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Objectives: To determine whether a new triage system safely diverts a proportion of emergency department (ED) patients to a general practitioner cooperative (GPC)., Methods: Unblinded randomised controlled trial with weekends serving as clusters (three intervention clusters for each control). The intervention was triage by a nurse using a new extension to the Manchester Triage System assigning low-risk patients to the GPC. During intervention weekends, patients were encouraged to follow this assignment; it was not communicated during control weekends (all patients remained at the ED). The primary outcome was the proportion of patients assigned to and handled by the GPC during intervention weekends. The trial was randomised for the secondary outcome: the proportion of patients assigned to the GPC. Additional outcomes were association of these outcomes with possible confounders (study tool parameters, nurse, and patient characteristics), proportion of patients referred back to the ED by the GPC, hospitalisations, and performance of the study tool to detect primary care patients (the opinion of the treating physician was the gold standard)., Results: In the intervention group, 838/6294 patients (13.3%, 95% CI 12.5 to 14.2) were assigned to the GPC, in the control group this was 431/1744 (24.7%, 95% CI 22.7 to 26.8). In total, 599/6294 patients (9.5%, 95% CI 8.8 to 10.3) experienced the primary outcome which was influenced by the reason for encounter, age, and the nurse. 24/599 patients (4.0%, 95% CI 2.7 to 5.9) were referred back to the ED, three were hospitalised. Positive and negative predictive values of the studied tool during intervention weekends were 0.96 (95%CI 0.94 to 0.97) and 0.60 (95% CI 0.58 to 0.62). Out of the patients assigned to the GPC, 2.4% (95% CI 1.7 to 3.4) were hospitalised., Conclusions: ED nurses using a new tool safely diverted 9.5% of the included patients to primary care., Trial Registration: ClinicalTrials.gov Identifier: NCT03793972., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: The second author is a general practitioner working in the surroundings of the study site, and as such, he performed on call shifts at the study site and treated some of the studied patients. Due to the anonymity of the studied data, the exact number of study patients seen by him cannot be determined, but it was definitely below ten. He is also a board member of the studied general practice cooperative receiving meeting fees. Author HP is coordinator of the iCAREdata project (database used for this study). She had an appointment at the University of Antwerp for this project until September 2020. The authors declare no other relationships or activities that could appear to have influenced the submitted work.

Introduction: Out of hours (OOHs) primary care is a critical component of the acute care system overnight and at weekends. Referrals from OOH services to hospital will add to the burden on hospital assessment in the ED and on-call specialties., Methods: We studied the variation in referral rates (to the ED and direct specialty admission) of individual clinicians working in the Oxfordshire, UK OOH service covering a population of 600 000 people. We calculated the referral probability for each clinician over a 13-month period of practice (1 December 2014 to 31 December 2015), stratifying by clinician factors and location and timing of assessment. We used Simul8 software to determine the range of hospital referrals potentially due to variation in clinician referral propensity., Results: Among the 119 835 contacts with the service, 5261 (4.4%) were sent directly to the ED and 3474 (3.7%) were admitted directly to specialties. More referrals were made to ED by primary care physicians if they did not work in the local practices (5.5% vs 3.5%, p=0.011). For clinicians with >1000 consultations, percentage of patients referred varied from 1% to 21% of consultations. Simulations where propensity to refer was made less extreme showed a difference in maximum referrals of 50 patients each week., Conclusions: There is substantial variation in clinician referral rates from OOHs primary care to the acute hospital setting. The number of patients referred could be influenced by this variation in clinician behaviour. Referral propensity should be studied including casemix adjustment to determine if interventions targeting such behaviour are effective., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Emergency departments in South African public hospitals have a high patient load after hours, with inadequate numbers of health care professionals available to satisfy patient influx. In addition, there is often no provision of after-hours diagnostic reporting services in public hospitals, to an extent that the emergency physician is responsible for interpreting all radiographic images requested themseves. Emergency physicians, in this study, can be described as any medical doctor registered with the Health Professions Council of South Africa and working in the emergency department as a registrar or consultant physician because there were no physicians specialized in emergency medicine working at the hospitals selected for this study., Aim: The aim of this study was to determine the views of emergency physicians on whether there is a need for an after-hours diagnostic radiological reporting service in selected public hospitals in KwaZulu-Natal Province, South Africa., Methods: A descriptive cross-sectional quantitative research design was utilized, through means of a survey, to assess the emergency physicians' perceptions regarding the need for after-hours diagnostic radiological reporting. In addition, the study used a descriptive quantitative research design to record the number of conventional diagnostic radiographic examinations performed at the selected hospitals, after hours, and the proportional number of these radiographic examinations that were reported on by radiologists during office hours, the following day. The distribution of questionnaires and data collection, with regard to the number of examinations reported on, and those not reported on, were carried out simultaneously during the execution of this study. The study was conducted over a three-month period in 2017, at four public hospitals in KwaZulu-Natal-one of the nine provinces of South Africa., Results: This study found that, during the study period, between 0.1% and 0.6% of the conventional diagnostic radiographic examinations performed, after hours, were reported on by radiologists during office hours, the following day. The surveyed emergency physicians felt that the interpretation of diagnostic images took up valuable time that could be spent on patient management, and there was near-total agreement, whereby 92% (n = 36) of the physicians would have preferred after-hours reporting to be performed by a radiologist. Physicians agreed that having a radiologist or reporting radiographer to provide radiological reports would allow for more effective and efficient patient management., Conclusion: The results of this study indicated that there is a need for after-hours radiographic reporting at the selected public hospitals and for the further training of emergency physicians in radiographic image interpretation. Based on the findings of this study, it is recommended that after-hours radiological reporting services be considered for public hospitals and that courses be offered to emergency physicians on the interpretation of diagnostic radiographic images. A hospital policy review may therefore be needed to adjust the focus of hospitals toward reducing the workload of emergency physicians, wherever possible, such as by incorporating support services like radiographic reporting and by providing further training on the interpretation of diagnostic radiographic images, which will both act to reduce the potential risk of misdiagnosis., (Copyright © 2020. Published by Elsevier Inc.)

Background: Diagnostic errors made by radiology resident physicians may lead to significant morbidity/mortality and patient dissatisfaction., Objective: To determine the etiology and disposition associated with radiology discrepancies on emergency department (ED) patients., Methods: We conducted a retrospective electronic chart review of patients presenting to our ED during "off hours" at the Penn State Hershey Medical Center during October 2013-November 2014 and had a radiology discrepancy, defined as a patient discharged from the ED with a diagnostic interpretation disagreement between the initial radiology resident physician read and final radiology attending physician read., Results: 81,201 images were performed during "off hours", with 174 radiology discrepancies (0.214%) identified. Most discrepancies were associated with CT scans (62%). The most common final diagnostic interpretations associated with discrepancies were missed fracture (10.9%), incidental findings of mass or cyst (10.3%), gastrointestinal inflammation (6.3%), and pneumonia (5.7%). 10% of radiology discrepancies were instructed to emergently return to the ED. The most common modality associated with ED follow-up was CT scan of the abdomen/pelvis (50%). Of the 17 patients that returned to the ED, 10 had additional diagnostic imaging, 9 received a subspecialist consult, 5 required surgical treatment, 5 required additional medications, and 1 required a medical hospitalization., Conclusions: Based on our sample, discrepancies were a small percentage of images performed during "off hours", and were associated with CT scans, missed fractures, and non-emergent outpatient follow-up. We suggest that ED and radiology departments work collaboratively to monitor their own rates of discrepancies, and subsequent morbidities and mortalities, to improve patient care., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Reversal of anticoagulation with four-factor prothrombin complex concentrate (4F-PCC) is critical, yet the optimal timing to 4F-PCC administration and whether quicker administration improves hemostasis remains unknown., Objective: The objective of this study was to determine if pharmacist presence is predictive of faster time to 4F-PCC., Methods: This retrospective cohort study included patients receiving 4F-PCC for life-threatening bleeding or urgent procedure in the emergency department (ED) from 2014 to 2018. Patients with pharmacists at bedside (PharmD group) were compared with physician teams alone (control group). The primary outcome was time from ED presentation to 4F-PCC administration., Results: Of 252 patients evaluated, 116 patients (46%) were included (n = 50 PharmD group; n = 66 control group). Most patients presented on warfarin (68.1%), and of the life-threatening bleeds (94%), intracranial hemorrhage was most common (67.2%). The median time to 4F-PCC administration was significantly shorter in the PharmD group (66.5 vs. 206.5 min, p < 0.001). Pharmacist at bedside was the only factor independently associated with reduction in time to 4F-PCC (β coefficient -163.5 min, 95% confidence interval -249.4 to -77.7). Although there was no difference in hemostasis or mortality, patients in the PharmD group had a shorter intensive care unit length of stay (LOS) (2 vs. 5 days, p < 0.01) and hospital LOS (5.5 vs. 8 days, p = 0.02)., Conclusion: A pharmacist at the bedside of patients who present to the ED with life-threatening bleeding or need for emergent procedure decreased time to 4F-PCC administration by 140 min, even after accounting for confounders. Faster time to 4F-PCC was associated with significantly shorter intensive care unit and hospital LOS., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Vascular laboratory (VL) venous duplex ultrasound is the "gold standard" for diagnosis of lower extremity deep venous thrombosis (DVT), which is linked to many morbid conditions. Decreasing night and weekend use of VL services in the emergency department (ED) represents a potentially viable means of reducing costs as skilled personnel must remain on call and receive a wage premium when activated. We investigated the effects of workflow changes that required ED providers to use a computerized decision-making tool, integrated into the electronic medical record, to calculate a Wells score for each patient considered for an after-hours venous duplex ultrasound study for suspected DVT., Methods: The rate of VL use and study positivity before and after implementation of the decision-making tool were examined in addition to measures of ED throughput, rate of concomitant pulmonary embolism, disposition of examined patients from the ED, observed thrombus distribution in duplex ultrasound studies positive for DVT, and calculated personnel costs of after-hours VL use., Results: A total of 391 after-hours, ED-initiated venous duplex ultrasound studies were obtained during the 4-year study period (n = 213 before intervention, n = 178 after intervention; P = .12). Whereas the period immediately after the start of the intervention saw a decrease in VL use, this was not sustained. Studies performed after the intervention were not more likely to be positive for acute DVT (12.2% vs 18%; P = .1179). The average Wells score was 2.8 (range, 0-6). VL personnel were called in 347 times during the 4-year period, with a total cost of $14,643.40. Nurse-ordered studies were significantly more likely to be positive, with 22% revealing acute DVT compared with 12% for physician-ordered studies (P = .042). The intervention resulted in significant improvements in ED throughput, with time between triage and study request falling from 226 minutes to 165 minutes (P < .001). Observed thrombus distribution revealed involvement of the most proximal external iliac system in a minority of cases (11%), whereas most thrombi (89%) were limited to the femoropopliteal, calf, and superficial venous systems., Conclusions: A requirement for ED providers to document a Wells score before obtaining an after-hours venous duplex ultrasound study resulted in only a transient decrease in VL use but improved ED throughput. Studies ordered by nurses were significantly more likely to be positive, possibly as a result of consistent protocol adherence compared with the physicians. Future studies may warrant investigation into this provider variance., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Primary care patients are often cited as a cause of Emergency Department overcrowding (ED). The aim of this study was to evaluate a physician led redirection procedure of selected patients towards an out of hours general practice (OHGP) in an Emergency Department with 55,000 admissions per year., Methods: Observational monocentric study over a period of 2 months. Every patient redirected to the OHGP was included and subsequently contacted by telephone to answer a standardized questionnaire, in order to measure: Redirection rate over the entire period and during weekdays or weekends/holiday Rate of redirected patients who went to the OHGP Rate of redirected patients who consulted in an ED in the next 72 h for the same reason Redirected patients' satisfaction rate RESULTS: During the study period 9551 patients presented to the ED, of which 288 were redirected towards the OHGP (3%). The redirection rate was 1.9% during weekdays and 5.7% during weekends/holiday (p < 0.001). Of the redirected patients, 77% answered the telephone interview. Ninety percent of these patients consulted the OHGP. The main reasons for not consulting were: unduly long wait, opening hours not suitable, too costly. The rate of redirected patients who consulted in an ED in the following 72 h for the same reason was 4.1%. The satisfaction rate was 79.6% among interviewed patients., Conclusions: A physician led procedure to redirect selected patients from the ED towards an OHGP results in a low redirection rate, unlikely to have a significant effect on ED patient flow. However, the procedure is safe and well accepted by a majority of patients.

Out of hours (OOH) doctors can have an important gate-keeping role over the access to the emergency department (ED), but the outcome and the quality of their ED referrals have been poorly studied. We aimed to investigate the outcome of patients referred to ED from OOH service and the determinants of admission or short-stay dispositions. We collected retrospectively data about referrals to ED from a local OOH service in the north-east of Italy using the OOH paper register and the ED electronic database, over the period of 01/10/2012 to 31/03/2013. Out of 5217 patients accessing the OOH service, 408 referrals were included in our analysis. 45.3% (185) of the referrals were admitted to hospital or the short-stay unit, 26 patients (=6.4%) were discharged as non-urgent outgoing codes after no specialist consultation or test, suggesting inappropriate referrals, and, of the remaining 197 (=48%), only 10 did not undergo any investigation or consultation. Significant determinants of admission were: age ≥65 years (OR = 2.619; 95% CI 1.528-4.491, p < 0.0001), domiciliary examination (OR = 2.168; 95% CI 1.353-3.476, p = 0.001), nursing home/palliative care setting (OR = 2.563; 95% CI 1.228-5.351, p = 0.012) and OOH triage code, ranging from an OR of 7.47 (95% CI 3.028-18.433) for minor urgencies to an OR of 26.835 (95% CI 6.761-106.508, p < 0.0001) for emergencies, in comparison to no urgent codes. OOH service seems to play an effective gate-keeping role limiting ED access. Determinants of admission to hospital suggest some simple interventions that could improve the adequacy of ED referral from OOH service.

Introduction: The aims of this study were to measure: (i) the growth in after-hours emergency department--referred CT (ED-CT) performed in accredited training departments between 2011 and 2013; (ii) the growth in ED CT relative to growth in ED presentations at the same hospitals; and (iii) trainee workload resulting from after-hours ED CT., Methods: Ethics approval was obtained for all participating sites. Accredited training facilities in Australia and New Zealand with three or more trainees and serving one or more EDs were invited to participate (N = 32). Four nights were surveyed between August and December 2013. For data collection, the number of ED patients having one or more CT scans; ED CT scan total images; non-contrast head CTs; and ED patients (total and categories 1 and 2) attending the ED in the preceding 24 h and first half of calendar year were collected for 2013 and corresponding days in 2012 and 2011. Trainee staffing levels were measured., Results: Eleven of 32 sites provided data for all four nights and 14 of 32 for one or more nights. A 15.7% increase in number of ED CTs between 1700 and 2200 h and 16.8% increase between 2201 and 0730 h occurred in the 2 years between 2011 and 2013 compared with a 6.9% increase in overall ED and 26% increase in categories 1 and 2 presentations over the same period. The number of CT images, however, increased 23%., Conclusion: Growth in demand by EDs for after-hours CT services has implications for service provision and trainee workloads in Royal Australian and New Zealand College of Radiologists-accredited training departments., (© 2015 The Royal Australian and New Zealand College of Radiologists.)

The English National Health Service is moving towards providing comprehensive 7-day hospital services in response to higher death rates for emergency weekend admissions. Using Hospital Episode Statistics between 1st April 2010 and 31st March 2011 linked to all-cause mortality within 30 days of admission, we estimate the number of excess deaths and the loss in quality-adjusted life years associated with emergency weekend admissions. The crude 30-day mortality rate was 3.70% for weekday admissions and 4.05% for weekend admissions. The excess weekend death rate equates to 4355 (risk adjusted 5353) additional deaths each year. The health gain of avoiding these deaths would be 29 727-36 539 quality-adjusted life years per year. The estimated cost of implementing 7-day services is £1.07-£1.43 bn, which exceeds by £339-£831 m the maximum spend based on the National Institute for Health and Care Excellence threshold of £595 m-£731 m. There is as yet no clear evidence that 7-day services will reduce weekend deaths or can be achieved without increasing weekday deaths. The planned cost of implementing 7-day services greatly exceeds the maximum amount that the National Health Service should spend on eradicating the weekend effect based on current evidence. Policy makers and service providers should focus on identifying specific service extensions for which cost-effectiveness can be demonstrated., (Copyright © 2015 John Wiley & Sons, Ltd.)

Objective: To assess the safety and efficiency of triaging low urgent self-referred patients at the emergency department (ED) to a general practitioner (GP) based on the Manchester triage system (MTS)., Methods: All self-referred patients in the evening, night and weekends were included in this prospective observational study. Patients were triaged by an ED nurse according to the MTS and allocated to a GP or the ED according to a predefined care scheme. For patients treated by the GP, assessments were made of safety as measured by hospitalisation and return to the ED within 2 weeks, and efficiency as measured by referral to the ED., Results: In 80% of cases allocation of the self-referrals to the ED or GP was according to a predefined scheme. Of the 3129 low urgent self-referred patients triaged to the GP, 2840 (90.8%) were sent home, 202 (6.5%) were directly referred to the ED, 36 (1.2%) were hospitalised. Within a random sample of low urgent patients sent home by the GP (222 of 2840), 8 (3.6%) returned to the ED within 2 weeks. Against the agreed MTS scheme, the ED also directly treated 664 low urgent patients, mainly for extremity problems (n=512). Despite the care agreements, 227 urgent patients were treated by the GP, with a referral rate to the ED of 18.1%, a hospitalisation rate of 4.0% and a 4.5% return rate to the ED within 2 weeks., Conclusions: Low urgent self-referrals, with the exception of extremity problems, were shown to be treated efficiently and safely by a GP. A selected group of more urgent patients also seem to be handled adequately by the GP. Triage of low urgent patients with extremity problems and reasons for nurses not following a predefined triage allocation scheme need further elaboration.

Recently, the United Kingdom Haemophilia Centre Doctors Organisation published recommendations for the standard of care for assessment and treatment of patients with bleeding disorders in the emergency department (A&E). An audit was undertaken to compare the level of care to the acceptable standards in a tertiary hospital A&E, attached to a haemophilia comprehensive care centre. A&E attendances were found by cross referencing all patients with known bleeding disorders against the EDMS attendance system. Visits from the past 3 years were identified to produce sufficient data and electronic notes from these visits were then accessed, and marked against the proforma. Data were available from 45 of a total of 54 patients, who had a total of 75 emergency visits documented. In all aspects of care, the standards were not adequately met including the average length of time between booking and clinical assessment, early initiation of specific haemostatic treatment, seeking haematology advice and arrangement of follow-up. Also no specialist clotting investigations were done with only 9/11 patients admitted having their haematological diagnosis recorded. In addition, only very few patients had the severity of bleeding disorder noted and less than half their first line treatment documented. There were significant differences in the standard of care for haemophilia patients provided by the A&E department when compared with acceptable standards. Measures have been put in place and policies have been drafted to improve this situation and provide the best possible care to persons with haemophilia., (© 2011 Blackwell Publishing Ltd.)

Objective: The effect of nightshift on ED staff performance is of clinical and risk-management significance. Previous studies have demonstrated deterioration in psychomotor skills but the present study specifically assessed the impact of nightshift on clinical performance., Methods: The ED registrars in a tertiary hospital were enrolled in a prospective observational study and served as their own controls. During nightshift, subjects were presented simulated scenarios and tested with eight clinical questions developed to Fellowship examination standard. Matched scenarios and questions for the same subjects during dayshift served as controls. Two investigators, blinded to subject identity and the setting in which questions were attempted, independently collated answers., Results: Of 22 eligible subjects, all were recruited; four were excluded owing to incomplete data. A correlation of 0.99 was observed between the independent scoring investigators. Of a possible score of 17, the median result for nightshift was 9.5 (interquartile range: 8-11); corresponding value for dayshift was 12 (interquartile range: 10-13); P = 0.047., Conclusion: Nightshift effect on clinical performance is anecdotally well known. The present study quantifies such effects, specifically for the ED setting, and paves the way for focused research. The implications for clinical governance strategies are significant, as the fraternity embraces the mandate to maintain quality emergency care 24 h per day.

Background: Prior studies have demonstrated an inconsistent association between patients' arrival time for acute myocardial infarction (AMI) and their subsequent medical care and outcomes., Methods and Results: Using a contemporary national clinical registry, we examined differences in medical care and in-hospital mortality among AMI patients admitted during regular hours (weekdays 7 am to 7 pm) versus off-hours (weekends, holidays, and 7 pm to 7 am weeknights). The study cohort included 62,814 AMI patients from the Get With the Guidelines-Coronary Artery Disease database admitted to 379 hospitals throughout the United States from July 2000 through September 2005. Overall, 33 982 (54.1%) patients arrived during off-hours. Compared with those arriving during regular hours, eligible off-hour patients were slightly less likely to receive primary percutaneous coronary intervention (adjusted odds ratio [OR], 0.93; 95% confidence interval [CI], 0.89 to 0.98), had longer door-to-balloon times (median, 110 versus 85 minutes; P<0.0001), and were less likely to achieve door-to-balloon < or = 90 minutes (adjusted OR, 0.34; 95% CI, 0.29 to 0.39). Arrival during off-hours was associated with slightly lower overall revascularization rates (adjusted OR, 0.94; 95% CI, 0.90 to 0.97). No measurable differences, however, were found in in-hospital mortality between regular hours and off-hours in the overall AMI, ST-elevated MI, and non-ST-elevated MI cohorts (adjusted OR, 0.99; 95% CI, 0.93 to 1.06; adjusted OR, 1.05; 95% CI, 0.94 to 1.18; and adjusted OR, 0.97; 95% CI, 0.90 to 1.04, respectively). Similar observations were made across most age and sex subgroups and with an alternative definition for arrival time (weekends/holidays versus weekdays)., Conclusions: Despite slightly fewer primary percutaneous coronary interventions and overall revascularizations and significantly longer door-to-balloon times, patients presenting with AMI during off-hours had in-hospital mortality similar to those presenting during regular hours.

Although the advisory opinion issued by the Department of Health and Human Services' Office of Inspector General (OIG) specifically states it only applies to the pay-for-call arrangement at one hospital, experts say the ED manager can use the opinion to establish bench-marks for their own on-call arrangements. * At the very least, the OIG has made it clear that paying for on-call coverage is not in and of itself a violation of any statutes. * Any per diem rates paid to ensure that specialists agree to take call must be "reasonable" and meet "fair market value." * The fact that the specialists also may be paid for the services they provide may not necessarily mean your arrangement is improper.

Objective: To determine whether being admitted with major trauma to an emergency department outside rather than within working hours results in an adverse outcome., Methods: The data were collected from hospitals in England and Wales participating in the Trauma Audit and Research Network (TARN). Data from the TARN database were used. Admission time and discharge status were cross matched, and this was repeated while controlling for Injury Severity Score (ISS) values. Logistic regression was carried out, calculating the effects of Revised Trauma Score (RTS), ISS, age, and time of admission on outcome from major trauma. This allowed observed versus expected mortality rates (Ws) scores to be compared within and outside working hours. As much of the RTS data were missing, this was repeated using the Glasgow Coma Score instead of RTS., Results: In total, 5.2% of people admitted "out of hours" died, compared with 5.3% of people within working hours, and 12.2% of people admitted outside working hours had an ISS score greater than 15, compared with 10.1% admitted within working hours. Outcome in cases with comparable ISS values were very similar (31.1% of cases with ISS >15 died out of hours, compared with 33.5% inside working hours.) The subgroup of data with missing RTS values had a significantly increased risk of death. Therefore, GCS was used to calculate severity adjusted odds of death instead of RTS. However, with either model, Ws scores were identical (both 0%) within and outside working hours., Conclusions: Out of hours admission does not in itself have an adverse effect on outcome from major trauma.

Objectives: To determine whether performance decrements at night actually translate into worsened measures of quality of patient care in the emergency department (ED). Emergency physicians and healthcare workers are sleepier and less cognitively proficient at night than during the day. Despite a lack of data, medical errors have been attributed to these deficits, and pharmacologic solutions recently have been suggested., Methods: The authors studied 36 months of emergency care and measured quality indicators, including early mortality (deaths occurring after arrival in the ED or within 48 hours of hospital admission), frequency of return after ED discharge, time to thrombolysis in acute myocardial infarction (AMI), frequency of aspirin use in AMI, and performance of endotracheal intubation. Comparisons were by time of day in eight-hour epochs., Results: There were 345,000 patient encounters in the study period. The distribution in time was determined for 25,079 sampled ED visits, 3,666 admissions, and 507 early deaths. Estimated early mortality was 0.5% (95% CI = 0.0 to 1.0%) greater at night compared with during the day. There was no effect of time of day on 1,828 returns with admission after ED discharge. In 257 patients who received thrombolytics for AMI, mean time-to-treatment and frequency of aspirin use were not worse at night. In 443 emergent endotracheal intubations, there was no difference at night in the duration or number of attempts required, or in protocol adherence., Conclusions: Quality indicators used in this study do not demonstrate marked deficits in patient care occurring at night. A very small, but measurable, increase in early mortality was identified. Improved measures to counter circadian disruption warrant study but may result in minimal improvements in patient care.

Objective: The aim of this study was to examine to what extent findings on ultrasonography performed in the emergency department (ED) after hours confirm or alter the referral diagnosis in patients without trauma as reflected in the discharge diagnosis., Methods: In this prospective study, data from 136 ultrasonographic examinations performed in patients without trauma after hours in the ED during January and February 2002 were evaluated against the suspected preimaging diagnosis of the referring ED physician and the actual discharge diagnosis from the ED or after hospitalization. The rate of preimaging and postimaging concordance was statistically analyzed and compared by calculation of confidence intervals and by the McNemar test., Results: Normal ultrasonographic findings were documented in 54 patients (40%), and pathologic findings were documented in 82 (60%). Thirty-four (25%) of the 136 examinations were concordant with the initial referring physician's diagnosis. Of the 102 studies that were not concordant with the initial referral suspected diagnoses, that is, being either a study with normal findings or offering an alternative diagnosis, 81 (79.4%) were concordant with the discharge diagnosis., Conclusions: After-hours ultrasonographic findings in patients without trauma seen in the ED seem to have a high impact on the discharge diagnosis and are concordant with it in more than 80% of cases.

'Action on ENT' has recently published advice as to the minimum requirements for equipment required to provide a safe and suitable out-of-hours service in ENT. Our objectives were to determine the availability of a dedicated ENT treatment room for seeing patients out of hours, appropriately maintained specialized ENT equipment and availability of appropriate assistance. In addition, the mechanism for disinfection of nasoendoscopes out of hours was determined. Telephone questionnaires of 106 ENT units in England, which provide an out-of-hours ENT service, were taken. At each unit the standard questionnaire was answered by the first on-call ENT doctor. One hundred and one units (95 percent) had access to a dedicated treatment room out of hours. The number of units with a microscope was 91 (86 percent), headlight/lamp and mirror was 105 (99 percent), flexible nasoendoscope was 86 (81 percent) and cautery (electrical or chemical) was 105 (99 percent). Seventy-nine units (75 percent) found that their treatment rooms were adequately stocked, and 62 units (58 per cent) had assistance available when needed. Twenty-four units (23 percent) sterilized their scopes adequately, 22 units (21 percent) used endosheaths, 26 units (24 percent) used a variety of inadequate cleaning methods, and 34 respondents (32 percent) were unsure how their scopes were cleaned. This survey has shown that not all ENT units have appropriately equipped out-of-hours facilities. There is a need for nationally agreed guidelines stating the minimum equipment and assistance required to provide a safe, adequate and suitable out-of-hours service. National guidelines on out-of-hours disinfection of flexible nasoendoscopes are also required.

Objective: To evaluate whether the quality and effectiveness of an emergency department (ED) are modified during weekends., Methods: Quality and effectiveness markers were determined during 539 consecutive days, comparing them according to the day of the week. Quality markers were the daily percentage of patients who died in the internal medical unit (deaths, D), leave ED without being seen (flights, F); returned to the ED (revisits, R), and the percentage of registered complaints (C). Effectiveness markers were: the "number of patients waiting to be seen" (WP), the "waiting time to be seen" (WT), and the "length of visit" (LV)., Results: Quality and effectiveness of ED do not worsen during weekend days and some markers significantly improved during such days: C experienced a 26% decrease (p = 0.001), WT decreased 65% (p<0.001), WP 59% (p<0.001), and LV 24% (p<0.01). Assessing the relation between daily number of visits to ED and the quality and effectiveness markers, a significant and direct association was found of the number of visits with D, F, R, and WP., Conclusion: Some of the quality and effectiveness markers of the ED improved during weekend days compared with workdays.

Objectives: 1)To study the alert system (on call duty) in the Spanish neurosurgical departments and main issues of the emergency neurosurgical attention; 2) To establish common sense criteria for a thorough review of the system; 3) To analyse the effects of the current alert system on neurosurgical planning in Spain from the point of view of aging of Spanish neurosurgeons., Material and Methods: An interview containing 11 items related to the main aspects of the alert system was developed. The interview was sent to 51 departments. Answer from 42 of them were received. Neurosurgical departments were categorized in two different patterns to analyse the results: 1 st )according to the size of the staff. Three different types were observed:Type A (more than 10 neurosurgeons);Type B (between 6 and 10), and Type C (less than 6). 2 nd ) according to qualification of the personnel receiving the patient in the emergency area:Type I (the patient is received by paramedic personnel);Type II (trainee sends patient to specialist);Type III (training doctor orders diagnostic procedures) and Type IV (neurosurgeon orders diagnostic procedures and decides next actions)., Results: Type A departments :This group is formed by 8 departments. Alerts are always mix (at home or in hospital). There are usually 3 neurosurgeons on call (sometimes 4). Staff personnel is on call duty at the hospital 5 days a month plus 5-6 days at home. In 38% of the hospitals, department is type I-II (the patient is initially attended by paramedic personnel, not responsible for diagnostic or treatment). Surgical emergencies account for 0.54 a day as a rule and 12.75 patients require neurosurgeon's attention every day. In 75% of the hospital the neurosurgeon must also read neuroimaging procedures and suture scalps in 37%. Next day, neurosurgeon on call is off duty almost routinely. Type B :it was formed by 21 services. Alert are always mix (at home or in hospital). There are usually two neurosurgeons on call. Staff personnel are on call 4-5 days a month at the hospital and 5-6 days at home. The patient is initially attended by a doctor starting diagnosis in 85% of the cases (types III and IV).They operate 0.52 times a day,attending 6.19 patients/day as a mean. Neurosurgeon must read neuroimaging procedures in 57%. They do not repair scalps (except for a 5%) and personnel is off duty next day routinely. Type C :Nine (9) departments were grouped under this lining. Staff is always on call at home. There is usually only one neurosurgeon (sometimes two). Staff perform 10-12 alerts at home along the month. In 4 of the departments they must duplicate the number of days as far as there are two of them on-call. Patients are attended initially as type III-IV in 100% of the cases (doctor asks for diagnostic tools and decides therapy in 78%). Neurosurgeon on-call receives 4-5 phone-calls a day. Surgical emergencies account for 0.34 a day and 1.84 patients a day are attended directly by them. They never suture scalps. They seldom are off-duty next day. Aging of the Spanish neurosurgeons (389 interviewed). Most important issues are: 152 neurosurgeons will be 55 yo between 2003 and 2008, so they can ask for leaving on-call duties. 121 neurosurgeons will be 65 yo between 2009 and 2013., Conclusions: 1 st ) Alert system, mostly in bigger departments, is disproportioned and does not to fit to reality. 2 nd ) Emergency is worse organized in bigger hospitals. Besides, neurosurgeon on-call is not properly consulted. 3 rd ) Almost routinely neurosurgeons are offduty the day after alert in hospital. 4 th ) 152 neurosurgeons are necessary in the next five years to maintain the current system, which is obviously unviable. 5 th ) Most of the finishing trainees (residents) should tolerate "on-call contracts"in bigger departments to sustain the actual system. 6 th )For future planning, Neurosurgical National Committee must offer 20 training places a year to fill jubilees to happen from 2009 on. Finally we believe that the current alert system cannot be maintained any more, so Health Administratt system cannot be maintained any more, so Health Administrations must develop a profound reform. In this sense, the role that Local Neurosurgical Societies must play is essential.

Objective: To identify characteristics associated with dissatisfaction following contact with an out of hours co-operative in Glasgow, and to identify reasons for this dissatisfaction. To make recommendations for good practice in the light of these findings., Design: Survey of attenders during one week of operation of an out of hours co-operative. Analysis of factors associated with dissatisfaction., Setting: The Glasgow Emergency Medical Service, October 1996., Subjects: Questionnaires were received from 1115 patients or their carers, representing a 69.3% response rate., Results: Dissatisfaction was associated with unmet expectations, particularly among those expecting home visits. Parents of young children, more affluent patients, and those experiencing problems with daytime services also tended to be dissatisfied. Seventy four (7%) respondents indicated that they were very dissatisfied with aspects of the service. A high proportion of this dissatisfaction was related to telephone contact. Transport to out of hours centres caused problems for some patients, particularly for those with young children. Perceptions of dismissive attitudes by medical staff, and of incorrect diagnoses and treatment were causes of strong dissatisfaction. Patients with adverse medical outcomes were also likely to be very dissatisfied., Conclusion: Clear reasons for dissatisfaction were found among our sample. In most cases, remedial management action could be taken to reduce the likelihood of major dissatisfaction with the service.