Bring back local GPs for urgent and out of hours care

No abstract: journal lette

Prehospital anaesthesia by a physician and paramedic critical care team in Southwest England

OBJECTIVES: Prehospital anaesthesia using rapid sequence induction (RSI) is carried out internationally and in the UK despite equivocal evidence of clinical benefit. It is a core skill of the prehospital critical care service established by the Great Western Ambulance Service NHS Trust (GWAS) in 2008. This retrospective analysis of the service's first 150 prehospital RSIs describes intubation success rates and complications, thereby contributing towards the ongoing debate on its role and safety. METHODS: Within the GWAS critical care team, RSI is only carried out in the presence of a qualified physician and critical care paramedic (CCP). The role of the intubating practitioner is interchangeable between physician and CCP. Data were collected retrospectively from RSI audit forms and electronic patient monitor printouts. RESULTS: GWAS physician and CCP teams undertook 150 prehospital RSIs between June 2008 and August 2011. The intubation success rate was 82, 91 and 97% for the first, second and third attempts, respectively. Successful intubation on the first attempt was achieved in 58 (85%) and 64 (78%) patients for physicians and CCPs, respectively. RSI complications included hypoxaemia (10.2%), hypotension (9.7%) and bradycardia (1.3%). CONCLUSION: Prehospital RSI can be carried out safely, with intubation success rates and complications comparable with RSI in the emergency department. The variation in the intubation success rates between individual practitioners highlights the importance of ongoing performance monitoring, coupled with high standards of clinical governance and training. © 2013 Wolters Kluwer Health Lippincott Williams & Wilkins

Patient satisfaction in emergency medicine.

A systematic review was undertaken to identify published evidence relating to patient satisfaction in emergency medicine. Reviewed papers were divided into those that identified the factors influencing overall satisfaction in emergency department patients, and those in which a specific intervention was evaluated. Patient age and race influenced satisfaction in some, but not all, studies. Triage category was strongly correlated with satisfaction, but this also relates to waiting time. The three most frequently identified service factors were: interpersonal skills/staff attitudes; provision of information/explanation; perceived waiting times. Seven controlled intervention studies were found. These suggested that increased information on ED arrival, and training courses designed to improve staff attitudes and communication, are capable of improving patient satisfaction. None of the intervention studies looked specifically at the effect of reducing the perceived waiting time. Key interventions to improve patient satisfaction will be those that develop the interpersonal and attitudinal skills of staff, increase the information provided, and reduce the perceived waiting time. Future research should use a mixture of quantitative and qualitative methods to evaluate specific interventions

Factors influencing parent satisfaction in a children's emergency department: Prospective questionnaire-based study

Objective: To identify the factors considered by parents to be most important in determining overall satisfaction with care in a children's emergency department, and to assess whether these factors are influenced by the child's age and triage category. Design: A prospective questionnaire-based study of parents attending a paediatric emergency department with their child. Setting: Bristol Royal Hospital for Children, Bristol, UK. Participants: The parent or next of kin adult accompanying a child to the emergency department during the study period. Outcome measures: The primary outcome measure was the response to the questionnaire. The secondary outcome analysed responses according to the child's age and triage category. Results: During the sampling period questionnaires were distributed to the parent or accompanying adult of 247 children, of which 225 (91%) were completed. The most important factors were: a clear explanation of the child's diagnosis and treatment plan; the ability of a parent to stay with their child at all times; rapid and adequate pain relief; and staff attitude. These factors significantly outranked waiting times and other process issues. The age and triage category of the child did not influence these preferences. Conclusion: Despite recent emphasis on waiting times and emergency department throughput in the UK, parents still value the clinical interaction above process issues when their child visits an emergency department. Current efforts to reduce the time spent by children in an emergency department must not undermine the core service values that are most appreciated by parents, and which will lead to the greatest satisfaction

Patient satisfaction in emergency medicine

A systematic review was undertaken to identify published evidence relating to patient satisfaction in emergency medicine. Reviewed papers were divided into those that identified the factors influencing overall satisfaction in emergency department patients, and those in which a specific intervention was evaluated. Patient age and race influenced satisfaction in some, but not all, studies. Triage category was strongly correlated with satisfaction, but this also relates to waiting time. The three most frequently identified service factors were: interpersonal skills/staff attitudes; provision of information/explanation; perceived waiting times. Seven controlled intervention studies were found. These suggested that increased information on ED arrival, and training courses designed to improve staff attitudes and communication, are capable of improving patient satisfaction. None of the intervention studies looked specifically at the effect of reducing the perceived waiting time. Key interventions to improve patient satisfaction will be those that develop the interpersonal and attitudinal skills of staff, increase the information provided, and reduce the perceived waiting time. Future research should use a mixture of quantitative and qualitative methods to evaluate specific interventions

Why are we here? A study of patient actions prior to emergency hospital admission

Introduction: Emergency department (ED) attendances and subsequent hospital admissions are rising in the United Kingdom. The reasons for this are unclear but may relate to recent changes in primary care and public perception. The actions taken by patients or their relatives before emergency hospital admission, the reasons for these actions and their outcome were determined. Methods: Adult patients admitted to an inner city teaching hospital with a medical or surgical illness were interviewed using a semistructured questionnaire. Data were collected and analyzed regarding the actions taken before arrival at hospital, the reasons for taking these actions, their outcome and future intentions. 200 patients were interviewed. Results: Direct attendance at the ED was more common when help was sought by bystanders or persons known only slightly to the patient (p = 0.03). 57 patients (28.5%) attended the ED directly, 45 of whom dialled 999 for an emergency ambulance. Most patients who attended the ED directly did so as a result of the perceived severity or urgency of their condition and there was incomplete awareness of the out-of-hours GP service. Conclusion: The majority of adult patients who are admitted to hospital with an acute illness seek professional help from primary care in the first instance. Those who attend the ED generally perceive their problem as more urgent or severe, or have an ambulance called on their behalf. The shift towards ED care appears partly driven by changes in general practice and unfamiliarity with the new arrangements for out-of-hours primary care provision

Characteristics of patients transported by an air ambulance critical care team

Background: The aim of this study was to review patients conveyed by the Great Western Air Ambulance to its main receiving hospital. Methods: Retrospective data were collected for all patients transferred to Frenchay Hospital by the Great Western Air Ambulance between 1 June 2008 and 1 March 2010. Results: 115 patients were included in the review. Patients were conveyed up to 85 km, 79% bypassing the closest emergency department (ED). 51% of these patients had major trauma and 35% were intubated at the scene. On arrival, the mean time to CT scan was 78 min, reduced to 63 min for those with a head injury. 16% of patients were discharged from the ED. Conclusions: This review provides an overview of the characteristics of patients transferred to a major receiving hospital by a prehospital critical care team

Can patients apply the Ottawa ankle rules to themselves?

ABSTRACT Objective: To determine whether patients with an ankle injury obtained the same results as clinicians when applying the Ottawa ankle rules (a validated clinical decision rule) to themselves. Methods: Patients aged .15 years presenting to an inner city emergency department within 48 h of an ankle injury were asked to assess their own injury using the Ottawa ankle rules. The results of their self-assessment were compared with those of a treating clinician. Results: Poor interobserver agreement was found between patients and clinicians. Conclusions: Making the Ottawa ankle rule more widely available to the general public is unlikely to reduce healthcare demand. Indeed, given the apparently low specificity of the rule, demand could actually increase as a result. The Ottawa ankle rules have been extensively validated as a clinical decision rule for use by healthcare professionals in detecting possible bony injury-and therefore the need for radiography-in patients with a recent ankle injury. 2 The Ottawa ankle rules can be reliably applied by a range of healthcare professionals, including emergency nurse practitioners. 3 If they could also be reliably applied by patients to their own ankle injuries, there is the potential to reduce healthcare consultations following ankle sprain with consequent resource savings, particularly if the rules were widely publicised. The aim of this pilot study was to determine the agreement between patients and clinicians when applying the Ottawa ankle rules, and therefore whether adult patients with a recent ankle injury are potentially able to accurately apply the Ottawa ankle rules to themselves. METHODS A convenience sample of 50 patients attending a single inner city emergency department with a recent (within 48 h) ankle injury were asked if they wished to participate in the study by a researcher triaging the patient. All patients were offered analgesia. Patients who elected not to enter the study were examined by a researcher and treated according to usual practice. If the patient entered the study, informed written consent was obtained and they were then given an information sheet and pictorial questionnaire describing the Ottawa ankle rules (see online Appendix 1). Participants were asked to examine their own ankle and to enter the results on the questionnaire before formal clinical assessment. The patient was then seen by an emergency department clinician (doctor, emergency nurse practitioner or extended scope physiotherapist) who was blind to the patient's assessment of his or her own injury. The clinician made an independent assessment of the injury and arranged radiographs as appropriate. The clinician then completed a study questionnaire giving details of his/her assessment and an interpretation of any radiographs. The formal radiology report was also reviewed and, where any disagreement occurred, the radiology report was taken as the reference standard. If radiography was not performed, the emergency and radiology department records were checked to see if the patient presented in the following month with a lower limb injury. The kappa statistic was used to determine the level of agreement between the patient and clinician, with x 2 testing to compare their overall opinion. RESULTS Fifty patients (25 men, 25 women) of mean age 32 years (range 16-63) were recruited to the study. The mean duration from injury to presentation was 17 h. All 50 patients rated themselves as positive on at least one of the five Ottawa criteria, and therefore all patients concluded that they required a radiograph. On examination by the clinician, 45 of the 50 patients were positive on at least one of the Ottawa criteria and therefore required a radiograph. Of the remaining five patients, one had a ruptured Achilles tendon and one underwent radiography for other reasons. None of the other three patients who did not undergo radiography returned to the emergency department or had lower limb radiographs at the same hospital during the following month. Of the patients who underwent radiography, seven (14%) had fractures identified by both the clinician and the reporting radiologist. Three (6%) had fractures suspected by the clinician but not confirmed by the radiologist. The remaining 36 patients (72%) who had radiographs did not have a fracture. No fractures were missed by an ED clinician. Agreement between the patient and clinician in relation to each of the five Ottawa criteria is shown in tables 1 and 2. There was very little agreement between patients and clinicians on whether they could walk initially or in the emergency department, but greater agreement regarding local tenderness. Overall, 90% of clinicians and 100% of patients rated the rule as positive, demonstrating a statistically significant difference between the final opinions of the two groups (p = 0.02, x 2 test). The kappa values show