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David J Wright,1 Richard J Adams,1 Jeanette Blacklock,1 Sarah A Corlett,2 Rebecca Harmston,3 Margaret McWilliams,3 Stephen-Andrew Whyte,4 Gail Fleming4 1School of Pharmacy, University of East Anglia, Norwich, UK; 2Medway School of Pharmacy, Universities of Greenwich and Kent at Medway, Chatham, UK; 3Patient and public involvement member of the research team, University of East Anglia, Norwich, UK; 4Health Education England, London, UK Purpose: To describe the most effective model for managing, educating, and training pharmacist advanced clinical practitioners (ACPs) in the urgent care center (UCC) setting, role evolution and how to measure their effectiveness. Participants and methods: Ethical approval was obtained to perform a qualitative longitudinal cohort study in three sites, with three pharmacists in each trained as ACPs from 2016 to 2017. ACP role, location, management, mentorship, and supervision were locally determined. ACPs attended focus groups (FGs) at 1 and 3 months (sites 1–3), 6 and 12 months (site 1 only), and the UCC staff were interviewed once with a topic guide regarding training, integration, role, and impact. Verbatim transcriptions were analyzed thematically. Results: Eight ACP FGs and 24 stakeholder interviews produced major themes of communication, management, education and training, role, and outcomes. Effective education, training, and integration required communication of role to address concerns regarding salary differentials, supportive management structure, and multi-professional learning. ACPs reported that the model of workplace training, experiential learning, and university-based education was appropriate. Training was better located in the minor injuries and general practitioner areas. Recommended measures of effectiveness included patient satisfaction and workload transfer. Conclusion: The education and training model was appropriate. Communication and management require careful consideration to ensure effective integration and role development. Pharmacists were better located initially in the minor illness rather than major trauma areas. Quality of patient experience resulting from the new role was important in addition to reassurance that the role represented a positive contribution to workload. Keywords: advanced clinical practitioner, accident and emergency, education, training, focus groups, interviews

Ataxia is a common presentation to an acute paediatric unit and it can often be difficult to determine the cause. It is important to distinguish between serious causes, for example, brain tumours and encephalitis, and more benign causes in order to guide investigations and treatment. In this review, we describe the different types of ataxia, the causes associated with them, the examination findings and what investigations to perform in order to make a diagnosis.

John Tingle, Associate Professor (Teaching and Scholarship), Nottingham Trent University, discusses a recent publication by the CQC and some court cases on hospital A&E services

Lighting is one of the environment factors that are important. Good and adequate lighting ensure proper task can be done successfully. Properly designed lighting will allow workers to work better with less risk of occupational hazard. The important of natural lighting is undeniable. However, there are certain buildings that have to depend on artificial lights only. The purpose of this study is to evaluate the lighting at resuscitation area of Accident and Emergency Department. Resuscitation area is one of area at the Red Zone where all the patient resuscitation will take place. This study had been carried out at Resuscitation Area, Accident and Emergency Department of Hospital Universiti Sains Malaysia (HUSM), Kubang Kerian, Kelantan, Malaysia. The existing lightings were evaluated using a lux meter (light meter). The evaluation was a procedure-based approached and carried out on the beds at where procedures were done. Since procedures were done on bed, the bed area was divided into six (6) equal squares. The light sensor was placed at the center of each squares and reading were recorded. Measurement from floor to the bed surface was also measured. Data from the lux meter will be compared with the existing guideline. The findings revealed that lighting in this zone were not designed based on tasks requirements, thus justified the additional lights added later.

Every ward at any departments in hospital will have a nurse counter. Nurse counter or nurse station is a determined place for nurses to do their deskwork. Urgent phone calls and note writing, are among common activities done at the station. Sometimes, discussions and short meeting are also done at the nurse station. Despite the name, this workstation is also used by medical officers, even specialist when they need to sit and write. A usual set of computer and printers, as well as stationeries and telephone are placed at this station. Chairs are also provided. Files and forms are also available at the station. Some stations have both sitting and standing counters for nurses or medical officers to do their works. This objective of this study is to evaluate the current condition of nurse station at Red Zone of Accident and Emergency Department, Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia. Measurement of the nurse station was taken during the evaluation. The body postures of personnel at the counter were observed. The lighting at the station was also recorded. This study is needed because nurse station is an important part at Accident and Emergency Department. The evaluation result shows, this area was not given a fair attention despite its important. This study justified how the current condition of nurse station has been overlooked and immediate attention should be given in order to ensure better working condition at the station.

Recent years have seen substantial reductions in public spending on social care for older people in England. This has not only led to large falls in the number of people over the age of 65 receiving publicly funded social care, but also to growing concern about the potential knock-on effects on other public services, and in particular the National Health Service (NHS). In this paper, we exploit regional variation in the reductions in public funding for social care to examine the impact on Accident and Emergency (A&E) departments in NHS hospitals. We find that reductions in social care spending on people aged 65 and above have led to increased use of A&E services, both in terms of the average number of visits per resident and the number of unique patients visiting A&E each year. We estimate that the average cut to social care spending for the older population over the period (£375) led to an increase of 0.09 visits per resident, compared to a mean of 0.37 visits in 2009. The effects are most pronounced among people aged 85 and above. This has also led to a modest increase in the cost of providing A&E care, increasing A&E costs by an additional £3 per resident for each £100 cut in social care funding.

Proper pain management is an essential process when dealing with a patient suffering from blunt thoracic trauma, because it blocks the vicious circle that leads to the development of trauma related complications. This retrospective study deals with the use of pain killers administered in the Accidents and Emergency Department (ED) and prescribed at discharge to patients suffering from blunt thoracic trauma. The analysis confirms the existence of oligoanalgesia, that is an inadequate pain treatment, in clinical practice. Out of 214 patients involved in the study, only 78 patients (36.4%) received at least one pain killing drug during their stay in the ED. More than half of the patients discharged within 24 hours of admittance to the ED received no detailed advice about pain relief therapy and 8% of them (11 out of 136) returned to the ED within 15 days for persisting symptoms. Four were eventually admitted to hospital due to deterioration in their clinical conditions.

In the past 10 years spirituality and spiritual care have been much debated in professional healthcare literature, highlighting the need for a recognised definition of spiritual care to enable appropriate assessment of, and response to, spiritual issues. This accessible and highly relevant book surveys the numerous statements, guidelines and standards highlighted by these discussions, and equips healthcare professionals with the knowledge, skills and competence to provide the essence of spiritual care within their professional practice. Practical and evidence-based, this manual proves that delivery of good, professional spiritual care can build on intuitive human skills, and can be taught, learned, assessed and quantified. It gives readers the opportunity to move on from uncertainties about their role in the delivery of spiritual care by allowing them to asses and improve their understanding, skills and clinical practice in this area of care. Spiritual Care for Healthcare Professionals clearly grounds spiritual care in clinical practice. It is highly recommended for supporting academic study and encouraging healthcare practitioners to reflect on their practice and develop skills in spiritual assessment and care. Aimed at all healthcare professionals, it can be used by individual practitioners for continuing professional development as well as by academic staff developing educational programmes.

This chapter discusses the issue of adolescent suicide and attempted suicide from the point of view of what is going on in the minds of young people who deliberately harm themselves. Many professionals who assess suicides in accident and emergency departments have observed institutional defences against the proper management of attempted suicides as though reflecting a modern day equivalent of historical attitudes and some departments can be very harsh to those who harm themselves. The attempted suicide can be treated with contempt and sometimes outright cruelty which goes far beyond the understandable irritation of busy staff dealing with someone who is responsible for their own condition. Suicide – the enactment of violence – was felt as an escape from an intolerable situation and the ultimate act of hatred against the object and the punishment for doing so at the same time.

Objective: The Emergency Department is a complex environment in which healthcare providers are confronted with uncontrolled and unpredictable critical patient workload. This necessitates multitasking, organization, critical thinking and clear communication. Safe practices during dispensing and administration of medications vastly reduces the potential for patient harm and decreases medication errors (Institute for Healthcare Improvement, 2008). Design/Methods: An eight-question survey was developed to determine nurses’ perceptions of the current medication storage system. Participants were asked to identify ways in which this system could be improved and medications organized in a safer, more systematic way. Following initial data collection, all medications were rearranged to improve medication organization and retrieval. The participants were then surveyed following the intervention to ascertain feedback. Results: 68% of participants noted that they perceived the current system to be chaotic. When asked if organizational changes might improve patient care delivery and safety, 96% responded in the affirmative. Labeling medication with both generic/ brand names and organizing them by class and alphabetically thereafter were all identified as potential options for reorganization. Following the intervention, a post-survey demonstrated that 100% of respondents remained enthusiastic about the new system approximately 9 months after implementation. Conclusions: The previous medication storage system was fractured and chaotic. Systematic organization of medications by name/class improved nurses’ perceptions of medication safety and delivery while inadvertently reducing the waste of expired medications. Greater measures are needed to truly minimize the risk for a medication administration errors including targeted continuing education and implementation of an electronic medication administration system.

Objective: Hand washing compliance amongst emergency healthcare providers is complicated by limited supplies, patient volume, mal-positioning of hygiene materials, and lack of education on the importance of hand hygiene. Design and Methods: A survey was distributed to A&E healthcare staff to determine baseline knowledge about the importance of hand hygiene. Participants were asked to identify departmental obstacles to the practice of proper hand hygiene. Using World Health Organization teaching materials, a hand hygiene clinical observation tool was implemented to determine compliance prior to delivery of tailored education. Education was done utilizing posters, flyers, and powerpoint presentation. Hand sanitizer stations were installed to improve compliance. Finally, the clinical observation tool was implemented following the education initiative to determine impact on provider compliance. A post-implementation survey was distributed to determine if increased education and supplies impacted baseline knowledge and compliance. Results: Only 88% of surveyed providers recognized that the A&E has a current hand hygiene policy with 64% noting GPHC does not stress hand hygiene enough. Providers reported they utilize hand hygiene 75% yet all participants acknowledged that proper hand washing greatly reduces the spread of infection. 53% of providers surveyed felt comfortable encouraging their peers to wash their hands. Conclusions: Initial provider hand hygiene within the A&E was abysmal. Though identified as a predominant barrier, supplies were readily available throughout the observation window. Educational materials placed throughout the department improved both the perception and compliance of hand hygiene. The importance of provider hand hygiene must be continually stressed in order to maintain optimal compliance.

Despite the frequent use of endotracheal tubes in daily practice of emergency medicine, not much emphasis has been put on the measurement of cuff pressure. We attempted to conduct a case series study of prospectively recruited patients to illustrate the risk of inappropriate cuff inflation without manometry. It was found that the pilot balloon palpation was an inaccurate method to estimate cuff under- or over-inflation, with large discrepancies when compared with an objective measure. Such discrepancies might be independent of doctors' and nurses' working experience in airway management. Use of an aneroid manometer remains an economical and cost-effective way to obtain an instantaneous yet reasonably reliable result and should become a routine in emergency departments.

Background: Rapid diagnostic test (RDT) is a simpler, easy to read malaria diagnostic test. It was introduced by the World Health Organization (WHO) to supplement the use of microscopy and can be used alone in areas where microscopy is unavailable. Its introduction was necessary to maintain the WHO test-based treatment protocol for malaria, as dependence of microscopy which is the gold standard is not possible in many areas in Sub-Saharan Africa which lack the wherewithal to run efficient laboratory services. WHO strongly recommends that only patients with parasitological confirmation of malaria should be treated with antimalarial drugs. In this study, the prevalence of malaria positive RDT and antimalarial treatment was evaluated in patients presenting with fevers at the outpatient section of the accident and emergency unit of the Effia Nkwanta Regional Hospital, Ghana. Methodology: This was a retrospective study carried out in the outpatient section of the accident emergency unit of Effia Nkwanta Regional Hospital. The outpatient register was reviewed from October 2014 to March 2015, for patients who came with fever. Data on demographics, malaria RDT status and antimalarial treatment were collected and analyzed. Result: A total of 607 patients with fever had their RDT performed. Of these, 131 (21.58%) were positive for malaria while 467 (78.42%) were negative. Out of the 131 tested positive, 55 represented patients above 12 years and 76 represent children aged 0 to12 years, p = 0.002. Fifty children under the age of 5 years tested positive for malaria whereas 26 were above the age 5 years, p = 0.03. All the 131 positive patients were treated for malaria while 276 out of 476 negative patients were also treated for malaria, p

Introduction Significant deaths of between 21% and 38% occur from non-trauma surgical conditions in the accident and emergency room. Access to emergency surgical care is limited in many developing countries including Nigeria. We aimed to study the spectrum of non-trauma surgical emergencies, identify challenges in management and evaluate outcomes. Methods A one year prospective cohort study of all non-trauma emergencies in adults seen at the surgical emergency room of LASUTH from 1st October, 2011 to 30th September, 2012 was conducted. Data was analyzed using SPSS version 15.0. Results Of a total of 7536 patients seen, there were 7122 adults. Those with non-trauma conditions were 2065 representing 29% of adult emergencies. Age ranged between 15 and 97 years and male to female ratio was 1.7:1. Acute abdomen (30%), urological problems (18%) and malignancies (10%) were the most common. Among 985 patients requiring admission only 464 (47%) were admitted while the remaining 53% were referred to other centers. Emergency surgical intervention was carried out in 222 patients representing 48% of admitted patients. There were 12 (24%) non-trauma deaths in the emergency room. They were due to acute abdomen and malignancies in half of the cases. Conclusion Facilities for patients needing emergency care were inadequate with more than half of those requiring admission referred. Attention should be paid to the provision of emergency surgical services to the teeming number of patients seen on yearly basis in the Teaching Hospital., Highlights • Non-trauma conditions constitute a third of surgical emergencies and a quarter of deaths in the emergency room. • Acute abdomen, urological conditions and malignancies are the leading causes of non-trauma emergencies. • Available facilities could provide care for only half of the non-trauma patients requiring emergency room admission.

Background Little is known about the use of sedation drugs for the management of acute agitation in Hong Kong's Accident and Emergency Departments (AEDs) and how it compares with Australasian practice. Objective The aim of this study was to determine drug preferences, clinicians' perceived confidence in management, barriers/gaps in training and perceived usefulness of existing clinical practice guidelines (CPGs) in Hong Kong. Method A validated questionnaire was used, with case vignettes typical of patients presenting to AEDs with acute agitation. The questionnaire was distributed by hand to all trainees and fellows of the Hong Kong College of Emergency Medicine (HKCEM). Two reminders were sent. Results Of 483 HKCEM members, 280 (58.0% [95% CI 53.5–62.3]) responded. For monotherapy, 46.8% (95% CI 41.0–52.6) of respondents chose haloperidol to manage the undifferentiated patient, followed by midazolam (33.9%, 95% CI 28.6–39.7) and diazepam (13.9%, 95% CI 10.4–18.5). Most respondents (83.6%, 95% CI 78.8–87.5) would not administer combination therapy. Respondents were confident in managing agitation overall. The lack of local/institutional CPGs (55.7%, 95% CI 49.9–61.4) was perceived as an important barrier. Institutional guidelines were considered the most useful CPGs (66.4%, 95% CI 60.7–71.7). Most respondents (72.9%, 95% CI 67.4–77.7) perceived a HKCEM endorsed CPG would be useful. Conclusion Haloperidol and benzodiazepines are frequently used as monotherapy for the management of acute agitation in Hong Kong's AEDs. Management in Hong Kong differs from Australasian practice in that combination therapy is less common and clinicians' choice of sedation drugs are less variable overall. Results suggest that future work on CPG development and training regarding the safe use of combination therapy would be well received.

Objective: The objective of the study is to study the procedure of endotrachealintubation; its methods between Rapid sequence intubation and crash intubation its successrates and the associated short term complications at the accident and emergency departmentof a government run hospital in Karachi, Pakistan. Study Design: Case series. Setting: Accidentand Emergency Department of Civil Hospital Karachi. Period: 2010 to 2012. Methods: Thesample size taken is of 260 patients, all of whom must be above the age of 14 years, andundergo the procedure of emergency endotracheal intubation. Rapid sequence intubation isanalyzed against crash intubation using descriptive type of statistical analysis. The significancelevel was p

Background: Although the primary mission of the Accident and Emergency Department (AED) is to provide initial treatment for life-threatening conditions, some patients make inappropriate use of the service. This study is aimed to determine the level of inappropriate use and the morbidity pattern of such patients presenting to the department in a tertiary hospital in Nigeria.Materials and methods: A cross-sectional descriptive study in which inappropriate users of the AED of University of Port Harcourt Teaching Hospital were recruited. Data on socio-demographic characteristics and diagnoses based on ICPC-2 were collected from them and analysed using SPSS version 17.Results: A total of 430 patients were recruited with age range of 18–62 years and mean of 38.45 ± 7.2 years. Considering the socio-demographic characteristics, only the association between gender and utilisation of the AED was statistically significant (p = 0.014). The prevalence of inappropriate use of the AED was 37.7%. The most frequent diagnosis among inappropriate users using the ICPC rubrics was polyuria and glycosuria (9.88%). When the cases were listed by the organ systems according to ICPC chapters, it was found that the commonest diagnoses were gastrointestinal (20.9%) and general and unspecified conditions (17.7%). Psychological conditions were not identified in this study. The most common reason for inappropriately presentation at the AED was patients referring themselves for quick attention (46.3%).Conclusions: The level of inappropriate utilisation of the accident and emergency department was very high in this institution. Creation of public awareness will curtail this sickness behaviour.

Unexpected increases in deaths, emergency admissions, accident and emergency (A&E) attendances, GP referral and NHS staff sickness absence appear to have occurred in 2014. These increases endure for around 12 months before abating. This is a repeat of the situation documented in 2008, 2010 and 2012; although the 2010 event was more sporadic. Unprecedented A&E pressures experienced during 2014 and into 2015 appear to have been exacerbated by the 2014 event. The usual factors which have been offered as ‘explanations’ for the increase in NHS demand may be merely contributory—but not causative of—the large surges in demand which occur during these events. Spatial spread of both deaths and sickness absence can be demonstrated. The ratio of follow-up to first attendances following GP referral for an outpatient attendance, show marked step-like changes during these events apparently due to the subtle changes in the case-mix and severity of the referred patients.

Background To estimate the diagnostic accuracy (sensitivity and specificity) of the AdenoPlus point-of-care adenoviral test compared to PCR in an ophthalmic accident and emergency service. These findings were compared with those of a previous study. Methods This was a prospective diagnostic accuracy study on 121 patients presenting to an emergency eye unit with a clinical picture of acute adenoviral conjunctivitis. AdenoPlus testing was carried out on one eye of each patient and a PCR analysis was also performed on a swab taken from the same eye. AdenoPlus and PCR results were interpreted by masked personnel. Sensitivity and specificity for the AdenoPlus test were calculated using PCR results as the reference standard. Results 121 patients were enrolled and 109 met the inclusion criteria. 43 patients (39.4%) tested positive for adenovirus by PCR analysis. The sensitivity of the AdenoPlus swab in detecting adenovirus was 39.5% (17/43, 95% CI 26% to 54%) and specificity was 95.5% (63/66, 95% CI 87% to 98%) compared to PCR. Conclusions The AdenoPlus test has a high specificity for diagnosing adenoviral conjunctivitis, but in this clinical setting, we could not reproduce the high sensitivity that has been previously published.

Introduction This paper reports on research conducted within a Hong Kong (HK) accident and emergency department (AED), which investigated the effectiveness of health care worker-patient communication over the course of patients' journeys from triage to disposition. Methods The research combined qualitative and quantitative ethnographic methods with linguistically-oriented discourse analysis of audiotaped interactions between patients and health care workers. It involved: (1) observations, (2) semi-structured interviews with management and health care workers, (3) surveys with AED staff, (4) audio-recordings of 10 patients' journeys, and (5) follow-up interviews with patients. Results The paper described the typically complex communication networks involved in AED care. It then exemplified how certain communicative strategies, balancing the communication of medical knowledge with interpersonal communication, could be used to achieve positive healthcare outcomes. This was illustrated by a case study of one patient's journey through the AED, pinpointing health care workers' effective use of communication strategies, their effect on the patient's participation and subsequently the patient's understanding and evaluation of the care he received. Conclusion The high stress nature of AEDs inevitably poses challenges to communication. The results of this study, however, strongly suggest a correlation between health care workers' use of effective, interpersonally sensitive communication strategies and positive patient outcomes. Health care worker-patient communication that effectively balances interpersonal communication with the communication of medical expertise is integral to ensuring patients' participation in, understanding of, and satisfaction with their healthcare. These communication strategies should be required components in health care worker communication training. (Hong Kong j.emerg.med. 2015;22:69-83)

Objective: The primary objective of this study was to determine the sociodemographic and clinical characteristics of all persons who presented to the Accident and Emergency Department of the University Hospital of the West Indies with a history of deliberate harm over a six-month period. Methods: The dockets of patients presenting with deliberate self-harm were collected and reviewed for the information. A questionnaire was designed to extract the information. Data were analysed using SPSS version 17 and RXC programme. Results: Of the total number of dockets reviewed (n = 61), 78% of patients were below age 40 years, with a mean age of 28 years. Sixty-four per cent were female, 82% were single, 83% lived with someone, 80% had a secondary school level of education and 72% were unemployed. Overdose of medications was the main method of harm. Seventy-five per cent of patients did not use illicit substances. There was a significant association found between reason for self-harm and psychiatric illness (p < 0.001). Conclusion: Given these preliminary results, it would be useful to conduct a wider, island-wide study to determine the extent of self-harming behaviour in Jamaica so that appropriate interventions can be implemented to reduce this problem.

School nurses can manage most minor cuts, scrapes and puncture wounds. However, the amount of bleeding is a poor guide to severity. Because an everyday injury occasionally hides serious damage, such as internal bleeding, nurses should take even seemingly minor cuts and scrapes seriously. In addition to acute wound care, knowing when to refer to accident and emergency services and GP practices, as well as advising parents and older children are essential elements of management.

Background and objectives: The aim of this study was to define the following in patients with acute heart failure (AHF) discharged directly from accident and emergency (A&E): rates of reconsultation to A&E and hospitalisation for AHF, and all-cause death at 30 days, rate of combined event at 7 days and the factors associated with these rates. Patients and method: The study included patients consecutively diagnosed with AHF during 2 months in 27 Spanish A&E departments who were discharged from A&E without hospitalisation. We collected 43 independent variables, monitored patients for 30 days and evaluated predictive factors for adverse events using Cox regression analysis. Results: We evaluated 785 patients (78 +/- 9) years, 54.7% women). The rates of reconsultation, hospitalisation, and death at 30 days and the combined event at 7 days were: 26.1, 15.7, 1.7 and 10.6%, respectively. The independent factors associated with reconsultation were no endovenous diuretics administered in A&E (HR 2.86; 95% CI 2.01-4.04), glomerular filtration rate (GFR) < 60 ml/min/m(2) (1.94; 1.37-2.76) and previous AHF episodes (1.48; 1.02-2.13); for hospitalisation these factors were no endovenous diuretics in A&E (2.97; 1.96-4.48), having heart valve disease (1.61; 1.04-2.48), blood oxygen saturation at arrival to A&E < 95% (1.60; 1.06-2.42); and for the combined event no endovenous diuretics in A&E (3.65; 2.19-6.10), GFR < 60 ml/min/m(2) (2.22; 1.31-3.25), previous AHF episodes (1.95; 1.04-3.25), and use of endovenous nitrates (0.13; 0.02-0.99). Conclusion: This is the first study in Spain to describe the rates of adverse events in patients with AHF discharged directly from A&E and define the associated factors. These data should help establish the most adequate approaches to managing these patients. (C) 2017 Elsevier Espana, S.L.U. All rights reserved.

Background Following the bomb attack on the government quarter on 22 July 2011, many of the injured were treated at the accident and emergency department in Oslo. Material and method The patients (n=79) were sent a questionnaire ten months after their treatment and again after three years. A total of 42 patients responded on one or both occasions. Post-traumatic stress reactions were measured using PTSD-RI (University of California at Los Angeles PTSD Reaction Index). Symptoms of anxiety and depression were measured with the aid of HSCL-8 (Hopkins Symptom Checklist). Physical symptoms were surveyed using twelve questions. Satisfaction with follow-up was measured with eight questions on a five-point scale. Results After ten months, the average score for PTSD-RI was 1.4 (95 % CI 1.0-1.7), and 31 % of the responses were at a clinical PTSD level. After three years, the average score was 1.3 (95 % CI 0.9-1.7), and 25 % were at a clinical PTSD level. Symptom score for anxiety and depression after ten months was 0.9 (95 % CI 0.6-1.2) and after three years 0.8 (95 % CI 0.5-1.2). The most frequent physical symptom was headache. The satisfaction with follow-up varied somewhat but was generally good. Interpretation Several patients who received treatment for injuries at the accident and emergency department in Oslo had mental symptoms for a long period following the terror attack. The patients were satisfied with the follow-up, which was mainly provided by the primary healthcare service.

Objectives. To review the modified Canadian Triage and Acuity Scale used in an accident and emergency department in Trinidad and Tobago. Design and Methods. A cross-sectional study was carried out. Times from assignment of triage category to being seen by a physician were collected from the patient notes on the days of presentation and compared to the reference standards. Times from decision to admit to obtaining a bed were also recorded. Results. 200 patients were included in the study. The median waiting time for patients in the immediate/blue category was 3 minutes (range = 3); for the red category, it was 31.2 minutes (range = 121.8); in the yellow category, it was 61.8 minutes (range = 805.2). The overall admission rate was 30.5%, with an admission rate of 25% for the blue category; 20% of patients in the red category waited more than 4 hours for a hospital bed. Conclusion. The patients assigned to the blue category were being seen almost immediately. Less critical persons wait longer than the reference times and this may be due to structural factors such as staffing. The admission rates per category highlighted a low admission rate for the blue category (25%), which is unusual. This study highlights the need for a further study to review clinical presentation, assignment to triage category, and outcomes.

It is well known that staff in accident and emergency (A&E) departments lack the knowledge and confidence needed to deal with maxillofacial emergencies, and that it is related to limited education at undergraduate and postgraduate levels. We therefore aimed to design a syllabus for a short course to educate staff about the most common emergencies. To find out which learning outcomes should be included and to reach a consensus, we did a 3-stage modified Delphi study of the opinions of members of the British Association of Oral and Maxillofacial Surgeons (BAOMS). Of a possible 890 members, 188 responded (21%) in the second round and 105 in the third (12%). Eighteen (37%) of the 49 proposed learning outcomes were rated very important and all of them were retained in the syllabus after the third round. Thirty (61%) items were retained with a consensus of 51% or above in the final round. The Delphi technique is a useful addition to the armamentarium of those involved in education, and has been used effectively in syllabus design. We achieved good consensus on the items to be included and the syllabus will be piloted locally.

Objectives To identify any relationship between deprivation and the level of presentation to Accident and Emergency with alcohol-related conditions in a busy East Coast teaching hospital in Scotland. Methods Over an 87-day-period initial screening to determine whether alcohol played a part in each presentation was conducted at triage. These patients were then streamed according to their Paddington Alcohol Test (Pat) score into Pat +ve and Pat −ve groups. The postcode of each patient was recorded before they were assigned deprivation levels using the DepCat scoring system. This information was then compiled in Microsoft Excel 2003 and a graph showing the differences in the number of presentations across the social spectrum was constructed. Results Nine hundred and forty four patients were screened as attending due to alcohol with 43.86% being Pat +ve and 56.14% being Pat −ve. Overall 66.42% of the Pat +ve group and 54.42% of Pat −ve were from deprived or very deprived areas. Conclusions The use of electronic-based screening was effective at highlighting patients presenting to Accident and Emergency with alcohol-related problems, and these presentations highlighted a direct link between the level of deprivation and attendances.

BACKGROUND Different countries have different wound treatment traditions. We have studied the incidence and different factors related to infections in wound injuries sutured at a Norwegian A&E department. METHOD In this prospective study, clinical data were collected on 102 patients with traumatic wound injuries treated with sutures at Bergen Accident and Emergency Department between 30 February 2011 and 30 June 2011. Any wound infections in 97 of these patients at the time of suture removal were assessed and classified according to severity on a scale of grade 0 to grade 4. RESULTS There were no serious infections, but mild clinical wound infections occurred in 15% of patients: 11% grade 1 and 4% grade 2 infections. Patients less than 65 years old had often cut themselves with knives (n = 33, 37%), and on their hands (n = 60, 67%), Men were most frequently injured at work (n = 38, 54%) and women most often at home (n = 18, 56%). No statistically significant correlation was found between the incidence of wound infections and the length of the wound, the time elapsed before suturing, the wound's location on the body, contamination or underlying chronic diseases. Two of the three self-inflictors in our study had clinical wound infections. Half of the bacteriological samples from ten of 15 wounds with clinical infection had plentiful growth of Staphylococcus aureus. One patient received oral antibiotic treatment for wound infection, and two had local antibiotic treatment. INTERPRETATION Mild clinical infections were found in almost one of six wounds sutured at a Norwegian A&E department. More studies are necessary to provide basic data to enable targeted improvements in wound treatment in the primary healthcare service.

Genital self-mutilation is an uncommon event that is commonly associated with psychotic disorders. Such injuries have also been reported secondary to complex religious beliefs and delusions regarding sexual guilt. Even though few case reports of male genital self-mutilation are available in literature, it is rareto have a combined self-genital mutilation and attempted suicide by cut throat occurring in the same patient at presentation. We presented the case of a 38-yr-old male who presented to the accident and emergency centre of a tertiary hospital in Accra, Ghana.

Background: Head injury is trauma to the brain and/or its coverings as a result of an externally applied mechanical force. Study of epidemiological pattern of head injuries is essential in developing necessary preventive strategies and control. To compare the prevalence and pattern of head injuries during the non-festive (February – September) and the festive (October – January) periods in our environment. Methods: Patients’ case files at the Accidents and Emergency unit of Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, were reviewed. Results: Two hundred and sixty-six out of 4,846 met the inclusion criteria for traumatic head injury and were recruited for the study, giving a prevalence of 5.5%. About 77.4% of these presentations were males while 22.6% were females. Both males and females were affected more in the festive period (52.4% and 48.3%) than in the non-festive period (51.7% and 47.6%). The >20 – 30 year group recorded the highest presentation at 30.5%. Traders and Commercial Motorcyclists were the most affected occupations with 25.9% and 24.1% respectively, with the most common causes of head injury during both the festive and non – periods being motorcycle and motor vehicle accidents (68% and 18% respectively). About 63% presented with mild head injury, 14% with moderate and 23% with severe head injuries. About 11.4% were discharged, 83.9% were transferred to the ward for further evaluation and monitoring while 4.7% died at the Accident and Emergency department. Conclusions: Traumatic head injury is one of the major causes of mortality and morbidity in our environment especially in the festive periods. Aggressive and sustained traffic safety education is recommended for all stakeholders in the broad field of accidentology.

Cardio pulmonary resuscitation (CPR) is a common procedure at Accident and Emergency Department, especially in the Red Zone or Resuscitation Room. This procedure is done as a method to save patients’ life, especially in the event of cardiac arrest. Medical doctors or nurses do continuous cycles of chest compressions manually in order to ensure the heart keep pumping. This is vital in making sure blood supply to the heart and brain is not interrupted. The external force needed to compress the chest is a result of continuous pressing of the heart at the level of mid chest. One cannot deny, the process can be exhausting and can cause muscular pain to the medical doctors or nurses. However, with innovation and technology, nowadays, CPR can be done using machine. The objective of this study is to justify how the relationship of human and machine, has not only save patients life, but also able to safe the medical doctors and nurses from the risk of musculoskeletal disorder (MSD). This study has been carried out at Red Zone of Accident and Emergency Department, Hospital Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia. During this study, 10 medical doctors participated. 8 females and 2 male doctors were voluntarily involved in this study. All of them were asked to perform CPR while standing on the floor and while standing on a stool and patient lying on the bed. Their body postures were recorded and score were given based on Rapid Entire Body Assessment (REBA). This score will determine whether they might have the risk of MSD due to performing CPR or not. For this study, a mannequin was used instead of real patient. Two mechanical CPR device machines were selected in this study, which were LUCAS and AutoPULSE. CPR by these machines was also performed on the mannequin. Result showed, REBA scores are high risk and very high risk. The REBA score when performing CPR while standing on stool were higher compared to REBA score when performing CPR while standing on the floor. Thus, the existing machine-like LUCAS and AutoPULSE in doing CPR not only save patients life, but also have helped the medical doctors and nurses as well. The teaming between machine and human in this study has proven to bring benefits to human life, especially to the medical doctors and nurses.

IntroductionGlobally, occupational therapists are establishing their role in emergency care, especially in emergency departments. This practice development merits investigation due to its nascence ...

Paracetamol (acetaminophen) is a commonly used analgesic; its ‘over the counter’ availability, low cost and popularity amongst patients often make it the first choice for dental pain. It is in this that its potential toxicity, made more complicated by the ever extending range of paracetamol-containing products, make the understanding of this medication key to the safe management of patients presenting to surgery with dental pain. CPD/Clinical Relevance: The purpose of this article is to supply dental practitioners with the knowledge to manage patients who present having taken an oral supra-therapeutic paracetamol overdose. Consideration is given to those patients who can be treated safely in primary care and to those who require transfer to Accident and Emergency (A&E).

We present a simple method of preparing a smart phone based ENT endoscopy for OPD clinic and for on call ENT to provide emergency ENT care in Accident and Emergency department when required. In our experience, this method is efficient, economical and ensures mobility and flexibility of remote visual inspection and documentation. This aids in better care for patients especially where there is no easy access to traditional ENT treatment room facility. This provides a fast and cost-effective solution to simultaneously view capture and save photos and videos with a smartphone and, if required, send these pictures to oncall Consultant. This enables quicker identification, documentation and support regardless of location.

Objective This study examined why patients with Chronic Obstructive Pulmonary Disease (COPD) or Heart Failure (HF) use Accident and Emergency (A and E) services and whether their perceived reasons are similar to or different from those of their family members or carers, or the hospital medical team. Design A mixed method approach was undertaken; (i) semi-structured interviews with patients and their family members (or carer) and (ii) a self-developed survey with hospital health professionals. Participants A purposive sample of 15 patients (9 COPD, 6 HF), six family members and carers (2 COPD, 4 HF) and 12 health professionals (5 doctors, 8 nurses) participated in the study. Setting The research was in one large teaching hospital in South London, UK, covering a diverse ethnic population. Results The patients’ main reason for A and E admission was severe exacerbation of their symptoms and all three parties (patients, family members or carers, health professionals) agreed with this decision. Three key factors were highlighted in relation to A and E attendance: (i) patients’ health seeking behaviour, (ii) perceptions about GP and A and E services by patients and (iii) patients’ attitudes towards managing their own conditions. Conclusions Improving patients’ perceptions of GP services in the management of exacerbations of HF and COPD will be important to increase patients’ trust in GP services so that patients will access primary care in a timely manner to prevent exacerbations of symptoms that require A and E admission. This may be achieved by developing a close collaboration between the patients, family members (carers) and health professionals over time.

The 1999 Report ‘Accident and Emergency Services for Children’ was published by a collaboration of several Royal Colleges and national organisations, and it was a major driver for accident and emergency departments (ED) to become more expertly child-focused. The paediatric emergency department (PED) provides an environment that is more suitable for young ages, shielding the child and family from the sights, sounds and smells of the adult ED, and staffed by nurses and doctors with specialist child health training. Yet now, NHS emergency services are creaking under enormous and increasing demands placed on it by the public. In England, 40% of all ED attendances are non-urgent (60% in the case of children), where the unwell person could be self-managed at home. Accident and Emergency (A&E) attendance costs nearly £100 m in 2011–2012 with ED on average being 36% more than an equivalent general practice (GP) visit. The waiting time target, introduced in 2004, meant that a patient would be seen, treated and sent on his/her way within 4 hours no matter how ill. As a result, the PED became quite an attractive option for the worried parent of a child with a non-urgent ailment, who would be almost guaranteed a paediatric opinion within that time period. Maybe PED has become a victim of its own success? So why do parents bring their children to the PED with minor illness, and what can be done to better understand the drivers and inform potential solutions so desired by policy makers? A recent report by Holden and colleagues1 attempts to answer the questions. Holden reviews and summarises the literature and brings fresh insights on parental decision-making. Behavioural …

Introduction Paediatric patient bone fractures are the source of a large number of orthopaedic outpatient visits, especially for fracture clinics. The National Institute for Health and Care Excellence (NICE) guideline NG38 provides guidance on assessing and managing non-complex fractures, such as buckle (i.e., torus) fractures in paediatric patients. Objective We retrospectively audited outpatient records of children younger than 12 years presenting with distal radius buckle fractures for May and June 2017. We compared our practice against the NICE guideline standards. We made certain changes in our practice and then repeated the exercise prospectively for two months from July 15 to September 15, 2017. Material and Methods We identified 31 patients who fit our inclusion criteria. After instituting changes based on the NICE guidelines, the number of children included in the prospective data collection was 33 patients. Results For the 31 children treated according to our older protocol, we had 59 outpatient visits, with an average of 1.90 visits for every child. After the NICE-driven changes were made to our management, 33 patients were treated in 39 visits with an average of 1.2 visits per child. Conclusion Introducing NICE guidelines allowed for considerable improvement in the management and treatment of paediatric patient bone fractures. It is important to fully implement the NICE guidelines not only in fracture clinics but also in other departments, such as accident and emergency departments.

Reviewing the landscape of Emergency Medicine (EM) publication and research over the past 50 years is an immensely rewarding exercise and emphasises with absolute clarity how far we have come as a specialty in such a relatively short time. The key words which apply to the review are prescient and resonant. The pioneering research undertaken in the earlier years of the specialty represents the very bedrock on which stands Emergency Medicine as we know it today. This paper will highlight some of the key publications during the 50 years of Emergency Medicine in the UK. During the early years from 1967, issues regarding Emergency Medicine in the UK were published in the British Medical Journal (BMJ) and Lancet, in the absence of any specific journal for the specialty then known as Accident and Emergency Medicine. In USA, the first edition of the Journal of the American College of Emergency Physicians (latterly Annals of Emergency Medicine) was published in January 1972. By the 1980s, there were two journals published in the UK—the British Journal of Accident and Emergency Medicine, initially edited by Sheila Christian from Wexham Park and later by Andrew Mason from Medway Hospital and Archives of Emergency Medicine edited by Tony Redmond. In the mid-1990s, the decision was made to move to a single journal, initially titled the Journal of Accident and Emergency Medicine which evolved into the Emergency Medicine Journal (EMJ) under the auspices of the BMJ publishing group. The authors have selected a number of papers from this period based on the following methodology

Background: The four-hour target is a key hospital emergency department performance indicator in England and one that drives the physical and organisational design of the ED. Some studies have identified time of presentation as a key factor affecting waiting times. Few studies have investigated other determinants of breaching the four-hour target. Therefore, our objective was to describe patterns of emergency department breaches of the four-hour wait time target and identify patients at highest risk of breaching. Methods: This was a retrospective cohort study of a large type 1 Emergency department at an NHS teaching hospital in Oxford, England. We analysed anonymised individual level patient data for 378,873 emergency department attendances, representing all attendances between April 2008 and April 2013. We examined patient characteristics and emergency department presentation circumstances associated with the highest likelihood of breaching the four-hour wait time target. Results: We used 374,459 complete cases for analysis. In total, 8.3% of all patients breached the four-hour wait time target. The main determinants of patients breaching the four-hour wait time target were hour of arrival to the ED, day of the week, patient age, ED referral source, and the types of investigations patients receive (pConclusions: There are a number of independent patient and circumstantial factors associated with the probability of breaching the four-hour ED wait time target including patient age, ED referral source, the types of investigations patients receive, as well as the hour, day, and month of arrival to the ED. Efforts to reduce the number of breaches could explore late-evening/overnight staffing, access to diagnostic tests, rapid discharge facilities, and early assessment and input on diagnostic and management strategies from a senior practitioner.