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Objectives: Patients presenting to hospital with acute, undifferentiated chest pain have a low, but important, risk of significant myocardial ischaemia. Potential diagnostic strategies for patients with acute, undifferentiated chest pain [...]

Objectives: To apply a previously validated clinical model for predicting pre-test probability of deep vein thrombosis (DVT) to patients attending an emergency deportment with symptoms suggestive of DVT and assess [...]

This paper forms the second part of the debate on prehospital thrombolysis (PHT). It is argued that large scale studies have failed to show a benefit for PHT, even when [...]

The recognition that the health services, like all other activities, have limited resources available has lead to the widespread adoption of cost effectiveness criteria in the assessment of new health [...]

Clinicians working in accident and emergency (A&E) medicine will have little difficulty accepting the idea that health service resources are scarce. Increasing demands for health care and limited resources with [...]

Emerg Med J 2004;21:51-53 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 [...]

Objectives--Developments in triage have led to patients being directed to triage rather than reception upon arrival in A&E. This study aimed to discover if attending triage or reception first, was [...]

Objectives--To determine whether access to a computer generated electrocardiogram (EGG) report can reduce errors of interpretation by senior house officers (SHOs) in an accident and emergency department. Methods--Ten SHOs were [...]

Background: The Northern General Chest Pain Observation Unit (CPOU) protocol tests selected patients presenting with acute chest am using serial ECG/ST segment monitoring, CK-MB(mass) (at baseline and at least two [...]

Background: Patients presenting to hospital with acute chest pain, undiagnosed by electrocardiograph and clinical assessment, have a law, but important, risk of significant myocardial ischaemia. Strategies for detecting ischaemia in [...]

R C Becker. (Pp 756; £39.95). Oxford University Press, 2000. ISBN 0-195-1233 1-X Developments in fibrinolytic and antithrombotic therapy are among the most important recent advances in emergency medicine. This [...]

IntroductionPain management in emergency departments (ED) is often inadequate despite the availability of effective analgesia, with many patients receiving insufficient and untimely analgesia. We conducted a systematic literature review to identify interventions that could improve pain management in the ED.MethodsWe systematically searched seven databases for studies reporting pain management outcomes after intervention to change professional practice to improve pain management in the ED, compared with pain management before or without intervention. Data was synthesised using principles of narrative synthesis.ResultsWe identified 43 relevant studies, including 40 uncontrolled before-and-after studies. Interventions included implementation of guidelines and protocols, educational interventions, pain scoring tools and changes in nursing roles, with many multifaceted interventions incorporating two or more of these elements. Interventions aimed to improve assessment and documentation of pain, knowledge and awareness of pain management and reduce time to analgesia. Due to the high probability of bias in study design and significant variation between studies, it was not possible to estimate the overall effectiveness of interventions, or identify which had the greatest impact. Intervention to improve pain management was reported to have some positive impact in most studies, but these findings may be explained by limitations in study design.ConclusionsMany interventions reported improvements in pain management, but current evidence is insufficient to recommend any for widespread adoption. In order to improve pain management we need to understand more about the theory underlying interventions, the context in which interventions work, and develop interventions based on this stronger theoretical understanding.

Objectives: To establish a chest pain observation unit, monitor its performance in terms of appropriate discharge after assessment, and estimate the cost per patient. Methods: Prospective, observational, cohort study of patients attending a large, city, teaching hospital accident and emergency department between 1 March 1999 and 29 February 2000 with acute undifferentiated chest pain. Patients were managed on a chest pain observation unit, entailing two to six hours of observation, serial electrocardiograph recording, cardiac enzyme measurement, and, where appropriate, exercise stress test. Patients were discharged home if all tests were negative and admitted to hospital if tests were positive or equivocal. The following outcomes were measured—proportion of participants discharged after assessment; clinical status three days after discharge; cardiac events and procedures during the following six months; and cost of assessment and admission. Results: Twenty three participants (4.3%) had a final diagnosis of myocardial infarction. All were detected and admitted to hospital. A total of 461 patients (86.3%) were discharged after assessment, 357 (66.9%) avoided hospital admission entirely. At review three days later these patients had no new ECG changes and only one raised troponin T measurement. In the six months after assessment, three cardiac deaths, two myocardial infarctions, and two revascularisation procedures were recorded among those discharged. The mean cost of assessment and hospital admission was £221 per patient, or £323 if subsequent interventional cardiology costs were included. Conclusions: The chest pain observation unit is a practical alternative to routine care for acute chest pain in the United Kingdom. Negative assessment effectively rules out immediate, serious morbidity, but not longer term morbidity and mortality. Costs seem to be similar to routine care.

The development of very high affinity, selective, and bioavailable h5-HT2A receptor antagonists is described. By investigation of the optimal position for the basic nitrogen in a series of 2-phenyl-3-piperidylindoles, it was found that with the basic nitrogen at the 3-position of the piperidine it was not necessary to further substitute the piperidine in order to obtain good binding at h5-HT2A receptors. This meant the compounds no longer had high affinity at the IKr potassium channel, an issue with previous series of 2-aryl-3-(4-piperidyl)indoles. Improvements could be made to oral bioavailability in this series by reduction of the pKa of the basic nitrogen, by adding a fluorine atom to the piperidine ring, leading to 3-(4-fluoropiperidin-3-yl)-2-phenyl-1H-indole (17). Metabolic studies with this compound identified oxidation at the 6-position of the indole as a major route in vitro and in vivo in rats. Blocking this position with a fluorine atom led to 6-fluoro-3-(4-fluoropiperidin-3-yl)-2-phenyl-1H-indole (22), an antagonist with 0.06 nM affinity for h5-HT2A receptors, with bioavailability of 80% and half-life of 12 h in rats.

It has previously been reported that a 3-(3-(piperazin-1-yl)propyl)indole series of 5-HT1D receptor ligands have pharmacokinetic advantages over the corresponding 3-(3-(piperidin-1-yl)propyl)indole series and that the reduced pKa of the piperazines compared to the piperidines may be one possible explanation for these differences. To investigate this proposal we have developed versatile synthetic strategies for the incorporation of fluorine into these ligands, producing novel series of 4-fluoropiperidines, 3-fluoro-4-aminopiperidines, and both piperazine and piperidine derivatives with one or two fluorines in the propyl linker. Ligands were identified which maintained high affinity and selectivity for the 5-HT1D receptor and showed agonist efficacy in vitro. The incorporation of fluorine was found to significantly reduce the pKa of the compounds, and this reduction of basicity was shown to have a dramatic, beneficial influence on oral absorption, although the effect on oral bioavailability could not always be accurately predicted.

Paramedic training and skills have been introduced in the United Kingdom in an attempt to improve prehospital patient care. There is presently little control and quality assurance in this potentially difficult environment and paramedic protocols have not been validated. We studied the use of nalbuphine by paramedics for patients with major injury in West Yorkshire. A case-control study was carried out using two cohorts of patients from the regional Major Trauma Outcome Study (MTOS) database; one group had received prehospital nalbuphine by paramedics (the intervention) and a matched group who had not (the control). Both groups of patients were reviewed by a panel of three consultants and a paramedic to assess which patients received or could have received nalbuphine appropriately. Only 85 patients from a database of 4170 patients received nalbuphine. Fifty-two (61) patients were thought by the panel to have been given nalbuphine appropriately. The panel also concluded that 21 (18) of the 115 patient control group could have been administered nalbuphine but did not receive the drug. This study demonstrates inadequate and sometimes inappropriate use of nalbuphine in prehospital trauma care. Quality assurance and audit systems should be implemented to identify and correct these deficiencies.

Clinically effective antimigraine drugs such as Sumatriptan have similar affinity at h5-HT1D and h5-HT1B receptors. In the search for a h5-HT1D-selective agonist as an antimigraine agent, a novel series of 3-(propylpiperazinyl)indoles have been synthesized and evaluated at h5-HT1D and h5-HT1B receptors. This class of compounds has provided subnanomolar, fully efficacious h5-HT1D agonists with up to 200-fold selectivity for the h5-HT1D receptor over the h5-HT1B receptor. Unlike other h5-HT1D-selective series, several propylpiperazines demonstrate good oral bioavailability. The optimum compound was 1-(3-[5-(1,2,4-triazol-4-yl)-1H-indol-3-yl]propyl)-4-(2-(3-fluorophenyl)ethyl)piperazine (7f) which has excellent selectivity for h5-HT1D receptors over other 5-HT receptor subtypes and good oral bioavailability in three species. Compound 7f has been selected for further investigation as a potential development candidate in the treatment of migraine.

OBJECTIVE: To define the role of the accident and emergency (A&E) short stay ward by a survey of departments in the United Kingdom and review of published reports. METHODS: A postal questionnaire with telephone follow up to all major A&E departments with short stay beds. RESULTS: 95 departments were found to have short stay beds. These units received between 19000 and 121000 new patients per year (mean 51000, median 50500) and had access to between two and 20 beds (mean 7.5, median 6). The level of provision varied from one bed per 2440 new attendances to one bed per 27250 new attendances (mean 8380, median 6625). Where data on admission rates were available the departments admitted between 0.1% and 13.3% of their new attendances (mean 2.62%, median 1.9%). Cover was typically provided by an A&E senior house officer with frequent senior ward rounds. While the casemix usually included minor head injuries and alcohol intoxicated patients, there was considerable variation in the cases admitted. CONCLUSIONS: Short stay provision is highly variable in the United Kingdom. While there are many reports of well run short stay units, consistent evidence of clinical value and cost-effectiveness compared to other methods of care is lacking. Further comparative studies are required to define the role of the A&E short stay ward. [ABSTRACT FROM PUBLISHER]

OBJECTIVE: To determine whether the frequency and pattern of use of the accident and emergency (A&E) department by individuals with diabetes is different from that of the general population. METHODS: A historical cohort of 696 individuals with diabetes from six randomly selected general practices and a non-diabetic comparison cohort matched on age, sex, and general practice were identified. The use of an urban A&E department by the two cohorts was compared for number of visits between 1984 and 1996 for injuries, diabetes related and non-diabetes related illness, proportion referred by a general practitioner, proportion arriving by ambulance, and proportion admitted. RESULTS: More visits were made by the diabetic cohort (1002 v 706, P = 0.0001); 121 visits were directly related to diabetes, including 52 for hypoglycaemia. The diabetic cohort also had more visits for medical illness unrelated to diabetes (357 v 231, P = 0.0001). The number of visits for injuries was similar (524 v 475, P = 0.3). Individuals with diabetes who attended A&E were not significantly more likely to be referred by a general practitioner (14% v 16%) or admitted (20% v 17%). CONCLUSIONS: Individuals with diabetes made more frequent visits than the general population to the A&E department. Since there was no excess of visits for injuries and the proportion requiring admission was similar, the hypothesis that they have a different threshold for attending is not supported. [ABSTRACT FROM PUBLISHER]

OBJECTIVE: To identify the impact of advanced life support skills on outcome for prehospital cardiac arrest in a defined population and to assess the value of certain physiological variables in predicting the outcome in those successfully resuscitated in the accident and emergency (A&E) department; to identify areas for improvement in the outcome of such patients. DESIGN: Prospective 12 month study. SETTING: Leicestershire, United Kingdom. MAIN OUTCOME MEASURE: Survival to hospital discharge and status at 6 months. RESULTS: 266 patients were identified as having suffered a prehospital cardiac arrest; of these, 86 had their resuscitation attempt terminated in the community by a general practitioner and 180 were transferred to the A&E department of the Leicester Royal Infirmary. Of the latter, 159 were felt to be of cardiac aetiology, and 19 were eventually discharged from hospital. All survivors had experienced a witnessed cardiac arrest, ventricular fibrillation (VF) being identified as the initial rhythm. After adjusting for age and sex using logistic regression, the Glasgow coma score (GCS) was found to be associated with subsequent mortality (chi 2 = 18.22 on 2 df, P < 0.0001). Compared to a baseline GCS of 9-15, the relative odds of death for a GCS of 3 were 25.3 (95% confidence interval 4.3 to 149-9), while a GCS of 4-8 gave a relative odds of death of 12-18 (95% CI 1.8 to 80.2). No significant association was found between postarrest arterial pH and mortality. CONCLUSIONS: The immediate GCS on admission is a predictor of outcome and it is important to monitor its trend in the first 24 h. Multidisciplinary audit and joint guidelines with other specialties are important in optimising the care of these patients. [ABSTRACT FROM PUBLISHER]

Early detection of deficient care is an increasingly important element of trauma audit. We aimed to assess the feasibility and demonstrate the use of a variable life adjusted display (VLAD) in trauma audit. Data from the Trauma Audit and Research Network database of Sheffield Teaching Hospitals NHS Trust were used to create a VLAD. A cumulative display of survival was plotted in which survivors were incorporated as a positive value equal to 1 minus the probability of survival, and deaths were incorporated as a negative value equal to the probability of survival. Downward deflections of the display thus indicated potentially deficient trauma care. Data from 191 consecutive patients over 1 year were plotted and displayed. The first 2 months of this period were characterised by a downward trend in the line, which may indicate suboptimum performance and provides an example of a trend that would prompt detailed review. The VLAD chart is a potentially useful "early warning" system for poor performance in trauma care. Further work should to be carried out to evaluate VLAD prospectively as an audit tool, perhaps involving comparison of VLAD charts from different institutions.

OBJECTIVES: To determine the level of agreement between senior medical staff when asked to perform retrospective case note review of nursing triage decisions, both before and after development of a consensus approach. METHODS: Four medical reviewers independently allocated triage categories to 50 emergency department patients after review of their case notes. They were blind to the identity of the triage nurse and their triage categorisation. The process was repeated twice, firstly after agreement on a consensus approach and then using formal guidelines. RESULTS: Agreement between reviewers was initially fair to moderate (kappa = 0.27 to 0.53). This failed to improve after development of a consensus approach (kappa = 0.29 to 0.57). There was a trend towards better agreement when guidelines were used but agreement was still only moderate (kappa = 0.31 to 0.63). CONCLUSIONS: Audit of nurse triage categorisation by senior medical staff performing case note review has only fair to moderate consistency between reviewers. Use of this technique will result in frustration among those whose performance is being audited if they recognise inconsistency in the standard they are compared against. [ABSTRACT FROM PUBLISHER]