The A&E physician recorded details of all patients referred for medical admission, any intervention made, and their disposal from A&E. Routine hospital data compared the mean daily number of medical admissions, non-medical admissions, and referrals to other hospitals.

Results: 124 days were randomised: 59 to A&E physician present, 65 to A&E physician absent. The A&E physician received 581 referrals and intervened in the management of 142 (24%). Of these, 80 were discharged home, apparently saving 1.4 admissions per day. However, randomised comparison showed that presence of the A&E physician was associated with a reduction of only 0.7 medical admissions per day (95% CI -1.7 to 3.2, p = 0.561), and an increase of 1.1 non-medical admissions (95% CI -0.2 to 2.3, p = 0.09) and 0.3 transfers to other hospitals per day (95% CI zero to 0.6, p = 0.09). Overall, hospital admissions were increased by 0.9 per day when the A&E physician was present (95% CI -1.8 to 3.6, p = 0.5).

Conclusion: Despite receiving many referrals and discharging a substantial proportion of these patients home, the A&E physician did not significantly change emergency medical admissions and may have increased admissions to other specialties.

     

Deliberate self harm assessment by accident and emergency staff--an intervention study.

OBJECTIVE: To examine the impact of specific training for accident and emergency (A&E) staff on the quality of psychosocial assessment of deliberate self harm patients. METHODS: A non-randomised intervention study that compared the psychosocial assessment of deliberate self harm patients before and after a one hour teaching session for the A&E departments nursing and junior medical staff. Adequacy of psychosocial assessment was judged by examining A&E case notes. The records of the hospital's parasuicide team were examined to assess administrative changes. Staff attitude to and knowledge of deliberate self harm were also measured before and after the intervention. RESULTS: 45 of 52 nurses and all 15 junior medical staff attended the teaching session. Sixteen (13%) of 125 sets of records before and 58 (46%) of 127 sets of records after the intervention were judged to be adequate. In the postintervention period, notes were more likely to be judged adequate when a proforma was used as part of the assessment (52 of 66 with a proforma and six of 61 without a proforma, chi2 = 60, p < 0.01). Following the intervention, communication between A&E staff and the hospitals parasuicide team improved. CONCLUSIONS: An intervention that provides teaching to A&E staff can lead to improvements in the quality of psychosocial assessment of patients with deliberate self harm.     

Use of an accident and emergency department by hospital staff.

OBJECTIVE: To assess the number of attendances by hospital staff at an accident and emergency (A&E) department, and reasons for their attendance. METHODS: A&E attendances by hospital staff were studied for a 12 month period. Comparison was made with attendances by non-hospital staff in full or part time employment. Differences between the observed and expected numbers of attendances were analysed using chi 2 analysis. RESULTS: 560 staff attendances were recorded out of 78,103 total attendances. There was an observed excess number of attendances by nursing staff for work related incidents when compared to the control group (P = 0.01). However, there were fewer attendances by nursing staff for non-work related incidents (P = 0.01). Staff other than doctors and nurses attended the A&E department more frequently than the control group for non-work related incidents (P = 0.01), but their attendance for incidents occurring at work were the same as the control group (P = NS). CONCLUSIONS: The increased use of A&E resources by staff other than doctors and nurses may be inappropriate and further research into their reasons for attendance is warranted.     

The effect of introducing guidelines for cervical spine radiographs in the accident and emergency department.

OBJECTIVE: To assess the effect of guidelines for x ray requests on requests for cervical spine x rays. SETTING: Accident and emergency (A&E) department of tertiary referral centre. METHODS: Guidelines for all x ray requests were introduced in the (A&E) department of the Royal Infirmary of Edinburgh in February 1992. The effect of the guidelines on requests for cervical spine x rays was assessed by retrospective review of all such x rays taken over two 30 d periods, before and after the introduction of the guidelines. Junior staff had been in post for 3 months during both periods assessed. Films were reviewed for quality by a consultant radiologist. RESULTS: Guidelines reduced the number of inappropriate requests significantly; however, 26% of requests were still unnecessary. The standard of radiography improved but 49% of x rays remained inadequate, usually because the C7/T1 level was not demonstrated on the lateral view. The A&E doctors correctly interpretated the radiographs in 95% of examinations. CONCLUSIONS: Guidelines reduce inappropriate x ray requests. Further improvements can be expected with continued education.     

Should accident and emergency nurses request radiographs? Results of a multicentre evaluation.

OBJECTIVE--To evaluate whether waiting time in accident and emergency (A&E) departments is shortened when experienced nurses request peripheral limb radiographs before a patient is assessed by a doctor. DESIGN--Simultaneous prospective trial in four A&E departments in the United Kingdom with doctors and nurses requesting radiographs; 2000 patients were randomly allocated to either a "Nurse First" or "Doctor First" category. SUBJECTS--Patients older than 5 years presenting with recent peripheral limb injuries. MAIN OUTCOME MEASURES--Timing of the various stages of a patient's passage through the A&E department comparing the orthodox route with a group of patients in whom an experienced A&E nurse had the option of requesting a radiograph before a medical assessment. RESULTS--There was a significant reduction in the time spent in A&E when no radiograph was requested (P << 0.001). The mean time saved in the "Doctor First" (DF) group was 51 min, and in the "Nurse First" (NF) group 36 min. For those who were sent for an x ray 14 min was saved by getting the patient to see the nurse first. However, because the overall referral rate for x rays was greater in the NF group, (78% of patients compared with 74% of the DF group, a significant 4% increase (P = 0.05) this potential benefit was largely lost. Overall the average waiting time in the DF group of 92.5 min (95% confidence interval: 89.2 to 96.1 min) was reduced to 88.5 min (95% CI:85.2 to 91.8 min) in the NF group, a non-significant saving of 4 min. There was no overall difference between the proportion of relevant abnormalities reported by the radiologists for the DF or NF groups (G2 = 0.739, 1df, P = 0.30); however, there was a significant association between the number of relevant abnormalities reported by the radiologists and the different hospitals (G2 = 9.7626, 3df, P = 0.02). Hospital C had the highest abnormality rate reported by the radiologists in both the DF (45%) and the NF (51%) groups. The most time saved in A&E was in the DF category when comparing those who did not have an x ray [58 (CI 54-63) min] with those who did [109 (CI 104-114) min], a saving of 51 min. The corresponding time saved in the NF category between those who did not have an x ray [59 (CI 53-65) min] and those who did [95 (CI 91-99) min] was 36 min. CONCLUSIONS--14 min can be saved by getting the patient to see the nurse first; however, because nurses in three out of four hospitals requested more radiological examinations than doctors, overall only 4 min waiting time was saved when peripheral limb radiographs were requested by nurses. The findings are somewhat against expectations but do identify that specific training and constant monitoring is essential if nurses are to request peripheral limb radiographs, as reflected in hospital C results.     

Survey of the use of rapid sequence induction in the accident and emergency department

Objectives—To determine the current position regarding the use of rapid sequence induction (RSI) by accident and emergency (A&E) medical staff and the attitudes of consultants in A&E and anaesthetics towards this.

Methods—A questionnaire was designed that was distributed to consultant anaesthetists and A&E physicians in hospitals receiving over 50 000 new A&E patients per year.

Results—A total of 140 replies were received (a response rate of 72%). The breakdown of results is shown. There was wide difference of opinion between anaesthetists and A&E consultants as to who performs RSI at present in their A&E departments, however two thirds of anaesthetists thought A&E staff with appropriate training and support should attempt RSI either routinely or in certain circumstances.

Conclusions—A&E staff in several hospitals routinely undertake RSI and the majority of A&E consultants thought that RSI would be undertaken by A&E staff if an anaesthetist were unavailable. There is disagreement regarding the length of anaesthetic training required before A&E medical staff should undertake RSI.

     

Detection of alcohol misusing patients in accident and emergency departments: the Paddington alcohol test (PAT)

OBJECTIVE: To develop an effective but practical screening questionnaire for use by accident and emergency (A&E) staff to detect alcohol misuse early on in its natural history, without unreasonably prolonging patient waiting times; and to integrate an alcohol health worker (AHW) into A&E to provide counselling for referred patients. METHODS: Two pilot studies for adult patients were undertaken to develop the 1 min Paddington alcohol test (PAT), which has only three compulsory questions for detecting alcohol misuse: two cover peak consumption and frequency of possible binge drinking, and the third asks whether in the patients' view their attendance at A&E was alcohol related. The use of the PAT was validated in "appropriate" adult patients over a one year period. Patients found to be positive were invited to attend the A&E review clinic for counselling by the AHW. RESULTS: The development of the PAT resulted in a referral rate of one patient per 158 A&E adult attenders, facilitating a counselling rate of one patient per 263 A&E adult attenders by the AHW. This counselling rate is a 10-fold increase on the rate of one patient per 2610 adult attenders found in a study undertaken during 1988-90. CONCLUSIONS: The use of the PAT is one practical method for A&E staff to detect the alcohol misusing patient for referral to a departmental alcohol health worker.     

Audit of telephone advice in a paediatric accident and emergency department.

This paper audits the telephone requests for advice to a paediatric accident and emergency (A&E) Department over a 4-week period. All calls were answered by senior nurses. Most calls were received in the early evenings when the A&E department was busy. Parents were the most frequent callers and the majority of calls were for children under 5 years of age. The problems presented were wide ranging but advice over the telephone meant that many unnecessary visits to hospital were prevented. The public use the A&E department as a primary source for health advice and very few of the calls resulted in admissions. This telephone advice service is effective and helpful to the public but time consuming for A&E nursing staff at peak workload periods in their own department.     

Cranial computed tomography in trauma: the accuracy of interpretation by staff in the emergency department

Objectives: Cranial computed tomography (CT) is replacing skull radiography in head trauma. Rapid radiological opinions on these images may not always be available. We assessed the ability of our permanent emergency department staff to interpret the images. Methods: A retrospective series of 100 consecutive cases was reviewed and interpreted by five permanent emergency department medical staff, and their interpretation compared with the consensus opinion of two radiologists. Results: An overall agreement of 86.6% (95% confidence interval (CI) 83.4 to 89.9) was achieved, with a false negative rate of 4.2% (95% CI 3.9 to 4.3). No findings that would have changed the overnight management of any patient were missed. Conclusions: Our results for CT scans are similar to studies of interpretation of other radiographic images in emergency departments. Our emergency staff could safely make the initial interpretation of cranial CT images in trauma out of hours, and formal reporting may wait until a suitably experienced radiologist is available.     

UK accident and emergency departments and emergency contraception: what do they think and do?

OBJECTIVES: A postal questionnaire survey was conducted to assess what staff in UK accident and emergency (A&E) departments thought of providing an emergency contraception service, the degree of enthusiasm in and level of provision of the service, and staff attitudes to the introduction or continuation of provision of the service. METHODS: A questionnaire was sent to all 560 departments providing A&E services in the UK. RESULTS: Of the 560 units sent questionnaires, 355 (63.4%) replied. Half the units were located in small county towns, and a quarter in large towns. Requests for emergency contraception were received by 96% of responding units, but only 57% provided treatment. Requests for emergency contraception in 84 of these units ranged between one and 50 per month. The A&E senior house officer (SHO) and the gynaecology SHO and registrar prescribed most of the pills. Nurses were more involved in nurse led or general practitioner (GP) led units. Initial treatment only was given by 77% of providing units while the remainder also discussed subsequent contraception. Follow up was arranged with GPs by 92 units, and with family planning clinics by 66 units. Information packs were available in only 37 providing units. A total of 155 of providing units felt it was worthwhile and 56% of respondents thought emergency contraception should be provided by A&E departments. However, 91 units could identify one or more groups within the hospital who were antagonistic to provision by A&E departments, of which non-A&E medical staff formed the largest group. Over the counter availability of emergency contraception was not supported by 62% of respondents. CONCLUSION: The results show that while the female population appears to see a need for emergency contraception services to be provided in A&E departments, there is some reluctance by UK A&E departments to provide the service. Given the current interest in approaches to reducing unplanned pregnancies, especially in teenagers, provision of emergency contraception by A&E departments requires a pragmatic approach to ensure their cooperation in providing the service when alternative sources of provision are not available.     

A study of the eye care provided by an accident and emergency department.

The eye care provided by an Accident and Emergency (A&E) Department was prospectively studied over a 2-month period. Six out of a total of 506 patients were deemed to have been treated unsatisfactorily by the A&E Department. None of these patients suffered serious sequelae. Approximately one in three of those patients seen solely by A&E staff failed to have their visual acuity recorded.     

Avoiding prolonged waiting time during busy periods in the emergency department: Is there a role for the senior emergency physician in triage?

STUDY OBJECTIVE: Patient satisfaction at emergency departments can be improved by reductions in waiting time. Traditional methods require registration and triage before seeing the doctor with senior emergency physicians mainly engaged in treating serious cases. We examine a radical change in workflow pattern on waiting time by placing a senior emergency physician with the triage nurse and examining the impact of treating simple cases upfront with discharge on the waiting times for stretcher cases. METHODS: A senior emergency physician was placed with the triage nurse in the Department of Emergency Medicine at Alexandra Hospital during peak busy periods of patient attendance over a period of 2 months. Measures were made of waiting time (registration to doctor consult) of PACS 3 and PACS 2 (Patient Acvity Score) cases accordingly. RESULTS: Ten days were chosen for the changed workflow practice and 10 days for controls in which normal traditional working practice followed. On all days, there was the same number of medical staff. The average waiting time for walk-in patients (PACS 3) was 19 min on experimental days as compared with 35.5 min on control days, with 78% being seen within 30 min in the experimental group compared with 48% on control days (P < 0.05). The PACS 2 waiting time was also significantly decreased on experimental days (P < 0.05). CONCLUSIONS: Placing a senior emergency physician with the triage nurse reduced waiting times for walk-in cases. One third of attendances were treated and discharged quickly, allowing the consulting room and PACS 1/PACS 2 doctors to act more efficiently.     

Review of police inquiries to an accident and emergency department.

OBJECTIVE: To assess the workload generated by police inquiries to an accident and emergency (A&E) department and the adherence of medical staff to departmental guidelines relating to these inquiries. DESIGN: Prospective analysis of the number, nature, and timing of police inquiries and the information released by medical staff. SETTING: A&E department of an inner city teaching hospital. OUTCOME MEASURES: Number of personal and telephone requests for information from police; completion of a form of inquiry; record of patient consent for release of information. RESULTS: A daily average of 8.7 police inquiries were made, but in only 10% of cases was a form of inquiry completed. The patient's consent for release of information to the police was recorded in 4% of cases. CONCLUSIONS: Police inquiries generate a significant workload for an A&E department, often at clinically busy times. Medical staff need further education to ensure that patient confidentiality is respected while assisting the police with their investigations.     

Section 136, The Mental Health Act 1983; levels of knowledge among accident and emergency doctors,senior nurses,and police constables

Objectives: Section 136 of the Mental Health Act 1983 empowers the police to detain those suspected of being mentally ill in public places, and convey them to a place of safety. In practice, accident and emergency (A&E) departments are often used. The authors assessed levels of knowledge of section 136 between A&E doctors, senior nurses, and police constables.

Methods: Doctors and senior nurses in all (A&E) departments in the Yorkshire region were asked to complete a multiple choice tick box type questionnaire, as were police constables from the Humberside Police Force.

Results: 179 completed questionnaires were returned, of which 16 were completed by consultants, 14 by SpRs, 24 by SHOs, 33 by senior nurses, and 92 by police officers. Some 24.1% of A&E staff and 10.9% of police failed to recognise that a person has to appear to be suffering from a mental disorder to be placed on a section 136; 40.2% of police did not know that section 136 is a police power; 55.2% of A&E staff and 14.1% of police incorrectly thought that a person could be placed on a section 136 in their own home; 43.75% of consultants and 50% of SpRs did not consider A&E departments to be a place of safety; 49.4% of A&E staff and 29.3% of police thought that patients could be transferred on a section 136. Only 10.3% of A&E staff and 22.8% of police had received any formal training.

Conclusions: The knowledge among A&E staff and the police of this difficult and complex piece of mental health legislation is poor and requires action through formal education and training. This study not only reflects the levels of knowledge within the groups, it may also reflect the different perceptions of each group as to their role and duties within section 136 of the Mental Health Act 1983.

     

An examination of the accident and emergency management of deliberate self harm.

OBJECTIVE: To examine the adequacy of assessment and management of deliberate self harm (DSH) undertaken by accident and emergency (A&E) medical staff. METHODS: The records for attendances to the Leicester Royal Infirmary A&E department with a diagnosis of "self inflicted" injury for the 12 month period April 1994 to March 1995 were scrutinised. If the episode was identified as DSH, then assessment and management were examined, using an instrument based on the Royal College of Psychiatrists' standards of service for the general hospital management of adult DSH. RESULTS: There were 934 episodes of DSH involving 854 patients. The mean age was 32 (SD 14.2), with an even sex distribution. Overdose was by far the most common method of DSH (91.5%). Information concerning suicide intent was documented in 70% of cases, and psychiatric history in 67%. Less information was recorded for medical history (50%), mental state (51%), recent stress (55%), or previous DSH (47%), and only 23% had an assessment of risk of further DSH. Very little was recorded concerning alcohol or substance misuse. In 291 cases (31%), the patient was discharged directly home by A&E medical staff, and 50 of these were referred for psychiatric outpatient follow up; 210 (23%) were referred for specialist assessment in the department and 423 (45.5%) were admitted to medical/surgical wards. The frequency with which information was recorded varied significantly between outcome groups. At night A&E staff were far more likely to discharge a patient home themselves than refer for specialist assessment (P << 0.001). CONCLUSIONS: With over half the sample not admitted, the responsibility for the initial risk assessment lies with A&E medical staff. The study reveals a need for improved planning and delivery of services.     

Results of an evaluation of the effectiveness of triage and direct transportation to minor injuries units by ambulance crews

Methods: Ambulance crews in two services were asked to transport appropriate patients to MIU during randomly selected weeks of one year. During all other weeks they were to treat such patients according to normal practice. Patients were followed up through ambulance service, hospital and/or MIU records, and by postal questionnaire. Semi-structured interviews were undertaken with crews (n = 15). Cases transferred from MIU to accident and emergency (A&E) were reviewed.

Results: 41 intervention cluster patients attended MIU, 303 attended A&E, 65 were not conveyed. Thirty seven control cluster patients attended MIU, 327 attended A&E, 61 stayed at scene. Because of low study design compliance, outcomes of patients taken to MIU were compared with those taken to A&E, adjusted for case mix. MIU patients were 7.2 times as likely to rate their care as excellent (95% CI 1.99 to 25.8). Ambulance service job-cycle time and time in unit were shorter for MIU patients (-7.8, 95% CI -11.5 to -4.1); (-222.7, 95%CI -331.9 to -123.5). Crews cited patient and operational factors as inhibiting MIU use; and location, service, patient choice, job-cycle time, and handover as encouraging their use. Of seven patients transferred by ambulance from MIU to A&E, medical reviewers judged that three had not met the protocol for conveyance to MIU. No patients were judged to have suffered adverse consequences.

Conclusions: MIUs were only used for a small proportion of eligible patients. When they were used, patients and the ambulance service benefited.

     

Study of early warning of accident and emergency departments by ambulance services.

OBJECTIVE: To determine the warning time given to accident and emergency (A&E) departments by the ambulance service before arrival of a critically ill or injured patient. To determine if this could be increased by ambulance personnel alerting within five minutes of arrival at scene. METHODS: Use of computerised ambulance control room data to find key times in process of attending a critically ill or injured patient. Modelling was undertaken with a scenario of the first responder alerting the A&E department five minutes after arrival on scene. RESULTS: The average alert warning time was 7 min (range 1-15 min). Mean time on scene was 22 min (range 4-59 min). In trauma patients alone, the average alert time was 7 min, range 2-15 min, with an average on scene time of 23 min, range 4-53 min. There was a potential earlier alert time averaging 25 min (SD 18.6, range 2-59 min) if the alert call was made five minutes after arrival on scene. CONCLUSIONS: A&E departments could be alerted much earlier by the ambulance service. This would allow staff to be assembled and preparations to be made. Disadvantages may be an increased "alert rate" and wastage of staff time while waiting the ambulance arrival.