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1.  Next day telephone follow up of the elderly: a needs assessment and critical incident monitoring tool for the accident and emergency department 
Background—Patients over the age of 75 years comprise an increasing proportion of accident and emergency (A&E) department attendances. Within this group there is a high incidence of comorbidity, which mandates effective discharge coordination from the A&E department.
Objectives—The aims of this study were to assess the needs of these patients the day after discharge, target patients for appropriate interventions and identify critical incidents.
Setting—The study was undertaken in a district general hospital A&E department that has 62 000 new patient attendances per year.
Inclusion criteria—Patients aged 75 years or over who were discharged from the A&E department.
Exclusion criteria—Nursing home patients. Patients without a telephone.
Study design—Pre-discharge information was collected from the medical notes. A community liaison nurse (CLN) then contacted patients by telephone. A semi-structured questionnaire was used to assess patients. Patients were risk stratified and appropriate interventions made. Interventions initiated by the CLN were scored from 1 to 6 based on the level of input required.
Results—551 patients or their carers were contacted by telephone. Existing home support was felt to be insufficient in 44 (8%) cases and in need of immediate intervention in a further 45 (8%) cases. Sixty five (11%) Category 1 patients required no intervention, 223 (42%) Category 2 patients required advice only, 107 (19%) Category 3 patients were referred to their GP, 127 (23%) Category 4 patients required a domicillary visit by a GP or a nurse, 26 (5%) Category 5 patients were at risk requiring urgent home assessment and three Category 6 patients had to re-attend A&E. Advice was given by the CLN on a broad range of issues and a wide range of health care services was accessed. Five hundred and fifty nine referrals were made by the CLN after telephone assessment.
Conclusions—Telephone follow up of patients over 75 attending our A&E department identified a number of areas where care could be improved before and after discharge. This low cost, high quality intervention has the potential for decreasing inappropriate return visits to the department by a vulnerable group of patients as well as improving overall quality of care.
doi:10.1136/emj.17.5.337
PMCID: PMC1725441  PMID: 11005403
2.  Safety and effectiveness of nurse telephone consultation in out of hours primary care: randomised controlled trial 
BMJ : British Medical Journal  1998;317(7165):1054-1059.
Objective To determine the safety and effectiveness of nurse telephone consultation in out of hours primary care by investigating adverse events and the management of calls.
Design Block randomised controlled trial over a year of 156 matched pairs of days and weekends in 26 blocks. One of each matched pair was randomised to receive the intervention.
Setting One 55 member general practice cooperative serving 97 000 registered patients in Wiltshire.
Subjects All patients contacting the out of hours service or about whom contact was made during specified times over the trial year.
Intervention A nurse telephone consultation service integrated within a general practice cooperative. The out of hours period was 615 pm to 1115 pm from Monday to Friday, 1100 am to 1115 pm on Saturday, and 800 am to 1115 pm on Sunday. Experienced and specially trained nurses received, assessed, and managed calls from patients or their carers. Management options included telephone advice; referral to the general practitioner on duty (for telephone advice, an appointment at a primary care centre, or a home visit); referral to the emergency service or advice to attend accident and emergency. Calls were managed with the help of decision support software.
Main outcome measures Deaths within seven days of a contact with the out of hours service; emergency hospital admissions within 24 hours and within three days of contact; attendance at accident and emergency within three days of a contact; number and management of calls in each arm of the trial.
Results 14 492 calls were received during the specified times in the trial year (7308 in the control arm and 7184 in the intervention arm) concerning 10 134 patients (10.4% of the registered population). There were no substantial differences in the age and sex of patients in the intervention and control groups, though male patients were underrepresented overall. Reasons for calling the service were consistent with previous studies. Nurses managed 49.8% of calls during intervention periods without referral to a general practitioner. A 69% reduction in telephone advice from a general practitioner, together with a 38% reduction in patient attendance at primary care centres and a 23% reduction in home visits was observed during intervention periods. Statistical equivalence was observed in the number of deaths within seven days, in the number of emergency hospital admissions, and in the number of attendances at accident and emergency departments.
Conclusions Nurse telephone consultation produced substantial changes in call management, reducing overall workload of general practitioners by 50% while allowing callers faster access to health information and advice. It was not associated with an increase in the number of adverse events. This model of out of hours primary care is safe and effective.
Key messagesTelephone consultation is becoming an increasingly accepted approach to patient care and improves public access to medical information and adviceThis study found that nurse telephone consultation halved the number of cases dealt with by general practitioners and was at least as safe as existing out of hours servicesNurse telephone consultation not only replaced telephone advice given by a doctor but led to reductions in both home visits and surgery attendances out of hoursFurther testing is required of variants to the system used in this trial, including the selection and training of nurses and the decision support software usedThere are clear opportunities for and potential benefits from integrating existing out of hours services with NHS Direct
PMCID: PMC28690  PMID: 9774295
3.  Avoidable readmission in Hong Kong - system, clinician, patient or social factor? 
Background
Studies that identify reasons for readmissions are gaining importance in the light of the changing demographics worldwide which has led to greater demand for hospital beds. It is essential to profile the prevalence of avoidable readmissions and understand its drivers so as to develop possible interventions for reducing readmissions that are preventable. The aim of this study is to identify the magnitude of avoidable readmissions, its contributing factors and costs in Hong Kong.
Methods
This was a retrospective analysis of 332,453 inpatient admissions in the Medical specialty in public hospital system in Hong Kong in year 2007. A stratified random sample of patients with unplanned readmission within 30 days after discharge was selected for medical record reviews. Eight physicians reviewed patients' medical records and classified whether a readmission was avoidable according to an assessment checklist. The results were correlated with hospital inpatient data.
Results
It was found that 40.8% of the 603 unplanned readmissions were judged avoidable by the reviewers. Avoidable readmissions were due to: clinician factor (42.3%) including low threshold for admission and premature discharge etc.; patient factor (including medical and health factor) (41.9%) such as relapse or progress of previous complaint, and compliance problems etc., followed by system factor (14.6%) including inadequate discharge planning, inadequate palliative care/terminal care, etc., and social factor (1.2%) such as carer system, lack of support and community services. After adjusting for patients' age, gender, principal diagnosis at previous discharge and readmission hospitals, the risk factors for avoidable readmissions in the total population i.e. all acute care admissions irrespective of whether there was a readmission or not, included patients with a longer length of stay, and with higher number of hospitalizations and attendance in public outpatient clinics and Accident and Emergency departments in the past 12 months. In the analysis of only unplanned readmissions, it was found that the concordance of the principal diagnosis for admission and readmission, and shorter time period between discharge and readmission were associated with avoidable readmissions.
Conclusions
Our study found that almost half of the readmissions could have been prevented. They had been mainly due to clinician and patient factors, in particular, both of which were intimately related to clinical management and patient care. These readmissions could be prevented by a system of ongoing clinical review to examine the clinical practice/decision for discharge, and improving clinical care and enhancing patient knowledge of the early warning signs for relapse. The importance of adequate and appropriate ambulatory care to support the patients in the community was also a key finding to reduce avoidable readmissions. Education on patient self-management should also be enhanced to minimize the patient factors with regard to avoidable readmission. Our findings thus provide important insights into the development of an effective discharge planning system which should place patients and carers as the primacy focus of care by engaging them along with the healthcare professionals in the whole discharge planning process.
doi:10.1186/1472-6963-10-311
PMCID: PMC2993701  PMID: 21080970
4.  Increased Risk of Mortality and Readmission Among Patients Discharged Against Medical Advice 
The American Journal of Medicine  2012;125(6):594-602.
Background
Approximately 500,000 patients are discharged from U.S. hospitals against medical advice annually, but the associated risks are unknown.
Methods
We examined 148,810 discharges from an urban, academic health system between 7/1/2002 and 6/30/2008. Of these, 3,544 (2.4%) were discharged against medical advice and 80,536 (54.1%) were discharged home. We excluded inpatient deaths, transfers to other hospitals or nursing facilities, or discharges with home-care. Using adjusted and propensity score matched analyses, we compared 30-day mortality, 30-day readmission, and length of stay between discharges against medical advice and planned discharges.
Results
Discharge against medical advice was associated with higher mortality than planned discharge, after adjustment (ORadj = 2.05, 95% CI: 1.48–2.86), and in propensity-matched analysis (ORmatched = 2.46, 95% CI: 1.29 – 4.68). Discharge against medical advice was also associated with higher 30-day readmission after adjustment (ORadj 1.84; 95% CI 1.69 – 2.01), and in propensity-matched analysis (ORmatched 1.65, 95% CI: 1.46 – 1.87). Finally, discharges against medical advice had shorter lengths-of-stay than matched planned discharges (3.37 vs. 4.16 days, p <0.001).
Conclusions
Discharge against medical advice is associated with increased risk for mortality and readmission. In addition, discharges against medical advice have shorter lengths-of-stay than matched planned discharges, suggesting that the increased risks associated with discharge against medical advice are attributable to premature discharge.
doi:10.1016/j.amjmed.2011.12.017
PMCID: PMC3372411  PMID: 22513194
5.  An audit of advice on fitness to drive during accident and emergency department attendance 
Emergency Medicine Journal : EMJ  2006;23(2):103-104.
Introduction
Large numbers of patients attending accident and emergency (A&E) departments drive to and from the consultation. This audit set out to examine if patients attending A&E were advised about their fitness to drive.
Method
The authors carried out a retrospective audit over a one month period. The Driver and Vehicle Licensing Authority (DVLA) booklet “At a glance guide to the current medical standards of fitness to drive” was used to derive a list of conditions that require driving restrictions. Any condition within these guidelines was audited. If the patient was discharged and diagnosed as having a condition requiring the patient to cease driving, the notes were scrutinised for any evidence that the doctor had given advice about driving.
Results
A total of 337 patients were discharged with conditions which may have required some restrictions to driving; 332 sets of notes were available. Twenty two patients needed restrictions to be placed on their driving. Only one patient had any documented evidence of the examining doctor informing them of restrictions to be placed on driving.
Conclusions
The study provides clear evidence that patients were not being informed about their fitness to drive following consultation in the authors' A&E department. Previous studies have shown that doctors' knowledge on driving restrictions is poor. Further education is needed for A&E doctors and patient information leaflets should be provided to explain the restrictions placed on a driver's licence if they have certain illnesses.
doi:10.1136/emj.2004.020776
PMCID: PMC2564026  PMID: 16439736
accident and emergency; DVLA, driving; patients; restrictions
6.  Clinical spectrum of discharges against medical advice in a developing country 
The Indian Journal of Surgery  2008;70(2):68-72.
Background
Patients who leave the hospital before clinician certification of fitness are referred to as discharge against medical advice (DAMA). This phenomenon of discharges against medical advice is an undesirable but relatively common occurrence worldwide. Professional liability and harmful effect of this practice to individual health are of concern.
Aims
The essence of this study is to determine the spectrum of patients who DAMA in a Nigerian teaching hospital.
Design
Descriptive study over a two-year period in an urban teaching hospital in Nigeria.
Materials and methods
All consecutive patients who discharge against medical advice at the surgical emergency room of University Teaching Hospital, Ilorin from January 2004 to December 2005 were studied prospectively. The patients’ demographic details, diagnosis, reason for discharge, signatory to discharge and length of hospital stay were studied.
Statistical analysis
Analysis of the data was done using Statistical Package for Social Sciences (SPSS) version 11.
Results
Prevalence rate of DAMA was 4.2%, comprising 110 of a total of 2,617 patients admitted during the study period. Male to female ratio was 3.8:1, the mean age was 30.0 years (range, 4–70 years). Trauma accounted for the highest number of patients 102(97.2%) out of whom 52 (51%) had long bones fracture. Patients who wish to seek alternate medical care accounted for 43.6%, while financial constraint contributed to 29.1% DAMA. Forty-five out of forty-eight (93.7%) of patients who DAMA to seek alternate medical care had fracture.
Conclusion
Trauma was the most common clinical condition for patients who DAMA. Most common reason for DAMA was to seek alternate treatment followed by financial constraint. Health education on potential benefit of orthodox treatment of fracture, treatment subsidy and full implementation of national health insurance scheme will reduce incidence of DAMA.
doi:10.1007/s12262-008-0018-8
PMCID: PMC3452395  PMID: 23133024
Discharge; Medical advice; Trauma; Health education
7.  Studying the Rate and Causes of Discharge Against Medical Advice in Hospitals Affiliated to Mazandaran University of Medical Sciences 
Materia Socio-Medica  2014;26(3):203-207.
Introduction:
Discharge against medical advice from the hospital is an important issue from point of view of treatment management, health costs as well as the side effects of treatment stop on patients and their accompanying. Therefore, health managers and planners should consider the predisposing factors that change patient’s mind in this regard. Since, there has been no study to carefully assess the rate and causes of self-discharge in this province, so this study is aimed to fill this gap.
Methods and Materials:
This descriptive and cross-sectional study was carried out in 6 months period, from 23 July 2010 till 20 January 2011 in all public hospitals of Mazandaran province. A form was set out for data collection and those patients willing to self-discharge were asked to participate in the study. Patients’ demographic information was filled using their medical record and by the help of department personnel. Furthermore, the form was completed by parents for patients over 18 year-old or by the help of first-rank relative for those having psychiatric disorders or anybody who wasn’t able to complete the form. In order to identify the causes of self-discharge, 18 variables were determined which were categorized in three general items and five main groups. Data were entered into the SPSS15 and were analyzed using descriptive statistics indices.
Results:
According to the results, 94441 were discharged from the university hospitals which 7967 patients (8.4 %) of them were self-discharged during the 6 month study period. Regarding admission type, 269 (3.3 %), (54.5 %) were admitted into the hospital by pre-determined appointment and as usual patients, respectively, and the rest were admitted by emergency department. Also, 31.4%(2504) were hospitalized in surgery ward, 63% (5026) in medical ward, 4.6% (374) in intensive care unit (ICU) and the rest were hospitalized in the psychiatric ward. The most important reasons for self-discharge were related to: 1-factors affecting patient illness (54.3%), 2-environmental issues as well as patients’ accompanying (37.6%) and 3-managerial and medical reasons(7.9%), respectively.
Conclusion:
Our study showed the same results for Discharge against medical advice rate as the others. From the view point of treatment management, its causes should be considered and practices should be done to improve the conditions. Meanwhile, the current self-discharge form doesn’t reflect the causes of the problem and it should be revised.
doi:10.5455/msm.2014.26.203-207
PMCID: PMC4130680  PMID: 25126018
Discharge against medical advice; Hospital management; Patient reverence; Medical cost
8.  Patients Discharged Against Medical Advice from a General Medicine Service 
This study compares the demographic features and hospital course of all 472 patients discharged against medical advice from the general medicine service of an urban teaching hospital between 1984 and 1995 and 1,113 control patients discharged with physician approval. In the multivariate analysis, younger age (odds ratio [OR] 0.97 per year; 95% confidence interval [CI] 0.96, 0.98), male gender (OR 1.9; 95% CI 1.4, 2.4), lack of health insurance (OR 2.0; 95% CI 1.3, 3.1), Medicaid applicant or recipient status (OR 2.2; 95% CI 1.6, 3.1), admission through the emergency department (OR 2.2; 95% CI 1.4, 3.5), and lack of a personal attending physician at the time of admission (OR 2.1; 95% CI 1.6, 2.8) increased the odds of discharge against medical advice. Fifty-four percent of patients who left against medical advice were readmitted to the hospital during the study period; 98% were then discharged with physician approval. Patients who left the hospital against medical advice included many disadvantaged individuals without ongoing primary care.
doi:10.1046/j.1525-1497.1998.00169.x
PMCID: PMC1496999  PMID: 9734795
discharge against medical advice; disadvantaged patients; Medicaid; readmission
9.  Recovery after Minor Traffic Injuries: A Randomized Controlled Trial 
PLoS Clinical Trials  2007;2(3):e14.
Objectives:
To assess the efficacy of an acute multidisciplinary group intervention on self-perceived recovery following minor traffic-related musculoskeletal injuries.
Design:
Open, randomized controlled trial.
Setting:
A large inner-city hospital.
Participants:
127 patients (≥15 y) with traffic-related acute minor musculoskeletal injuries and predicted to be at risk for delayed recovery were randomized into an intervention group (n = 65) or a control group (n = 62).
Intervention:
Four 1½-h sessions in open groups with the aim of providing information about injuries in general, calling attention to the importance of self-care and promoting physical activity. In addition, both groups received standard medical care by regular staff.
Outcome measures:
The main outcome measure was self-reported recovery at 12 mo. Secondary outcome measures were ratings of functional health status (SF-36, SMFA), pain and mental distress on visual analog scales, and self-reported duration of sick leave.
Results:
At 12 mo, there was a 21.9 percentage point difference: 52.4% of the patients in the intervention group and 30.5% in the control group reported self-perceived recovery (95% confidence interval for the difference 5%–38%; p = 0.03). There were no statistically significant differences between the groups regarding the secondary outcome measures.
Conclusion:
A simple group intervention may accelerate the self-perceived recovery in selected patients. As we did not find evidence of improvements in the secondary outcome measures, the clinical significance of the treatment benefit remains to be defined.
Editorial Commentary
Background: Worldwide, road traffic accidents contribute substantially to the number of deaths and also to the burden of disability. However, there is a lack of research into road traffic accidents as compared to other causes of ill-health. In particular, minor injuries resulting from traffic accidents are not well-studied even though some people with such injuries might be unwell for a long period of time. Support programs that provide people who have had minor traffic-related injuries with psychological help, physical training, and other types of interventions might help people to recover more quickly. However, there is little evidence that would help to answer this question. In the trial reported here, the researchers aimed to find out whether a support program would increase the chance of recovery in people who had experienced minor traffic-related injuries and who were thought to be less likely to recover. Trial participants were randomized to receive either standard medical care or to receive standard care and also to attend a series of workshops where surgeons, psychiatrists, pain specialists, and other staff gave advice about healing, pain management, exercises, and other aspects of self-care. The primary outcome of the trial was whether participants considered themselves to have recovered, 12 mo after the injury.
What the trial shows: 127 patients were recruited into the study, 62 of whom were assigned to receive standard care only and 65 of whom were assigned to also attend the support workshops. Most participants assigned to the support arm did attend all of the workshop sessions. Patients assigned to attend the support workshops were more likely to report that they had recovered as compared to patients receiving standard care only, and this difference seemed quite substantial. However, there were no statistically significant differences between these two groups in the trial's secondary outcome measures. These secondary measures included scores on rating scales which attempt to measure physical and mental distress and coping ability and the amount of sick leave taken.
Strengths and limitations: Although the trial was fairly small, it did recruit enough participants to detect an effect in the primary outcome measure, recovery at 12 mo. Additionally, a large proportion of the participants randomized to attend support sessions did actually attend the sessions, and follow-up for the primary outcome measure was virtually complete. Limitations of this study include low follow-up of patients for the secondary outcome measures in the trial. This meant that there was low power to detect clinically relevant changes in these outcome measures. Finally, although many patients were eligible for the trial, only a small proportion could be successfully contacted after being discharged from hospital, and it is possible that those people who did agree to participate were more motivated to recover than patients in general who have these injuries.
Contribution to the evidence: Most evidence relating to the benefits of support programs such as these have evaluated their effects in patients who have whiplash injuries rather than general traffic-related injuries. However, the results from this trial are compatible with those of similar trials in patients with whiplash injuries and suggest that support programs such as these may be beneficial in patients at risk of not recovering well from their injuries.
doi:10.1371/journal.pctr.0020014
PMCID: PMC1829405  PMID: 17380190
10.  Chest pain units: A necessity or only a name to encourage patients 
ARYA Atherosclerosis  2012;8(3):158-160.
BACKGROUND
Acute chest pain is a common symptom among patients presenting to emergency wards. Identification and admission of patients with real acute coronary syndrome and preventing the hospitalization of people with false diagnosis of coronary syndrome are the most important tasks in emergency wards. The purpose of this study was to investigate the usefulness of designing a special chest pain unit in emergency department of Imam Khomeini Hospital (Ahvaz, Iran).
METHODS
The patients with markers of ongoing cardiac ischemia underwent selective coronary angiography. The chest pain unit protocol was applied to selected patients with no definite evidence of acute coronary syndrome or alternative pathology. The protocol consisted of twelve hours of observation and serial 12-lead electrocardiography, transthoracic echocardiography, and biochemical testing followed by an exercise treadmill test. We compared the number of patients who were discharged after work up, discharged themselves against medical advice, admitted at coronary care unit (CCU), underwent invasive procedures or died between 2007 and 2010.
RESULTS
During 2010, 43% of patients were discharged after evaluation in the chest pain unit. In 2007 however, 26% were discharged following traditional assessments. The admission rate increased from 23% in 2007 to 36% in 2010. The percentage of patients who discharged themselves against medical advice decreased from 37% in 2007 to 14% in 2010. There was not a statistically significant difference between mortality rates in 2007 and 2010.
CONCLUSION
Providing a special chest pain unit in emergency ward in our condition is helpful. It reduces unnecessary admissions and improves patient satisfaction.
PMCID: PMC3557000  PMID: 23359791
Chest Pain Unit; Acute Coronary Syndrome; Myocardial Infarction
11.  Optimizing triage and hospitalization in adult general medical emergency patients: the triage project 
Background
Patients presenting to the emergency department (ED) currently face inacceptable delays in initial treatment, and long, costly hospital stays due to suboptimal initial triage and site-of-care decisions. Accurate ED triage should focus not only on initial treatment priority, but also on prediction of medical risk and nursing needs to improve site-of-care decisions and to simplify early discharge management. Different triage scores have been proposed, such as the Manchester triage system (MTS). Yet, these scores focus only on treatment priority, have suboptimal performance and lack validation in the Swiss health care system. Because the MTS will be introduced into clinical routine at the Kantonsspital Aarau, we propose a large prospective cohort study to optimize initial patient triage. Specifically, the aim of this trial is to derive a three-part triage algorithm to better predict (a) treatment priority; (b) medical risk and thus need for in-hospital treatment; (c) post-acute care needs of patients at the most proximal time point of ED admission.
Methods/design
Prospective, observational, multicenter, multi-national cohort study. We will include all consecutive medical patients seeking ED care into this observational registry. There will be no exclusions except for non-adult and non-medical patients. Vital signs will be recorded and left over blood samples will be stored for later batch analysis of blood markers. Upon ED admission, the post-acute care discharge score (PACD) will be recorded. Attending ED physicians will adjudicate triage priority based on all available results at the time of ED discharge to the medical ward. Patients will be reassessed daily during the hospital course for medical stability and readiness for discharge from the nurses and if involved social workers perspective. To assess outcomes, data from electronic medical records will be used and all patients will be contacted 30 days after hospital admission to assess vital and functional status, re-hospitalization, satisfaction with care and quality of life measures.
We aim to include between 5000 and 7000 patients over one year of recruitment to derive the three-part triage algorithm. The respective main endpoints were defined as (a) initial triage priority (high vs. low priority) adjudicated by the attending ED physician at ED discharge, (b) adverse 30 day outcome (death or intensive care unit admission) within 30 days following ED admission to assess patients risk and thus need for in-hospital treatment and (c) post acute care needs after hospital discharge, defined as transfer of patients to a post-acute care institution, for early recognition and planning of post-acute care needs. Other outcomes are time to first physician contact, time to initiation of adequate medical therapy, time to social worker involvement, length of hospital stay, reasons for discharge delays, patient’s satisfaction with care, overall hospital costs and patients care needs after returning home.
Discussion
Using a reliable initial triage system for estimating initial treatment priority, need for in-hospital treatment and post-acute care needs is an innovative and persuasive approach for a more targeted and efficient management of medical patients in the ED. The proposed interdisciplinary , multi-national project has unprecedented potential to improve initial triage decisions and optimize resource allocation to the sickest patients from admission to discharge. The algorithms derived in this study will be compared in a later randomized controlled trial against a usual care control group in terms of resource use, length of hospital stay, overall costs and patient’s outcomes in terms of mortality, re-hospitalization, quality of life and satisfaction with care.
Trial registration
ClinicalTrials.gov Identifier, NCT01768494
doi:10.1186/1471-227X-13-12
PMCID: PMC3723418  PMID: 23822525
Triage; Biomarker; Post-acute care needs; Emergency medicine; Manchester triage system
12.  A national census of those attending UK accident and emergency departments with asthma. The UK National Asthma Task Force. 
OBJECTIVE: To obtain a representative national picture of the type of people with asthma attending accident and emergency (A&E) departments in the UK, the reasons why they attend, and to determine the proportion admitted to hospital. DESIGN: A national census involving questionnaires. SETTING: 100 A&E departments throughout the UK. SUBJECTS: All those with asthma attending because of asthma during a one week period in September 1994. RESULTS: Details were obtained about 1292 attendances. About half of all attendances were by adults and half by children, and 87.8% were previously diagnosed asthmatics; 18.8% of adult attenders were unemployed. Perceived severity of asthma was the reason for attendance in 65.5%, but 11.5% reported non-availability, or perceived non-availability, of the general practitioner (GP) as the reason for attending. One fifth of adults had been kept awake by their asthma for over three nights before attendance. 425 of the 1292 attenders (32.9%) had been admitted to hospital in the previous 12 months and 316 (24.5%) had attended the A&E department in the previous three months. Only 24.6% of attenders had had contact with their general practitioner in the previous 24 h. 61.6% of under-5 attenders (n = 341) were admitted to hospital; the figures for those aged 5-15 and 15+ years and above were 265 (41.4%) and 665 (38.7%). CONCLUSIONS: Many people with asthma attend A&E departments without first having seen their GP. In many adult cases the asthma, while severe, is not acute, but a high proportion of both adults and children are admitted to hospital. Many of these attendances and admissions are repeat attendances. To enhance the quality of care provided to those with asthma may require easier access to primary care, enhanced patient education, or enhanced health professional education. Further study is needed of a variety of potential interventions.
PMCID: PMC1342836  PMID: 9023616
13.  Review of calls to NHS Direct related to attendance in the paediatric emergency department 
Emergency Medicine Journal : EMJ  2006;23(12):911-914.
Objective
To examine the outcomes of calls to NHS Direct (NHS‐D) in relation to attendance at the accident and emergency (A&E) department.
Design
A prospective collection of data about consecutive calls to NHS‐D North West Coast was matched with attendances at the A&E department over a period of 3 months.
Setting
NHS‐D Regional Trust and a large urban paediatric A&E department.
Patients
Children and young adults aged <16 years living in local postal code areas.
Main outcome measures
To examine (1) whether advice given by NHS‐D was followed and (2) the differences in disease severity and necessity of attendance of patients referred by NHS‐D and those referred by general practitioners and self‐presenters.
Results
The relationship between the advice given and subsequent action is complex. Only 70% of calls advised to attend the A&E department did so. A further 1% (176) were advised not to attend the A&E department did in fact attend the department. Patients referred by NHS‐D represented only 3.2% of department attendances. There was little difference in the triage categories of the presenting groups, but there were significantly less admissions (p<0.01) in the NHS‐D group.
Conclusions
Delivering telephone advice about illness severity in children is difficult as visual clues are so important. More collaborative prospective studies are needed, including with primary care, to understand families' choices, and to refine and assess NHS‐D's ability to discriminate those requiring further clinical assessment.
doi:10.1136/emj.2006.039339
PMCID: PMC2564250  PMID: 17130596
14.  An audit of care received by patients injured during sporting activities. 
Archives of Emergency Medicine  1993;10(3):203-208.
A summary of injuries sustained by 340 sportsmen over 9 successive weekends from 16 November 1991 to 12 January 1992 attending an accident and emergency (A&E) department is presented. Most injuries occurred in young males usually as a result of soccer or rugby. Sixty-seven per cent of patients were discharged with no further followed up in hospital. Seventy-two per cent of patients were X-rayed, 33% of X-rays showed a fracture or dislocation. A total of 193 attendees received minimal treatment, (defined as discharge with advice only, simple analgesia or strapping only with no hospital follow-up) and of these 152 were X-rayed. A total of 100 patients who received minimal treatment were selected randomly by computer to receive a follow-up letter asking about certain issues relating to their care in the A&E department. Most patients felt that the A&E Department was the most appropriate source of treatment for their sports injury, and over half attended specifically for an X-ray examination. Despite the doctors view that many of these minor injuries could have been self-treated, few patients felt able to treat future similar minor injuries themselves. They were, however, more likely to go elsewhere for treatment on subsequent occasions.
PMCID: PMC1285989  PMID: 8216595
15.  Consequences of Gestational Diabetes in an Urban Hospital in Viet Nam: A Prospective Cohort Study 
PLoS Medicine  2012;9(7):e1001272.
Jane Hirst and colleagues determined the prevalence and outcome of gestational diabetes mellitus in urban Vietnam and found that choice of criteria greatly affected prevalence, and has implications for the ability of the health system to cope with the number of cases.
Background
Gestational diabetes mellitus (GDM) is increasing and is a risk for type 2 diabetes. Evidence supporting screening comes mostly from high-income countries. We aimed to determine prevalence and outcomes in urban Viet Nam. We compared the proposed International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criterion, requiring one positive value on the 75-g glucose tolerance test, to the 2010 American Diabetes Association (ADA) criterion, requiring two positive values.
Methods and Findings
We conducted a prospective cohort study in Ho Chi Minh City, Viet Nam. Study participants were 2,772 women undergoing routine prenatal care who underwent a 75-g glucose tolerance test and interview around 28 (range 24–32) wk. GDM diagnosed by the ADA criterion was treated by local protocol. Women with GDM by the IADPSG criterion but not the ADA criterion were termed “borderline” and received standard care. 2,702 women (97.5% of cohort) were followed until discharge after delivery. GDM was diagnosed in 164 participants (6.1%) by the ADA criterion, 550 (20.3%) by the IADPSG criterion. Mean body mass index was 20.45 kg/m2 in women with out GDM, 21.10 in women with borderline GDM, and 21.81 in women with GDM, p<0.001. Women with GDM and borderline GDM were more likely to deliver preterm, with adjusted odds ratios (aORs) of 1.49 (95% CI 1.16–1.91) and 1.52 (1.03–2.24), respectively. They were more likely to have clinical neonatal hypoglycaemia, aORs of 4.94 (3.41–7.14) and 3.34 (1.41–7.89), respectively. For large for gestational age, the aORs were 1.16 (0.93–1.45) and 1.31 (0.96–1.79), respectively. There was no significant difference in large for gestational age, death, severe birth trauma, or maternal morbidity between the groups. Women with GDM underwent more labour inductions, aOR 1.51 (1.08–2.11).
Conclusions
Choice of criterion greatly affects GDM prevalence in Viet Nam. Women with GDM by the IADPSG criterion were at risk of preterm delivery and neonatal hypoglycaemia, although this criterion resulted in 20% of pregnant women being positive for GDM. The ability to cope with such a large number of cases and prevent associated adverse outcomes needs to be demonstrated before recommending widespread screening.
Please see later in the article for the Editors' Summary.
Editors' Summary
Background
Gestational diabetes mellitus (GDM) is diabetes that is first diagnosed during pregnancy. Like other types of diabetes, it is characterized by high levels of sugar (glucose) in the blood. Blood-sugar levels are usually controlled by insulin, which is made by the pancreas. Hormonal changes during pregnancy and the baby's growth demands increase a pregnant woman's insulin needs, and if her pancreas cannot make enough insulin, GDM develops, usually in mid-pregnancy. Risk factors for GDM include a high body mass index (a measure of body fat), excessive weight gain or lack of physical activity during pregnancy, and glucose intolerance (an indicator of diabetes that is measured using the “oral glucose tolerance test”). GDM increases the risk of premature delivery, induced delivery, and having a large-for-gestational-age baby (gestation is the time during which the baby develops within the mother). It also increases the baby's risk of having low blood sugar (neonatal hypoglycemia). GDM, which can often be controlled by exercise and diet, usually disappears after pregnancy but increases the risk of diabetes developing later in both mother and baby.
Why Was This Study Done?
The prevalence (occurrence) of diabetes is increasing rapidly, particularly in low/middleincome countries as they become more affluent. Because GDM increases the subsequent risk of diabetes, some experts believe that screening for GDM should be included in prenatal care as part of diabetes preventative strategies. However, most of the evidence supporting GDM screening comes from high-income countries, so in this prospective cohort study (a study that analyses associations between the baseline characteristics of a group of patients and outcomes), the researchers investigate the prevalence of GDM (diagnosed using the oral glucose tolerance test) and the consequences of GDM among women attending an urban hospital in Viet Nam, a low/middle-income country. An oral glucose tolerance test measures a patient's blood-sugar level after an overnight fast, and one and two hours after consuming a sugary drink. The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) and the American Diabetes Association (ADA) guidelines state, respectively, that one and two of these blood-sugar measurements must be abnormally high for a diagnosis of GDM. In this study, the researchers use both guidelines to diagnose GDM.
What Did the Researchers Do and Find?
Nearly 3,000 women who attended the hospital for routine prenatal care had a glucose tolerance test at around 28 weeks' gestation and were followed until discharge after delivery. Women who had GDM diagnosed by the ADA criterion were referred for dietary advice and glucose monitoring. Those diagnosed by the IADPSG criterion only were described as having “borderline” GDM and received standard prenatal care. GDM was diagnosed in 6.1% and 20.3% of the women using the ADA and IADPSG criteria, respectively. After allowing for other factors that might have affected outcomes, compared to women without GDM, women with GDM or borderline GDM were more likely to deliver prematurely, and their babies were more likely to have neonatal hypoglycemia. Also, women with GDM (but not borderline GDM) were more likely to have their labor induced than women without GDM.
What Do These Findings Mean?
These findings show that the criterion used to diagnose GDM markedly affected the prevalence of GDM among pregnant women attending this Vietnamese hospital—the use of the IADPSG criterion more than tripled the prevalence of GDM and meant that a fifth of the study participants were diagnosed as having GDM. Importantly, the findings also show that GDM diagnosed using the IADPSG criterion was associated with an increased risk of preterm delivery and neonatal hypoglycemia. Although these findings may not be generalizable to other settings within Viet Nam or to other countries, they highlight the need to demonstrate that sufficient resources are available to cope with an increased GDM burden before recommending widespread screening using the IADPSG criterion. Moreover, because the long-term significance of GDM diagnosed using the IADPSG criterion is not known, all the potential benefits and harms and the costs of screening and treating GDM in low-income settings need to be further investigated before any recommendation for “universal” GDM screening is made.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10. 1371/journal.pmed.1001272.
The US National Institute of Diabetes and Digestive and Kidney Diseases provides information for patients on diabetes and on gestational diabetes (in English and Spanish)
The UK National Health Service Choices website also provides information for patients about diabetes and about gestational diabetes, including links to other useful resources
The American Diabetes Association also provides detailed information for patients and professionals about all aspects of diabetes, including gestational diabetes (in English and Spanish)
The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) 2010 recommendations on the diagnosis and classification of gestational diabetes are available
The charity Diabetes UK provides detailed information for patients and carers, including information on gestational diabetes; its blog includes a personal story about gestational diabetes, and its website includes a selection of other stories from people with diabetes; the charity Healthtalkonline also has an interview describing a personal experience of gestational diabetes
MedlinePlus provides links to additional resources on diabetes and on gestational diabetes (in English and Spanish)
doi:10.1371/journal.pmed.1001272
PMCID: PMC3404117  PMID: 22911157
16.  Outpatients revisited: subjective views and clinical decisions in the management of general surgical outpatients in south west England. 
STUDY OBJECTIVE--To assess the scope for reducing unnecessary outpatient reattendances, using a benchmark an acute specialty at a site recognised to have an especially low ratio of repeat to new attendances. DESIGN--This was a survey of the re-attendance workload at general surgery outpatient clinics over a three month period. Patient re-booking and discharge rates for different grades of staff; clinicians' perception of the ability of the GP to have managed the patient; perception of the value of individual re-attendances; reason given for discharging/re-booking; and outcome of attendance for patients in relation to diagnostic category were determined. SETTING--General surgery outpatients clinics with re-attendance rates that were 50% below average, in Taunton and Somerset Hospital, a non-teaching district general hospital. PATIENTS--Altogether 454 patients who made 470 second or subsequent visits (re-attendances) within the same episode of outpatient care. MAIN RESULTS--Thirty eight percent (178/470) of visits were perceived as manageable by the GP, 45% (79, 17% of total re-attendances) of which were also thought to have been of marginal or little value. A substantial group of patients was being followed up largely for reasons of convention and traditional policy. Re-booking rates were higher among junior staff. Subjective views of the value of attendance at the hospital outpatient clinic and the ability of the GP to have seen the patient varied systematically between consultants and junior staff. Judgements varied to some extent according to the diagnostic group. CONCLUSION--The numbers of patients being followed up equivocally at most general surgical outpatient departments will be 50% more an average than those in this benchmark department. A department seeing 2000 new patients per annum will have 3600 reattendances, 25.5% (918) of which may be avoidable on the basis of these results. A variety of approaches can be used to increase the proportion of patients seen appropriately by GPs. In some cases this might be achieved without the intensive commitment required to plan and develop shared care protocols or new formal discharge guidelines, but by encouraging GPs to manage some patients, increasing of hospital clinicians' access to knowledge of local general practices, and internal clinic review of 'routine' follow up policies as shown in this study. This type of review of outpatient practice can also help prioritise conditions likely to repay the effort of developing and implementing clinical management guidelines and local protocols.
Images
PMCID: PMC1060176  PMID: 8596096
17.  Characteristics of attenders and their attendances at an urban accident and emergency department over a one year period. 
OBJECTIVES: To describe (1) the characteristics of attenders to an urban accident and emergency (A&E) department over a one year period according to the frequency of their attendance and (2) the features of their attendances according to the frequency which the patient attended the department during the study period. METHODS: A dataset containing information on all new attendances to an urban A&E department in 1995 was formed. For each attendance the following information was recorded: day of the week, hour of attendance, referral source, triage category, and disposal. A second dataset, consisting of the individuals ("attenders") who made the A&E visits ("attendances") during 1995 was also produced. For each attender the following information was recorded: age, sex, postal code of residence, socioeconomic status, marital status, and number of attendances during 1995. A methodology reviewing the trends of frequency of attendance was utilised, as opposed to the use of an arbitrary cut off point. RESULTS: 34,908 patients made 46,735 visits in 1995. Increasing frequency of attendance was significantly associated with increasing age (Kruskal-Wallis < 0.001), being male (chi 2 for linear trend 14.06, p < 0.001), having a local postal address (chi 2 279.79, p < 0.0001), general medical services eligibility (chi 2 781.67, p < 0.0001), and inversely associated with being married (chi 2 33.91, p < 0.0001). Increasing frequency of attendance was significantly associated with attendance between the hours of 1700 and 0900 (chi 2 295.62, p < 0.001), being triaged as a non-emergency (chi 2 1254.33, p < 0.0001), and self referral (chi 2 141.4, p < 0.0001). CONCLUSIONS: A small group of A&E attenders accounts for a disproportionately large percentage of the total number of departmental attendances. The characteristics of frequent A&E attenders suggest that they may represent a vulnerable group of patients. A follow up study of the utilisation of all primary care services by such patients is suggested.
PMCID: PMC1343407  PMID: 10572815
18.  Patients telephoning A&E for advice: a comparison of expectations and outcomes. 
OBJECTIVE: To investigate the expectations of patients when they phone the accident and emergency (A&E) department, how this relates to the advice they receive, the action they subsequently take, and their satisfaction with the service. SETTING: The study was undertaken at an inner city hospital in south east London. METHODS: 597 calls to the department were documented during the study period, and callers for whom a phone number had been recorded were followed up by structured interviews carried out by a trained interviewer within 72 h of the call. Up to three attempts were made to contact each patient. The interviews were conducted at various times of the day to avoid excluding people with different work or social patterns. RESULTS: The interviewer was able to contact 203 patients within 72 h of their call to the A&E department. Of these 197 (97%) agreed to participate. Almost two thirds stated that when they phoned A&E they anticipated receiving self care advice; 11% expected to be advised to see or contact their general practitioner. Only a quarter of callers stated that they had expected to be told to attend A&E. There was disagreement between the advice that nurses documented as having been given, the advice the caller recalled receiving, and the action the patient subsequently took. Even so, 107 (55%) callers were very satisfied and 62 (32%) were satisfied, while 11 (6%) were dissatisfied with the telephone consultation; 15 (8%) were unsure. In all, 170 (87%) thought the advice they received was helpful. CONCLUSIONS: Understanding the reasons why patients phone A&E departments and their expectations should contribute to developing more responsive and effective services.
PMCID: PMC1342837  PMID: 9023617
19.  Cholinesterase Inhibitors and Hospitalization for Bradycardia: A Population-Based Study 
PLoS Medicine  2009;6(9):e1000157.
Laura Park-Wyllie and colleagues examined the health records of more than 1.4 million older adults and show that initiation of cholinesterase inhibitor therapy is associated with a more than doubling of the risk of hospitalization for bradycardia.
Background
Cholinesterase inhibitors are commonly used to treat dementia. These drugs enhance the effects of acetylcholine, and reports suggest they may precipitate bradycardia in some patients. We aimed to examine the association between use of cholinesterase inhibitors and hospitalization for bradycardia.
Methods and Findings
We examined the health care records of more than 1.4 million older adults using a case-time-control design, allowing each individual to serve as his or her own control. Case patients were residents of Ontario, Canada, aged 67 y or older hospitalized for bradycardia between January 1, 2003 and March 31, 2008. Control patients (3∶1) were not hospitalized for bradycardia, and were matched to the corresponding case on age, sex, and a disease risk index. All patients had received cholinesterase inhibitor therapy in the 9 mo preceding the index hospitalization. We identified 1,009 community-dwelling older persons hospitalized for bradycardia within 9 mo of using a cholinesterase inhibitor. Of these, 161 cases informed the matched analysis of discordant pairs. Of these, 17 (11%) required a pacemaker during hospitalization, and six (4%) died prior to discharge. After adjusting for temporal changes in drug utilization, hospitalization for bradycardia was associated with recent initiation of a cholinesterase inhibitor (adjusted odds ratio [OR] 2.13, 95% confidence interval [CI] 1.29–3.51). The risk was similar among individuals with pre-existing cardiac disease (adjusted OR 2.25, 95% CI 1.18–4.28) and those receiving negative chronotropic drugs (adjusted OR 2.34, 95% CI 1.16–4.71). We found no such association when we replicated the analysis using proton pump inhibitors as a neutral exposure. Despite hospitalization for bradycardia, more than half of the patients (78 of 138 cases [57%]) who survived to discharge subsequently resumed cholinesterase inhibitor therapy.
Conclusions
Among older patients, initiation of cholinesterase inhibitor therapy was associated with a more than doubling of the risk of hospitalization for bradycardia. Resumption of therapy following discharge was common, suggesting that the cardiovascular toxicity of cholinesterase inhibitors is underappreciated by clinicians.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Alzheimer disease and other forms of dementia principally affect people aged over 65. These conditions result in confusion, long term memory loss, irritability, and mood swings. As the population of developed countries ages, the prevalence of dementia is expected to increase significantly. It is forecast that the proportion of people with dementia in the US will quadruple by 2045.
A common treatment for Alzheimer disease is a class of drug called an acetylcholinesterase inhibitor or cholinesterase inhibitor. These include donepezil (brand name Aricept), rivastigmine (marketed as Exelon and Exelon Patch), and galantamine (branded Razadyne).
The benefit of taking cholinesterase inhibitors is generally small and they cannot reverse the effects of dementia. In about 50% of patients they delay the worsening of symptoms for between six months and a year, although a small number of patients may benefit more. They can have unpleasant side effects, which may include diarrhoea and muscle cramps.
Why Was This Study Done?
Existing evidence is inconclusive on whether cholinesterase inhibitors increase the risk of bradycardia, an abnormally slow resting heart rate of below 60 beats a minute, which can cause fatigue, dizziness, fainting, palpitations, shortness of breath, or death. In this paper, the authors use routinely collected health care data to investigate whether an older person taking a cholinesterase inhibitor is at increased risk of bradycardia.
What Did the Researchers Do and Find?
They began by supposing that cholinesterase inhibitors might induce bradycardia soon after a patient first began to take them. To investigate this, they obtained health care data on 1.4 million patients aged 67 or over in Ontario, Canada. They identified 161 patients who had visited a hospital for bradycardia and who had previously taken a cholinesterase inhibitor only within specific periods of time. They found that 139 had taken a cholinesterase inhibitor within the previous three months compared with 22 who had stopped taking it at least six months before.
They compared these cases with up to three “control” patients who matched each of the initial “case” group of 161 patients by age, sex, and risk of bradycardia on the basis of their general health. None of the 466 controls had visited a hospital for bradycardia by the “index date,” that is, the date of hospitalization of the case patient they matched. The researchers found 349 of the control patients had begun to take a cholinesterase inhibitor in the three months prior to the index date, compared with 117 who had stopped taking it at least six months before. A statistical analysis of these data showed that recent initiation of cholinesterase inhibitors was associated with approximately a doubling of the risk of hospitalization for bradycardia.
The authors repeated their procedure to see whether another class of drug, proton pump inhibitors, had a similar effect. As they had expected, it did not. They repeated the analysis for patients taking into account other drugs that slow the heart rate and found that their increased risk of bradycardia when taking a cholinesterase inhibitor persisted. The increase in risk was also similar in patients with pre-existing heart problems.
The researchers' data also showed that, excluding patients who while in the hospital had a pacemaker fitted to control their heart rate, over half of the patients released from hospital started taking a cholinesterase inhibitor again. Of these, a few returned to hospital with bradycardia within 100 days.
What Do These Findings Mean?
Recent guidelines suggest that doctors should not prescribe cholinesterase inhibitors for dementia patients as a matter of course, but weigh the potential risks and benefits. This paper provides evidence of an additional risk, of which at least some doctors are unaware. It was not possible to compare risk for different cholinesterase inhibitors because most patients took donepezil.
A population-based study like this cannot prove that cholinesterase inhibitors cause bradycardia. The authors used routinely collected data and so did not have information on all relevant risk factors, and thus there remains a possibility of bias due to unmeasured factors. In addition the authors had to make assumptions, for instance that patients took the drugs prescribed for them. They also considered only diagnoses of bradycardia made by a hospital doctor and not those made elsewhere, which means the incidence of bradycardia may have been underestimated. A strength of the study is the use of a case-time-control design, which has the advantage of reducing bias due to the different health conditions and lifestyle of individual patients, and also bias due to factors changing over time.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000157.
Wikipedia contains information on Alzheimer disease (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
Information on bradycardia and its causes can be found in Wikipedia (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The UKs National Health Service provides information on dementia, including symptoms, causes, diagnosis, treatment, and prevention
MedlinePlus provides US-based health information (in English and Spanish)
The US National Institute on Aging provides information on health, relevant to older people, including Alzheimer Disease and dementia (in English and Spanish)
The US Alzheimers Association contains useful information on the disease, including on medication
The Public Health Agency of Canada website provides information on senior health (in English and French)
The UK-based Alzheimers Society provides advice on caring for people with dementia
doi:10.1371/journal.pmed.1000157
PMCID: PMC2742897  PMID: 19787032
20.  Specialist geriatric medical assessment for patients discharged from hospital acute assessment units: randomised controlled trial 
Objective To evaluate the effect of specialist geriatric medical management on the outcomes of at risk older people discharged from acute medical assessment units.
Design Individual patient randomised controlled trial comparing intervention with usual care.
Setting Two hospitals in Nottingham and Leicester, UK.
Participants 433 patients aged 70 or over who were discharged within 72 hours of attending an acute medical assessment unit and at risk of decline as indicated by a score of at least 2 on the Identification of Seniors At Risk tool.
Intervention Assessment made on the acute medical assessment unit and further outpatient management by specialist physicians in geriatric medicine, including advice and support to primary care services.
Main outcome measures The primary outcome was the number of days spent at home (for those admitted from home) or days spent in the same care home (if admitted from a care home) in the 90 days after randomisation. Secondary outcomes were determined at 90 days and included mortality, institutionalisation, dependency, mental wellbeing, quality of life, and health and social care resource use.
Results The two groups were well matched for baseline characteristics, and withdrawal rates were similar in both groups (5%). Mean days at home over 90 days’ follow-up were 80.2 days in the control group and 79.7 in the intervention group. The 95% confidence interval for the difference in means was −4.6 to 3.6 days (P=0.31). No significant differences were found for any of the secondary outcomes.
Conclusions This specialist geriatric medical intervention applied to an at risk population of older people attending and being discharged from acute medical units had no effect on patients’ outcomes or subsequent use of secondary care or long term care.
doi:10.1136/bmj.f5874
PMCID: PMC3793323  PMID: 24103444
21.  Patterns and outcomes of medical admissions in the accident and emergency department of a tertiary health center in a rural community of Ekiti, Nigeria 
Background:
Low and middle-income countries like Nigeria face many challenges in emergency medical care owing to poor treatment facilities and inadequately trained personnel. Most Nigerians live in rural areas. The disease and death burdens in accident and emergency departments in this setting have not been closely studied.
Aim:
To determine the basic demographics, disease burden, and outcomes for accident and emergency admissions.
Settings and Design:
This retrospective study was carried out on patients admitted to an accident and emergency department.
Materials and Methods:
A retrospective review of medical admissions to the accident and emergency wards of the Federal Medical Centre, Ido-Ekiti, Ekiti State, southwest Nigeria, between January 2010 and December 2012.
Statistical analysis used:
The data were analyzed using SPSS Version 16 software. The results were presented in descriptive and tabular forms.
Result:
In all, 2922 patients were admitted during the study period (age range, 11-100 years; mean, 51.89 ± 20.11 years). There were 1679 (57.5%) males and 1243 (42.5%) females, with a ratio of 1.4:1. Young adults (aged 40 years and under) formed the highest age group (46.8%). The number of patients admitted for non-communicable diseases were high (1989 patients: 68.07%). Among non-communicable diseases, cardiovascular disorders were the most frequent (797; 27.28%). The most common cause of deaths was cardiovascular disease (33.5%).
Conclusion:
Young adults and males were the groups most commonly admitted. Non-communicable diseases were more frequent than communicable diseases. The proportion of patients discharged against medical advice and fatalities requires urgent attention.
doi:10.4103/0974-2700.142744
PMCID: PMC4231261  PMID: 25400386
Emergency; medicine; Nigeria; patient outcome; rural community
22.  Impact of a pharmacist-prepared interim residential care medication administration chart on gaps in continuity of medication management after discharge from hospital to residential care: a prospective pre- and post-intervention study (MedGap Study) 
BMJ Open  2012;2(3):e000918.
Objectives
To test the impact of a hospital pharmacist-prepared interim residential care medication administration chart (IRCMAC) on medication administration errors and use of locum medical services after discharge from hospital to residential care.
Design
Prospective pre-intervention and post-intervention study.
Setting
One major acute care hospital and one subacute aged-care hospital; 128 residential care facilities (RCF) in Victoria, Australia.
Participants
428 patients (median age 84 years, IQR 79–88) discharged to a RCF from an inpatient ward over two 12-week periods.
Intervention
Seven-day IRCMAC auto-populated with patient and medication data from the hospitals' pharmacy dispensing software, completed and signed by a hospital pharmacist and sent with the patient to the RCF.
Primary and secondary outcome measures
Primary end points were the proportion of patients with one or more missed or significantly delayed (>50% of prescribed dose interval) medication doses, and the proportion of patients whose RCF medication chart was written by a locum doctor, in the 24 h after discharge. Secondary end points included RCF staff and general practitioners' opinions about the IRCMAC.
Results
The number of patients who experienced one or more missed or delayed doses fell from 37/202 (18.3%) to 6/226 (2.7%) (difference in percentages 15.6%, 95% CI 9.5% to 21.9%, p<0.001). The number of patients whose RCF medication chart was written by a locum doctor fell from 66/202 (32.7%) to 25/226 (11.1%) (difference in percentages 21.6%, 95% CI 13.5% to 29.7%, p<0.001). For 189/226 (83.6%) discharges, RCF staff reported that the IRCMAC improved continuity of care; 31/35 (88.6%) general practitioners said that the IRCMAC reduced the urgency for them to attend the RCF and 35/35 (100%) said that IRCMACs should be provided for all patients discharged to a RCF.
Conclusions
A hospital pharmacist-prepared IRCMAC significantly reduced medication errors and use of locum medical services after discharge from hospital to residential care.
Article summary
Article focus
Medication administration errors are common when patients are discharged from hospital to a residential care facility (RCF). In Australia, a contributing factor is the need for the patient's primary care doctor to attend the RCF at short notice to write a medication administration chart; when the doctor cannot attend, doses may be missed or delayed and a locum doctor may be called to write a medication chart.
The objective of this study was to test the impact of a hospital pharmacist-prepared residential care medication administration chart (IRCMAC) on medication administration errors and use of locum medical services after discharge from hospital.
Key messages
Provision of a hospital pharmacist-prepared IRCMAC resulted in significant reductions in missed or delayed medication doses and use of locum medical services after discharge from hospital.
RCF staff reported that the IRCMAC improved continuity of care, and primary care doctors reported that it reduced pressure on them to attend RCFs at short notice.
Strengths and limitations of this study
This is the first study to evaluate the impact of a hospital-provided IRCMAC on medication errors or use of locum medical services. Strengths were that the two study groups were well matched in terms of demographics, ward type, number of medications and number of RCFs.
The main limitations were the use of a pre-intervention and post-intervention study design and data collection via RCF staff telephone interview. However, quantitative data on medication errors and use of locum services were validated by strongly positive feedback from RCF staff and doctors and widespread uptake and ongoing use of the IRCMAC.
doi:10.1136/bmjopen-2012-000918
PMCID: PMC3367148  PMID: 22637373
23.  Do callers to NHS Direct follow the advice to attend an accident and emergency department? 
Emergency Medicine Journal : EMJ  2003;20(3):285-288.
Methods: A representative three week period in May 2000 was investigated. During this period there were no health scares, major health campaigns, or bank holidays that may have affected the call rate. NHS Direct callers who were advised to attend A&E were identified. Data from the four A&E departments for the same three week period and two additional days were searched and matched to NHS Direct data by surname, date of birth, and post code. This process created three groups: (1) callers triaged to A&E who attended, (2) callers triaged to A&E who did not attend, (3) callers with different triage outcome who attended A&E. The age, sex, relationship of caller, time of call, and distance to nearest A&E were compared for groups (1) and (2).
Results: Just less than two third of callers triaged to A&E attended with the same presenting complaint. There were no statistically significant differences between group (1) and (2) in terms of age, sex, relationship of caller, time of call, and distance to A&E. A small number of callers (2.4%) were identified as being given other advice and attending A&E for the same presenting complaint. This group took significantly longer to attend A&E than group (1) (χ2 =139.01, df=7, p<0.001).
Conclusions: Assessing levels of compliance is difficult. These findings suggest that NHS Direct may have comparatively high levels of compliance compared with other similar services. However, using the single triage outcome as the means of identifying the advice given may oversimplify the range of possible advice given. The delay in attending A&E for the group of callers who were given other advice may indicate they had tried other actions. Further larger studies are needed to assess the appropriateness of referrals through investigation of clinical outcomes.
doi:10.1136/emj.20.3.285
PMCID: PMC1726112  PMID: 12748156
24.  Patients who do not receive continuity of care from their general practitioner--are they a vulnerable group? 
BACKGROUND: Continuity of care is much valued by general practitioners but little is known about those patients who do not receive continuity of care. AIM: This study set out to identify and describe a group of patients who did not receive continuity of care from the general practitioner with whom they were personally registered. METHOD: A total of 110 patients (71 female and 39 male) were identified, who did not receive continuity of care, defined as four consecutive face to face consultations which did not take place with the doctor with whom they were registered. This group was compared with an age and sex matched control group who did receive continuity of care, using general practice records, for demographic characteristics, morbidity, relationship problems, number of 'difficult' consultations, failure to attend appointments, and use of an accident and emergency department and of open access clinics. RESULTS: Patients in the study group were more likely to be under the age of 65 years than all patients on the doctor's list. Study patients were more likely than control patients to be in social class 4 or 5 living in a council house. Patients in the study group were more likely than controls to be depressed. Women patients in the study group were more likely to suffer from vaginal discharge. Men patients in the study group were more likely to complain of non-cardiac chest pain. The study group had more marital problems, parent-child relationship problems, and problems involving violence in the family, as well as other relationship problems. Relationship problems included the relationship with the doctor, since a third of all the consultations in the study group were recorded as 'difficult', compared with 3% in the control group. The study group patients were more likely than controls not to attend appointments which they had made, to use the accident and emergency department repeatedly, and to have used other open access clinics. CONCLUSION: Lack of continuity of care is associated with some additional morbidity, an increased number of relationship problems, 'difficult' consultations, and non-attendances, and an increase in the use of open access clinics. The characteristics of this group of patients represent a syndrome which merits further study.
PMCID: PMC1239173  PMID: 7772390
25.  Discharge Against Medical Advice in the Pediatric Wards in Boo-ali Sina Hospital, Sari, Iran 2010 
Acta Informatica Medica  2013;21(4):253-256.
Introduction:
Since children neither comprehended nor contribute to the decision, discharge against medical advice is a challenge of health care systems in the world. Therefore, the current study was designed to determine the rate and causes of discharge against medical advice.
Methods:
This descriptive cross-sectional study was done by reviewing the medical records by census method. Data was analyzed using SPSS software and x2 statistics was used to determine the relationship between variables. The value of P<0.05 was considered significant.
Results:
Rate of discharged against medical advice was 108 (2.2%). Mean of age and length of stay were 2.8±4 (SD).3 years old and 3.7±5.4 (SD) days, respectively. Totally, 95 patients (88.7%) had health insurance and 65 (60.2%) patients lived in urban areas. History of psychiatric disease and addiction in 22 (20.6%) of the parents were negative. In addition, 100 (92.3%) patients admitted for medical treatment and the others for surgery. The relationship of the signatory with patients (72.3%) was father. Of 108 patients discharged against medical advice, 20 (12%) were readmitted. The relationship between the day of discharge and discharge against medical advice was significant (ρ =0/03).
Conclusion:
Rate of discharge against medical advice in Boo-ali hospital is the same as the other studies in the same range. The form which is used for this purpose did not have suitable data elements about description of consequence of such discharge, and it has not shown the real causes of discharge against medical advice.
doi:10.5455/aim.2013.21.253-256
PMCID: PMC3916186  PMID: 24554800
Discharges against medical advice; Hospital; parents discharge; pediatric patients.

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