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Objective: The authors set out to investigate perceived and actual availability of antidotes recommended for stocking in emergency departments (EDs) by the College of Emergency Medicine in EDs in the South West of England., Methods: Data collectors were asked to physically locate each relevant antidote in the ED, and check whether the recommended quantity was available. If the antidote was not available in the department, the data collector located where in the hospital stocks were available. Senior medical and nursing staff were asked to specify where they believed the antidotes were stored or who they would ask if they did not know. It was then ascertained whether their source of advice would have known the location., Results: 5 out of 6 departments returned data with an overall response rate from senior medical and nursing staff of 80%. Knowledge of common antidote locations was variable, and stocking of antidotes did not universally meet the College of Emergency Medicine recommendations., Conclusion: Stocking of important antidotes should be rationalised and simplified using central locations, preferably close to the ED. Clinically important antidotes may not be available for patients when they need them. Clear guidance should be available for staff detailing the location of antidotes. There is a need for clarification around the treatment of cyanide poisoning to facilitate rational antidote stocking for this potentially lethal condition.

Background: Emergency department (ED) crowding is a significant international problem. There is increasing overseas research into this field. In the UK, the focus has been on waiting times in EDs, and on the government's 4 h standard, rather than on crowding itself., Aims: To examine the causes and effects of ED crowding, along with solutions. To consider whether the 4 h standard has had an effect on ED crowding in the UK., Methods: A structured literature review on ED crowding., Results: The evidence base largely consists of retrospective or descriptive studies (65% combined) from North America and Australasia (89% combined). Measurement of crowding is not well developed, and the lack of a gold standard additionally limits the quality of research. The main cause of crowding is access block, because of high levels of hospital occupancy. Crowding carries a number of adverse consequences for patients and staff. Many solutions are described, but with weak evidence behind them. Most of these focus on interventions in the ED, despite the fact that the main causes lie outside. Solutions aimed at achieving the 4 h standard may mitigate crowding., Conclusion: The extent of ED crowding in the UK is unknown. The problem is probably mitigated by process standards such as the 4 h standard. The causes and effects of crowding are likely to be the same as overseas, but there is little research to validate this. The best solutions are not known.

Introduction: Uncontrolled haemorrhage is the leading cause of potentially reversible early in-hospital death following trauma. Approximately 25% of trauma patients arriving in the emergency department have evidence of early coagulopathy. It is vital that staff within the emergency department understand the basic pathophysiological consequences of massive blood loss in trauma and are familiar with when and how to administer blood and specific blood components in trauma resuscitation., Methods: A structured questionnaire designed to test knowledge of the use of blood and blood components in trauma resuscitation was distributed to the emergency physicians attending a regional conference in the South West of England. The questionnaire consisted of 16 questions, both multiple choice and short answer format, referenced via Medline., Results: 32/32 questionnaires distributed were completed and returned. Massive transfusion protocols existed in 4/11 hospitals surveyed. 5/32 doctors were able to define the term 'massive transfusion' while 9/32, 6/32 and 3/32 were consistent with current guidelines in their prescription of platelets, fresh frozen plasma, and cryoprecipitate. 20/32 were consistent with current guidelines in identifying optimal haemoglobin levels. When asked more specifically about blood component therapy, 18/32 correctly identified target fibrinogen levels, 27/32 knew that fibrinogen is a component of fresh frozen plasma or cryoprecipitate and 1/32 correctly identified that fibrinogen is a component of both. 10/32 identified indications for beriplex and 5/32 doctors correctly identified indications for the use of recombinant factor VIIa. 20/32 doctors guessed >50% of the answers and the remaining 12/32 guessed 50%., Conclusions: The survey found that emergency physicians lacked core knowledge about the use of blood and blood component therapy in the context of massive haemorrhage following trauma. Doctors were unaware of how to prevent and treat early coagulopathy. Educational resources specifically for use by emergency physicians are limited on this topic. The use of massive transfusion protocols--that standardised blood component therapy is automatically delivered at specific points within resuscitation--would not only guide doctors, but be a clear step towards minimising the complications associated with massive transfusion.

Background: Unless emergency departments have adequate capacity to meet demand, they will fail to meet clinical and performance standards and will be operating in the 'coping zone'. This carries risks both for staff and patients., Methods: As part of a quality improvement programme, the authors undertook an in-depth analysis of demand and capacity for an emergency department in the UK. The paper describes this rigorous approach to capacity planning, which draws on techniques from other industries., Discussion and Conclusions: Proper capacity planning is vital, but is often poorly done. Planning using aggregated data will lead to inadequate capacity. Understanding demand, and particularly the variation in that demand, is critical to success. Analysis of emergency department demand and capacity is the first step towards effective workforce planning and process redesign.

Background: Tracheal mucosal blood flow is impaired when tracheal tube cuff pressure is above 30 cm of water, with the potential for tracheal mucosal necrosis. Previous studies have found excessive cuff pressures in simulated patients intubated by North American emergency physicians as well as patients intubated in the prehospital setting and emergency department (ED). This study assessed whether patients intubated in a UK prehospital setting or ED had excessive cuff pressures., Method: Prospective observational study in five ED in southwest England over a 2-month period. All patients over 18 years and intubated in the prehospital setting or in the ED were included. Clinical staff independent of the patients' care recorded the following: age, sex, presenting complaint and indication for intubation, tube size and cuff pressure. Neither the paramedics nor the participating ED staff were aware of the study purpose. Cuff pressure measurements were recorded using a standardised cuff inflator pressure gauge., Result: 61 patients were recruited. The median and mean cuff pressures were 58 and 62 cm of water, respectively. 75% of patients had a cuff pressure greater than 30 cm of water. The median cuff pressures in those patients intubated by senior emergency physicians, junior emergency physicians and paramedics were 70, 46 and 79 cm of water, respectively., Conclusion: Excessive tracheal tube cuff pressures were demonstrated in the majority of patients intubated both in the prehospital setting and ED. This is in keeping with existing evidence. Early measurement and adjustment of cuff pressures is recommended for those patients who require ongoing care.

Time is a precious commodity and with more junior doctors coming through our departments for shorter periods of time it has been useful to lay down some ground rules to facilitate their induction. These are presented in the form of the twelve commandments of emergency medicine.

Payment by results is a new funding mechanism being introduced into the National Health Service. It is a key part of current health reforms and will impact significantly on the way emergency departments are financed and run. This paper aims to describe the basics of payment by results, examines how it relates to and impacts upon emergency medicine, and considers how emergency physicians can set about integrating this new system into current practice and thinking.

Subungual malignant melanoma is a rare form of malignancy that can present at an advanced stage. We describe a case that was diagnosed after a presentation to the emergency department for a traumatic injury of the affected area. Initial presentations of malignant disease and its complications form a relatively low proportion of the caseload of emergency doctors. In this case, a patient presented after a minor injury that had failed to recover; subsequent investigation of this injury led to the diagnosis of subungual malignant melanoma in an otherwise asymptomatic patient. This is a rare case which presented in an atypical fashion, with a confounding history of minor trauma. It is presented to highlight the differential diagnosis of destructive bone lesions.

The surviving sepsis campaign developed guidelines in 2003 that were designed to increase physician awareness of sepsis and to develop a series of recommendations for the management of the patient with sepsis. The guidelines had the support of 11 international professional organisations across a variety of specialties, and advocate aggressive, early goal-oriented resuscitation in appropriate patients.

Intravenous drug users (IVDUs) often present to the emergency services with the medical complications of drug use. We report a case in which an acutely ischaemic lower limb of one such patient was thought to be the cause of cardiac arrest occurring during treatment in the emergency department (ED). Amputation of the limb was performed with cardiopulmonary resuscitation (CPR) in progress, spontaneous cardiac output was restored, and the patient made an excellent neurological recovery despite a total arrest time of 85 minutes. Possible causes of cardiac arrest, in relation to the release of potassium and metabolic toxins are discussed, as well as the decision making processes of the involved clinicians and other possible management strategies.

Background: The need for palliative care in HIV management is underlined by the high prevalence of pain and symptoms, the toxicity, side effects, and virological failure associated with antiretroviral therapy, emergence of co-morbidities, continued high incidence of malignancies, late presentation of people with HIV disease, and the comparatively higher death rates among the infected individuals., Methods: A systematic review was undertaken to appraise the effect of models of palliative care on patient outcomes. A detailed search strategy was devised and biomedical databases searched using specific terms relevant to models of palliative care. Data from papers that met the inclusion criteria were extracted into common tables, and evidence independently graded using well described hierarchy of evidence., Results: 34 services met the inclusion criteria. Of these, 22 had been evaluated, and the evidence was graded as follows: grade 1 (n = 1); grade 2 (n = 2); grade 3 (n = 7); grade 4 (n = 1); qualitative (n = 6). Services were grouped as: home based care (n = 15); home palliative care/hospice at home (n = 7); hospice inpatient (n = 4); hospital inpatient palliative care (n = 4); specialist AIDS inpatient unit (n = 2); and hospital inpatient and outpatient care (n = 2). The evidence largely demonstrated that home palliative care and inpatient hospice care significantly improved patient outcomes in the domains of pain and symptom control, anxiety, insight, and spiritual wellbeing., Conclusions: Although the appraisal of evidence found improvements across domains, the current body of evidence suffers from a lack of (quasi) experimental methods and standardised measures. The specialism of palliative care is responding to the clinical evidence that integration into earlier disease stages is necessary. Further studies are needed to both identify feasible methods and evaluate the apparent beneficial effect of palliative care on patient outcomes in the post-HAART era.

Objectives: To develop an outcome measure for patients with advanced cancer and their families which would cover more than either physical symptoms or quality of life related questions. To validate the measure in various specialist and non-specialist palliative care settings throughout the UK., Design: A systematic literature review of measures appropriate for use in palliative care settings was conducted. In conjunction with a multidisciplinary project advisory group, questions were chosen for inclusion into the scale based on whether they measured aspects of physical, psychological, or spiritual domains pertinent to palliative care, and whether similar items had shown to be valid as part of another measure. A staff completed version was developed to facilitate data collection on all patients throughout their care, and a patient completed version was designed to enable the patient to contribute to the assessment of their outcomes when possible. A full validation study was conducted to evaluate construct validity, internal consistency, responsiveness to change over time, and test-retest reliability. Assessments were timed., Setting: Eight centres in England and Scotland providing palliative care, including inpatient care, outpatient care, day care, home care, and primary care., Patients: A total of 450 patients entered care during the study period. Staff collected data routinely on patients in care long enough to be assessed (n = 337). Of these, 262 were eligible for patient participation; 148 (33%) went on to complete a questionnaire., Main Measures: The Palliative Care Outcome Scale (POS), the European Organisation for Research on Cancer Treatment, and the Support Team Assessment Schedule., Results: The POS consists of two almost identical measures, one of which is completed by staff, the other by patients. Agreement between staff and patient ratings was found to be acceptable for eight out of 10 items at the first assessment. The measure demonstrated construct validity (Spearman rho = 0.43 to 0.80). Test/re-test reliability was acceptable for seven items. Internal consistency was good (Cronbach's alpha = 0.65 (patients), 0.70 (staff)). Change over time was shown, but did not reach statistical significance. The questionnaire did not take more than 10 minutes to complete by staff or patients., Conclusion: The POS has acceptable validity and reliability. It can be used to assess prospectively palliative care for patients with advanced cancer.

Objectives: To work with specialist community teams to assess the practicality and acceptability of identified outcome measures for routine use in dementia services., Setting: Seven specialist dementia services: four multidisciplinary teams, a specialist service for carers, a community psychiatric nurse team, and a day hospital., Subjects: 20 members of staff from the specialist dementia services including psychiatry, community psychiatric nursing, social work, occupational therapy, Admiral nursing, ward management, geriatric nursing., Main Measure: A questionnaire designed to assess staff views on the use of six outcome measures in routine practice in terms of practicality, relevance, acceptability, and use in improving care., Results: Each of the outcome measures took 15 to 30 minutes to administer. All were rated as easy to use and as relevant to dementia services and to carers. Staff commented that the measures could be useful in routine practice for structured assessment and service evaluation, but highlighted the need for sensitive use of measures with carers., Conclusions: These measures consider the main domains of functioning for people with dementia and their carers. The measures are suitable for use in routine practice in dementia services and are acceptable to staff and carers. The project underlined the need for management support, staff ownership of measures, and training in using outcome measures. Staff concerns about service evaluation need to be acknowledged.