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Introduction. The goals of health care provision include that it be accessible, acceptable, affordable and adequate. Discharge against medical advice (DAMA) is a failure of proper health care provision as there is disagreement arising from dissatisfaction with provided health care. DAMA is common in our sub-region because of many reasons; these includes ignorance, financial constraint of the patient, beliefs in unorthodox care and patients feeling that they are well when their caregivers do not think so. Aim. The objectives of this study are to determine the incidence, method of documentation of DAMA in the case notes and patients reasons for DAMA in our tertiary health institution. The A&E of any hospital in our environment attracts public criticism when there is dissatisfaction with services and DAMA when not handled well can lead to justifiable criticisms and/or litigations. Material and methods. This is a retrospective study. It was carried out at the adult accident and emergency department of Enugu state university of technology teaching hospital Enugu. Duration of the study was from January 2017 to December 2018. Results. A total of 8,152 patients were seen in the accident and emergency during this period. One hundred and seventy one (171) case notes were retrieved and reviewed for the study, DAMA rate of 2.1% was obtained. Fifty one folders (29.8%) did not have reason for the DAMA documented in them. The commonest reason for the DAMA was to seek traditional medical care with frequency of 17.5%. This was closely followed by financial constraint with 15.8%. Documentation for DAMA was done directly in the case notes. Conclusion. The incidence of DAMA from this study is similar to what is obtainable from other local studies, financial constraint on the patients and seeking alternative medical treatment were the commonest reasons for DAMA in our sub-region. Also, the documentation for the DAMA in this study was poorly done.

The patient record is an essential patient data were the nursing documentation part is fundamental. .Competent nursing care is based on correct and complete records, and keeping record is an essential skill that needs to be developed by each and every health staff. The present study was conducted in order to assess the documentation on current medical patient’s records in the Accident and Emergency Hospital/Sulaimani city. A quantitative descriptive design. Research was accomplished, based on retrospective data made available by the Accident and Emergency Hospital. Non-probability (purposive sample) of 201 patient files were selected from 1,194 patient files during 6 months between Jun to December 2016.The present study showed that the face sheet was completely recorded about %95 which means satisfactory, other items which were recorded by physician such as chief complaint and history of present illness, radiology, laboratory, medication intervention report, consent forms, physical examination, and consultant report were unsatisfactorily recorded. Last items which were recorded by the nurse who working in Accident and Emergency Hospital medication and administration record and a graphic sheet of vital signs were unsatisfactorily recorded. Deficiency in documentation system and most of the provided medical and nursing care remains undocumented given numerous deficiencies in the documentation system. It is recommended the components of the nursing record tool can be utilized once a paperless system is implemented as planned in the hospital.

In this paper, a novel particle swarm optimization (PSO) algorithm is proposed in order to improve the accuracy of traditional clustering approaches with applications in analyzing real-time patient attendance data from an accident & emergency (A&E) department in a local UK hospital. In the proposed randomly occurring distributedly delayed particle swarm optimization (RODDPSO) algorithm, the evolutionary state is determined by evaluating the evolutionary factor in each iteration, based on which the velocity updating model switches from one mode to another. With the purpose of reducing the possibility of getting trapped in the local optima and also expanding the search space, randomly occurring time-delays that reflect the history of previous personal best and global best particles are introduced in the velocity updating model in a distributed manner. Eight well-known benchmark functions are employed to evaluate the proposed RODDPSO algorithm which is shown via extensive comparisons to outperform some currently popular PSO algorithms. To further illustrate the application potential, the RODDPSO algorithm is successfully exploited in the patient clustering problem for data analysis with respect to a local A&E department in West London. Experiment results demonstrate that the RODDPSO-based clustering method is superior over two other well-known clustering algorithms. European Union’s Horizon 2020 Research and Innovation Programme (INTEGRADDE); 10.13039/501100000266-Engineering and Physical Sciences Research Council; 10.13039/501100000288-Royal Society; Alexander von Humboldt Foundation of Germany

The revised National Early Warning Score (NEWS2), a tool used to measure acute deterioration in hospital, has been introduced in acute NHS hospitals and ambulance services. Community nurses report that when they call 999 requesting an ambulance to take a person to hospital, they are asked to provide a NEWS score. They report that when the NEWS score is high, ambulance staff prioritise the call. The NEWS score is being introduced in the community by default. This article will outline how the NEWS score is calculated, its uses and limitations and asks if the NEWS score accurately measures acute deterioration in people living in the community and predicts the need for referral to accident and emergency services.

This article explores the extent to which disabled individuals experience interpersonal violence due to victimization. Data on people injured by violence were collated directly from the accident and emergency units in hospitals. High frequency daily data were obtained from computerized records of 26 major accident and emergency departments in London for each day throughout the year of 2016. The final sample consisted of 408,000 observations. A fundamental distinction of our research lies in applying the Generalized Method of Moments system panel estimator to our sample. This makes our empirical estimates robust to endogeneity and joint determination unlike previous empirical research in this area. Data analysis provides strong evidence confirming the victimization of people with disabilities and the necessity to focus on disability equality in violence prevention work.

Background: Overutilisation of the Accident and Emergency Department is an increasingly serious healthcare challenge. Online symptom checkers could help alleviate this challenge by allowing patients to self-triage before visiting the Accident and Emergency Department. Objectives: This study aimed to assess the triage accuracy of online symptom checkers, which would help determine the potential roles of symptom checkers in an Accident and Emergency Department setting. Methods: A total of 100 random Accident and Emergency Department records were sampled from the Queen Mary Hospital in Hong Kong. The inclusion criteria were patients over the age of 18 attending the Queen Mary Hospital Accident and Emergency Department in 2016. Symptom checkers by Drugs.com and FamilyDoctor were selected as representative tools. One triage recommendation was generated by each symptom checker for each case record. Each symptom checker’s triage accuracy was then evaluated using a few outcome measures: overall sensitivity, sensitivity for emergency cases and specificity for non-emergency cases, when compared with the triage categories assigned by the triage nurses. Results: The results showed that Drugs.com had a higher overall triage accuracy than FamilyDoctor (74% and 50%, respectively), but both checkers are inadequately sensitive to emergency cases (70% and 45%, respectively) with low negative predictive values (43% and 24%, respectively). Conclusion: In their current states, symptom checkers are not yet suitable as alternatives to Accident and Emergency Department triage protocols due to their low overall sensitivities and negative predictive values. However, symptom checkers might serve as useful Accident and Emergency Department adjuncts in other ways, such as to provide more information prior to a patient’s arrival to streamline the triage and preparation process at the Accident and Emergency Department.

OBJECTIVES Falls have a significant negative impact on the health and well-being of people with dementia and increase service costs related to staff time, paramedic visits, and accident and emergency (A&E) admissions. We examined whether a remote digital vision-based monitoring and management system had an impact on the prevention of falls. METHODS Our study was conducted within the Manor dementia inpatient wards at the Coventry and Warwickshire Partnership Trust. Data were retrieved from incident reports before and 22 months after installation of the system. We examined number of night time falls, severity of fall, number of paramedic visits and A&E admissions, and the number of enhanced observations during both time periods. RESULTS There was a significant 48% reduction in the number of nighttime falls (P < 0.01), a 49% reduction in visits from paramedics (P < 0.2), and a 68% reduction in A&E admissions (P < 0.02). In addition, the data indicated an 82% reduction in the number of moderate severity falls and that enhanced one-to-one observation hours were reduced by 71%. CONCLUSIONS The study demonstrated that a contact-free, remote digital vision-based monitoring and management system reduced falls, fall-related injuries, emergency services time, clinician time, and disruptive night time observations. This benefits the clinicians by allowing them to undertake other clinical duties and promotes the health and safety of patients who might normally experience injury-related stress and disruption to sleep.

BackgroundInpatients experiencing homelessness are often discharged to unstable accommodation or the street, which may increase the risk of readmission.MethodsWe conducted a cohort study of 2772 homeless patients discharged after an emergency admission at 78 hospitals across England between November 2013 and November 2016. For each individual, we selected a housed patient who lived in a socioeconomically deprived area, matched on age, sex, hospital, and year of discharge. Counts of emergency readmissions, planned readmissions, and Accident and Emergency (A&E) visits post-discharge were derived from national hospital databases, with a median of 2.8 years of follow-up. We estimated the cumulative incidence of readmission over 12 months, and used negative binomial regression to estimate rate ratios.ResultsAfter adjusting for health measured at the index admission, homeless patients had 2.49 (95% CI 2.29 to 2.70) times the rate of emergency readmission, 0.60 (95% CI 0.53 to 0.68) times the rate of planned readmission and 2.57 (95% CI 2.41 to 2.73) times the rate of A&E visits compared with housed patients. The 12-month risk of emergency readmission was higher for homeless patients (61%, 95% CI 59% to 64%) than housed patients (33%, 95% CI 30% to 36%); and the risk of planned readmission was lower for homeless patients (17%, 95% CI 14% to 19%) than for housed patients (30%, 95% CI 28% to 32%). While the risk of emergency readmission varied with the reason for admission for housed patients, for example being higher for admissions due to cancers than for those due to accidents, the risk was high across all causes for homeless patients.ConclusionsHospital patients experiencing homelessness have high rates of emergency readmission that are not explained by health. This highlights the need for discharge arrangements that address their health, housing and social care needs.

A foreign body sensation following fishbone ingestion is a common presentation to the Accident and Emergency Department. Simple removal is achieved with acute presentations and accessible locations. The risk of complications increases with delay in seeking medical attention. We report a case of a migratory fishbone lodged in the larynx for 6 months in a patient with delayed presentation due to COVID-19 pandemic

Dear EditorWe have recently read the article by Hellawell et al. (2020) about how to maximise learning during Accident and Emergency (A&E) placements. As medical students who have just completed ou...

Accidents are associated with airway complications. Tracheobronchial injury, pneumothorax, pneumomediastinum, atelectasis, and subcutaneous emphysema can be observed. Therefore airway management in emergency medicine requires skills and equipment. Rapid-sequence intubation, effective preoxygenation, apneic oxygenation, manual inline stabilization technique should be used properly. Rapid-sequence intubation consists of sedation, analgesia, and muscle paralysis components. Videolaryngoscopes, supraglottic and extraglottic airway devices, bougie and surgical airway tools are among training materials. A range of training materials have been described to improve providers’ understanding and knowledge of patient safety. In conclusion providing oxygenation, minimizing the risk of complications and choosing the appropriate devices constitute the airway management’s pearls.

There is no doubt that the COVID-19 pandemic has impacted surgical training, with the cancellation of elective operating lists, exams, courses and conferences and redeployment of staff to front-line services. Like many others, as a group of core surgical trainees in plastic surgery we were redeployed, in our case to our local accident and emergency department (ED) for 3½ months. While we recognised the need for this, we were also concerned about the implications that this would have on our surgical training. To maximise our learning opportunities and maintain a degree of surgical training while in redeployment, we formulated a number of strategies. With the threat of a further wave of COVID-19 still looming and the possible need for further redeployment periods, we would like to share our experiences with other trainee surgeons, including the approaches we found effective in providing safe care to our patients while maximising our own learning. Working in ED gave us front-line experience of assessing patients. With lockdown do it yourself projects and avocado salads gone awry in addition to numerous sourdough bakery-related burns, there were plenty of patients who presented with common plastic surgery injuries, giving regular practice in assessing wounds and burns and opportunities to keep our suturing skills proficient. Furthermore, our ED consultants took the time to discuss and understand our learning …

Background The number of mental health-related 999 calls to emergency services has increased in recent years. However, emergency services staff have an unfavourable reputation when it comes to supporting people experiencing mental health problems. Aims To assess the levels of explicit and implicit mental health stigma among accident and emergency, ambulance and police staff, and draw comparisons with the general population. Additional analyses sought to identify which variables predict mental health stigma among emergency services staff. Method A cross-sectional survey of 1837 participants, comprising four independent groups (accident and emergency, ambulance and police staff, and the general population). Results Levels of mental health stigma across all four groups were lower than those reported in recent surveys of the general population by the ‘Time to Change’ campaign. Within this study, explicit levels of mental health stigma were lower among the general population compared with emergency services staff. There was no difference between emergency service professions, nor were there any between-group differences in terms of implicit mental health stigma. The only consistent predictors of mental health stigma were attitudes and future behavioural intentions, whereby increased stigma was predicted by increased fear, reduced sympathy and greater intended discrimination. Conclusions Our findings suggest that levels of mental health stigma have improved over time, but there is room for improvement in emergency services staff. Interventions to improve mental health stigma may be most effective if, in line with the cognitive–behavioural model of stigma, they target attitudes and behavioural intentions.

Purpose This case report highlights the potential for error when removing corneal foreign bodies in a shared speciality area in Accident and Emergency (A&E). Observations This case presents the accidental use of a silver nitrate stick rather than a cotton bud to remove a corneal foreign body. This resulted in a corneal injury requiring ophthalmological referral and management with topical antibiotics, topical steroids and lubricants. Conclusions Mistaking a silver nitrate stick for a cotton bud is a tangible risk in a busy A&E and can result in significant corneal injury. Clinicians and departments can greatly reduce this risk by having separate and secure storage of similar consumables, as well as keeping consumables in original packaging and discarding of the remainder after a pack has been opened. Minimizing the risk for error will better safeguard and improve patient safety.

Introduction: Non-contrast Computerised Tomography (NCCT) Brain is a common referral made from the Accident and Emergency (A&E) department both for traumatic and non traumatic causes. Aim: To evaluate the veracity of the referrals made by the Accident and Emergency Department clinicians for non-contrast computed tomography Head. Materials and Methods: This was the Retrospective evaluation of diagnostic yield of head Computed Tomography (CT) referrals made from A&E Department of a tertiary care hospital located in northern-central India over three year period between January 2015 to December 2017. CT reports were first grouped into two major group’s trauma and non trauma referrals with further subdivision into positive and negative scan on the basis of presence of abnormality. Subsequently, the positive trauma reports were classified into Major findings (three subgroups extra-axial haemorrhage, brain contusions and other miscellaneous findings) and minor findings like undisplaced fractures of the skull or facial bones with or without subgaleal haematoma. Distribution of trauma cases as per National Institute for Health and Care Excellence (NICE) criteria was then tabulated. Non-trauma reports were also further classified in to the two major clinically important findings of haemorrhage and infarct as well as non-specific minor findings. Results: Of the total data of 2185 head CT (980 trauma cases and 1205 in non trauma cases) referrals done by A&E Department during the study period. The 144 (58.5%) out of trauma cases and 328 (27.2%) out of non trauma cases were with major findings. 788 (80.4%) of trauma cases and 965 (80.1%) out of non trauma cases were referred by Medical Officer (MO)/ Resident as revealed from the audit. Positivity percentages for traumatic and non traumatic causes were 25.1% and 27.2%, respectively. Conclusion: Due to non adherence to existing guidelines or due to poor clinical knowledge, there is poor diagnostic yield of CT referrals made from A&E department. Thus clinical Audit is essential at Department of Radiodiagnosis to streamline the referring protocols and improves the overall efficiency of the healthcare system.

About 20-30% of children access the Pediatric Accident and Emergency Department (AE) for non-urgent health care that should normally follow other health care paths. This study aimed to investigate why parents take their children to the AE for non-urgent visits rather than using primary care services.A one-year cross-sectional study was conducted in a large pediatric AE in Italy. A paper-and-pencil 40-item questionnaire was administered to parents of children aged between 3 months to 6 years who accessed the AE for non-urgent visits between July 2018 and June 2019.Parents of 238 children completed the questionnaire (mean age = 2.6 years; male 58%). The most common symptoms were fever (n = 105; 44.1%) and skin rash (n = 63; 26.5%); symptoms usually started more than 24 h earlier (n = 163; 69.4%). Reasons for accessing the AE for non-urgent visits included the availability of rapid medical tests (n = 71; 29.8%), deterioration of the clinical conditions after the pediatrician's visit (n = 67; 28.2%), and the perceived need for urgent care (n = 65; 27.3%). Besides, 26.6% (n = 63) of parents reported not being able to contact their pediatrician before accessing AE.Parents may need further education to distinguish between urgent and non-urgent pediatric health conditions.

BACKGROUND Poisonings by substances of abuse are potentially dangerous and indicate risky substance use behaviour. To be prepared to handle patients with poisonings by substances of abuse, we need updated knowledge about the kinds of substances we can be expected to encounter. Most substance use-related poisonings in Oslo are treated at the OAEOC, and we describe the poisonings observed there in the period 2014-2018. MATERIAL AND METHOD We included all patients treated for poisoning by substances of abuse at the OAEOC in the years 2014-18, with the exception of lone ethanol poisonings. For 2018, these were also included. The patients were identified retrospectively by a review of the patient registration lists in the clinic's electronic records system. The diagnosis of the substances involved was based on the clinical assessment made by the doctor responsible for treatment. RESULTS In the period 2014-18, altogether 8 116 cases of poisoning by a substance of abuse were treated at OAEOC, lone ethanol poisonings not included. The most frequently occurring intoxicants were heroin (3 237 cases), benzodiazepines (2 196), amphetamine/methamphetamine (1 827), cannabis (1 081), gamma-hydroxybutyrate (GHB) (904), cocaine (569) and unspecified opioids (546). There was an increasing trend in number of cases per year for central stimulants, cannabis and GHB, and a decreasing one for benzodiazepines. The number of heroin poisonings fell until 2017, but rose again in 2018. In 2018 there were 4 021 poisonings by substances of abuse, of which 2 022 were lone ethanol poisonings. INTERPRETATION The number of poisonings increased for most substances in 2014-18, but fell for heroin and benzodiazepines.

BackgroundSyndromic surveillance provides public health intelligence to aid in early warning and monitoring of public health impacts (e.g. seasonal influenza), or reassurance when an impact has not occurred. Using information collected during routine patient care, syndromic surveillance can be based on signs/symptoms/preliminary diagnoses. This approach makes syndromic surveillance much timelier than surveillance requiring laboratory confirmed diagnoses.The provision of healthcare services and patient access to them varies globally. However, emergency departments (EDs) exist worldwide, providing unscheduled urgent care to people in acute need. This provision of care makes ED syndromic surveillance (EDSyS) a potentially valuable tool for public health surveillance internationally.The objective of this study was to identify and describe the key characteristics of EDSyS systems that have been established and used globally.MethodsWe systematically reviewed studies published in peer review journals and presented at International Society of Infectious Disease Surveillance conferences (up to and including 2017) to identify EDSyS systems which have been created and used for public health purposes. Search criteria developed to identify “emergency department” and “syndromic surveillance” were applied toNICE healthcare, Global HealthandScopusdatabases.ResultsIn total, 559 studies were identified as eligible for inclusion in the review, comprising 136 journal articles and 423 conference abstracts/papers. From these studies we identified 115 EDSyS systems in 15 different countries/territories across North America, Europe, Asia and Australasia. Systems ranged from local surveillance based on a single ED, to comprehensive national systems. National EDSyS systems were identified in 8 countries/territories: 2 reported inclusion of ≥85% of ED visits nationally (France and Taiwan).ConclusionsEDSyS provides a valuable tool for the identification and monitoring of trends in severe illness. Technological advances, particularly in the emergency care patient record, have enabled the evolution of EDSyS over time. EDSyS reporting has become closer to ‘real-time’, with automated, secure electronic extraction and analysis possible on a daily, or more frequent basis.The dissemination of methods employed and evidence of successful application to public health practice should be encouraged to support learning from best practice, enabling future improvement, harmonisation and collaboration between systems in future.Prospero numberCRD42017069150.

Objective We compared pain and degree of disability in patients with acute ankle sprains receiving regular scheduled ibuprofen versus pro re nata (PRN). Methods This study is a randomized single-blinded controlled trial of children aged 7 to 17 years presenting with acute ankle sprain to an emergency department. Patients were randomized to receive 10 mg/kg of ibuprofen per dose (maximum 600 mg) every 6 hours regular scheduled versus PRN. Outcome measures included a 100-mm visual analog scale pain and degree of disability at day 4. A sample size of 72 children had a power of 80% to detect a clinically meaningful difference of 20 mm between the regular and PRN group. Results We randomly assigned 99 patients to receive regular scheduled (n = 50) or PRN (n = 49) ibuprofen. Pain scores and degree of disability at day 4 showed no significant differences between groups. The rate of reported adverse effects was higher in the regular scheduled group (11.4% vs 9.5%) versus the PRN group. Conclusions Our study suggests that there is little benefit from routinely using a regular scheduled ibuprofen regimen for acute pediatric ankle sprains.

Accident and emergency departments (A&E) are the first place of contact for urgent and complex patients. These departments are subject to uncertainties due to the unplanned patient arrivals. After arrival to an A&E, patients are categorized by a triage nurse based on the urgency. The performance of an A&E is measured based on the number of patients waiting for more than a certain time to be treated. Due to the uncertainties affecting the patient flow, finding the optimum staff capacities while ensuring the performance targets is a complex problem. This paper proposes a robust-optimization based approximation for the patient waiting times in an A&E. We also develop a simulation optimization heuristic to solve this capacity planning problem. The performance of the approximation approach is then compared with that of the simulation optimization heuristic. Finally, the impact of model parameters on the performances of two approaches is investigated. The experiments show that the proposed approximation results in good enough solutions.

BackgroundThere is no published algorithm predicting asthma crisis events (accident and emergency [A&E] attendance, hospitalisation, or death) using routinely available electronic health record (EHR) data.AimTo develop an algorithm to identify individuals at high risk of an asthma crisis event.Design and settingDatabase analysis from primary care EHRs of people with asthma across England and Scotland.MethodMultivariable logistic regression was applied to a dataset of 61 861 people with asthma from England and Scotland using the Clinical Practice Research Datalink. External validation was performed using the Secure Anonymised Information Linkage Databank of 174 240 patients from Wales. Outcomes were ≥1 hospitalisation (development dataset) and asthma-related hospitalisation, A&E attendance, or death (validation dataset) within a 12-month period.ResultsRisk factors for asthma-related crisis events included previous hospitalisation, older age, underweight, smoking, and blood eosinophilia. The prediction algorithm had acceptable predictive ability with a receiver operating characteristic of 0.71 (95% confidence interval [CI] = 0.70 to 0.72) in the validation dataset. Using a cut-point based on the 7% of the population at greatest risk results in a positive predictive value of 5.7% (95% CI = 5.3% to 6.1%) and a negative predictive value of 98.9% (95% CI = 98.9% to 99.0%), with sensitivity of 28.5% (95% CI = 26.7% to 30.3%) and specificity of 93.3% (95% CI = 93.2% to 93.4%); those individuals had an event risk of 6.0% compared with 1.1% for the remaining population. In total, 18 people would need to be followed to identify one admission.ConclusionThis externally validated algorithm has acceptable predictive ability for identifying patients at high risk of asthma-related crisis events and excluding those not at high risk.

Background Given a persistent nursing shortage in Canada and a decline in new nurses entering the profession, new graduate nurses (NGNs) are being hired into positions historically reserved for more experienced staff. Critical care settings, which are areas of specialty nursing practice, are now routinely hiring NGNs in many hospitals. While evidence on NGN transition into critical care is emerging, best practices around training and support for these nurses are limited internationally, and non-existent within the Canadian context. Therefore, the aim of this systematic review is to identify, describe, and assess the effectiveness of interventions that support NGN transition into critical care clinical practice settings. Methods This is a systematic review of interventions using the Joanna Briggs Institute Methodology. Data sources will include MEDLINE, CINAHL, PsychINFO, Education Source, and Nursing and Allied Health electronic databases. Two independent reviewers will screen titles and abstracts using predetermined inclusion criteria. A consensus meeting will be held with a third reviewer to resolve conflicts when necessary. Full texts will also be screened by two independent reviewers and with conflicts resolved by consensus. Data will be extracted using a standardized extraction form. We will assess the quality of all included studies using Joanna Briggs Institute quality assessment tools. Data describing interventions will be reported narratively and a meta-analysis will be conducted to determine effectiveness, if appropriate. Discussion This systematic review will identify interventions that support NGN transition into critical care nursing practice. The findings of this study will provide a foundation for developing strategies to support NGN transition into these areas of specialty nursing practice. Systematic review registration PROSPERO CRD42020147962.

Aims With vague presenting features, malaria can be difficult for clinicians to diagnose. The current guideline recommends 3-day screening to rule out malaria. We aimed to audit the presentation and investigation of children with suspected malaria in Accident and Emergency between February 2014 – January 2019, with comparison of the accuracy of one versus three screens. Methods Retrospective data was collected from the electronic patient record of all children investigated for malaria between 2014–2019. Data collected included demographics, travel destination, laboratory results and number/results of malaria screens. The reference standard to diagnose malaria was Malaria Reference Laboratory confirmation. Malaria risk was determined using www.fitfortravel.nhs.uk. Fisher’s exact test was used for association between categorical variables, with P Results 205 children were investigated for malaria from 2014–2019, with 63% travelling to a high-risk destination. Only 14% had three consecutive screens; 64% had one, 16% had two and 6% had >3 non-consecutive screens. 19 children had malaria (90% falciparum), and 95% had travelled to Africa. Travellers to a high-risk destination were much more likely to contract malaria (odds ratio 9.90, P All initial screens included a rapid diagnostic test (RDT) and blood smear, with every case detected on day one. P. falciparum RDT had the best accuracy, with 100% sensitivity and negative predictive value (NPV) (P Conclusion Malaria should always be considered in any febrile child that has traveled to a malaria-endemic region. We have modified our guidelines to recommended that a single screen is sufficient to exclude malaria in low-risk travellers where malaria is not strongly suspected. In those that have travelled to a high-risk destination or in whom malaria is strongly suspected, three consecutive screens should remain gold-standard.

The way in which gynaecology services are provided in the UK has drastically changed within a short space of time due to the global COVID-19 pandemic. Gynaecologists are not considered front-line staff in the treatment of the novel coronavirus unlike our intensive care or accident and emergency colleagues. However, the impact this is having on those with chronic problems is significant, and the morbidity associated with missed malignancies could be problematic. This article summarises the strategies developed at King’s College Hospital to remodel services to best provide optimum treatment to patients in this new era.

Funding has been made available to upgrade 25 hospital accident and emergency departments in England ahead of winter, the government has announced. Bedfordshire, York, Liverpool, and Bristol are among the trusts that will receive a share of the £150m capital injection to expand their A&E departments to make more physical space to treat patients and manage patient flow while improving infection control. England’s health and social care secretary, Matt Hancock, also announced details of a pilot scheme for NHS 111 to be the “first point of contact” for patients seeking urgent care. Under the plans, which are intended to roll out nationally from December, patients will call the helpline before being booked into A&E or urgent treatment centres, or to see …

Introduction:\ud \ud Emergency departments have seen altered patterns of attendance since the beginning of the COVID-19 pandemic, with reductions in the number of attendances for non-COVID-19 – patients. We assessed the use of the emergency department by frequent attenders during the height of the COVID-19 pandemic and explored any changes in emergency department attendance by this group.\ud \ud Methods:\ud \ud As part of ongoing improvement work, we utilised a cohort design to evaluate the difference in patterns of attendance for the frequent attender group in a single centre. We created a 2019 ‘top attender’ cohort and a similar cohort for 2020. We compared admission patterns between the two time periods in order to understand the impact of the COVID-19 pandemic on this group.\ud \ud Results:\ud \ud Both groups were predominately male. Mental health and substance misuse use problems were common across both cohorts. The majority of patients lived in a socio-economically deprived areas. The median number emergency department visits in 2019, for the top attender cohort was 6 (IQR: 4-9) vs 4 (IQR: 2-7) for the top attender cohort of 2020 (p

Background Delays to diagnosis of anterior cruciate ligament (ACL) injury and specialist consultation continue to place patients at risk of early onset osteoarthritis. Incorporating acute knee clinics within a streamlined accident and emergency (A&E) pathway have shown potential in reducing delay but specific evaluative research is lacking. The aim of this service evaluation was to investigate the effectiveness of an acute knee clinic at one NHS Trust in the United Kingdom (UK), on reducing the delay to diagnosis of ACL injury and specialist consultation compared to a standard A&E pathway. Methods An uncontrolled before and after design was utilised for this service evaluation. Data were collected from historical electronic patient records over a 1-year period with analysed results compared against previously collected data from the same NHS Trust. Results 81 records met the criteria for the streamlined A&E pathway and were compared against 50 from the standard A&E pathway. For the streamlined A&E pathway median delay to diagnosis reduced from 97 to 14 days and delay to specialist consultation reduced from 158.5 to 45 days and were of statistical significance. The incorporation of an acute knee clinic was identified as the most influential factor on delay in addition to the location of presentation and mechanism of injury. Conclusions Introducing an acute knee clinic within a streamlined A&E pathway has a clinically relevant effect on reducing delay to diagnosis and specialist consultation and allows findings to be extrapolated and implemented to all UK based NHS Trust A&E departments.

Psychoactive substance use is frequently encountered in hospitals' emergency departments (EDs). It accounts for major health-care problems frequently leading to accident and ED admissions, yet it is frequently unidentified. The aim of this study was to determine the prevalence and pattern of psychoactive substance use among patients presenting in the Accident and EDs and to compare the case detection rate of psychoactive substance use between self-report questionnaire and biochemical markers (e.g., urine toxicology).To achieve this, 200 consenting participants attending the accident and emergency unit of a tertiary hospital were consecutively enlisted into the study within 2 weeks. They were screened for psychoactive substance use with the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and the urine drug test (UDT).The lifetime prevalence of psychoactive substance use was 45.5%, while the past 3 months (recent use) prevalence was 27.0%. The pattern of psychoactive substance use revealed that alcohol was the predominant psychoactive substance use with a lifetime prevalence of 13.0% and recent use of 12.0%. The UDT significantly detected more patients who used psychoactive substance compared to self-report (P0.001).The prevalence of drug use recorded among attendees of the accident and emergency unit was high in this study. The UDT significantly detected more patients who used psychoactive substances compared to self-report (P0.001). Several patients with major health problems as a result of psychoactive substance use were identified with the aid of these screening tools.

An accident and emergency doctor who used hospital records to look up the phone numbers of two patients, and had sexual relations with both, has been struck off the UK medical register. Christopher Uzodike, who worked at the Norfolk and Norwich University Hospital, contacted the two female patients after they visited the emergency department in 2016. After drinks, he had a one night stand with one of them, referred to as Patient B. He texted her soon after her hospital visit, telling her he could not let her “curves walk past.” With the other woman, known as Patient A, the married doctor had an emotional and sexual relationship that lasted for nearly two years, ending in April 2018. He knew she had just come …

Paediatric endogenous endophthalmitis is an uncommon but potentially devastating intraocular infection which should not be missed. Often cases present to the accident and emergency department. Accurate and prompt assessment is key in saving sight and life. We present one such case and how it was surgically managed.

Background: Constipation is a common condition that impacts quality of life, often causing psychological distress and incurring considerable healthcare costs in terms of unnecessary emergency admissions due to poor management. Aintree University Hospital has a healthy bowel clinic for treating patients presenting with functional bowel disorders, including constipation, in an outpatient setting. From December 2013 to November 2014, 301 patients were admitted to hospital with a primary diagnosis of constipation, 216 of these through the accident and emergency department, with an average length of stay of 3.3 days. Methods: To prevent unnecessary admission, a successful bid provided £16 000 to fund a 12-month pilot study to develop a new emergency constipation pathway, including an emergency constipation clinic and linked to the main healthy bowel clinic. Results: Over the pilot study period, more than 70 patients were seen through the new pathway, which saved 231 bed days. At an average cost per bed day of £400, this equates to a total annual saving of £92 400. Conclusion: A new emergency pathway linked to an already established outpatient clinic prevented admission of patients presenting with primary constipation.