‘Inappropriate’ attenders to the Adult Emergency Department – A Critical Review

Background: The Department of Health (DoH) emphasise the increased attendance rates to the Emergency Department (ED) over the last decade from 14,044,018 in 2001- 2 (DoH, 2002) up to 21,342,543 in 2010-11 (DoH, 2010-11). Ainsworth (2008) identified that annually up to 14 million attenders could have been treated by their General Practitioner which coincides with Lee, Hazlett, Chow, Lau, Kam, Wong & Wong’s (2003) suggestion that ‘inappropriate’ attenders are the cause of the increased attendance rates. The literature is heavily criticised for the lack of definition and this is respective in society illustrated through the increased attendance rates. Aims: This study aims to critically review literature on ‘inappropriate’ adult attenders to the Emergency Department. Method: A critical review was used, reviewing 24 literature articles from ScienceDirect, CINAHL, Medline and Embase using the keywords: “Emergency Service, Hospital/”, “Emergency Medical Services/”, “Emergency Department.mp”, “Inappropriate.mp”, “Primary Care.mp or Primary Health Care/”. Findings: A lack of consistency between definitions of ‘inappropriateness’ to the ED was found from the literature, leading to a vast discrepancy between definitions generated by healthcare professional’s opinions and patients’. The role of the ED was found to relate to functionality through name, suggesting that society is unaware of the role of the ED. The reasons patients attend ED are variable, complex and consider health seeking behaviour from a psychology approach. VIII Conclusion: The review found that the definition of ‘inappropriate attendance’ is elusive and therefore open for interpretation by staff and patients. The use of personal opinions as a definition has created a vast discrepancy between staff and patients’, leading to ‘blame’ and ‘labelling’ of patients

Ice tectonic deformation during the rapid in situ drainage of a supraglacial lake on the Greenland Ice Sheet.

We present detailed records of lake discharge, ice motion and passive seismicity capturing the behaviour and processes preceding, during and following the rapid drainage of a 4 km<sup>2</sup> supraglacial lake through 1.1-km-thick ice on the western margin of the Greenland Ice Sheet. Peak discharge of 3300 m<sup>3</sup> s<sup>−1</sup> coincident with maximal rates of vertical uplift indicates that surface water accessed the ice–bed interface causing widespread hydraulic separation and enhanced basal motion. The differential motion of four global positioning system (GPS) receivers located around the lake record the opening and closure of the fractures through which the lake drained. We hypothesise that the majority of discharge occurred through a 3-km-long fracture with a peak width averaged across its wetted length of 0.4 m. We argue that the fracture's kilometre-scale length allowed rapid discharge to be achieved by combining reasonable water velocities with sub-metre fracture widths. These observations add to the currently limited knowledge of in situ supraglacial lake drainage events, which rapidly deliver large volumes of water to the ice–bed interface

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

‘Inappropriate’ attenders to the Adult Emergency Department – A Critical Review

Background: The Department of Health (DoH) emphasise the increased attendance rates to the Emergency Department (ED) over the last decade from 14,044,018 in 2001- 2 (DoH, 2002) up to 21,342,543 in 2010-11 (DoH, 2010-11). Ainsworth (2008) identified that annually up to 14 million attenders could have been treated by their General Practitioner which coincides with Lee, Hazlett, Chow, Lau, Kam, Wong & Wong’s (2003) suggestion that ‘inappropriate’ attenders are the cause of the increased attendance rates. The literature is heavily criticised for the lack of definition and this is respective in society illustrated through the increased attendance rates. Aims: This study aims to critically review literature on ‘inappropriate’ adult attenders to the Emergency Department. Method: A critical review was used, reviewing 24 literature articles from ScienceDirect, CINAHL, Medline and Embase using the keywords: “Emergency Service, Hospital/”, “Emergency Medical Services/”, “Emergency Department.mp”, “Inappropriate.mp”, “Primary Care.mp or Primary Health Care/”. Findings: A lack of consistency between definitions of ‘inappropriateness’ to the ED was found from the literature, leading to a vast discrepancy between definitions generated by healthcare professional’s opinions and patients’. The role of the ED was found to relate to functionality through name, suggesting that society is unaware of the role of the ED. The reasons patients attend ED are variable, complex and consider health seeking behaviour from a psychology approach. VIII Conclusion: The review found that the definition of ‘inappropriate attendance’ is elusive and therefore open for interpretation by staff and patients. The use of personal opinions as a definition has created a vast discrepancy between staff and patients’, leading to ‘blame’ and ‘labelling’ of patients

Correction to: Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise descrip-tion of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respec-tively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty