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2.  Short stay emergency admissions to a West Midlands NHS Trust: a longitudinal descriptive study, 2002–2005 
Emergency Medicine Journal : EMJ  2007;24(8):553-557.
To describe changes and characteristics in emergency admissions to a West Midlands National Health Service Trust, 2002–2005, with a focus on short stay emergency admissions.
A longitudinal descriptive study using retrospective analysis of routine admissions data. Admissions were categorised as short (0/1 day) or long (⩾2 days) and examined separately using a General Linear Model. Factors favouring short stays as opposed to long stays were examined using multivariable logistic regression.
There were 151 478 emergency admissions to the Trust between 1 April 2002 and 31 December 2005, of which 2910 (1.92%) had no discharge date recorded. Adjusted means showed a 7.76% increase in emergency admissions in winter months (October–January) and a 14.50% increase across the study period. Increases were greater in short stay (34.03%) than long stay emergency admissions (8.38%). Odds of short stays in admitted patients increased by 25%. Higher odds of short stays were also associated with younger age, winter month and medical admitting specialty (p<0.001).
Increases in emergency admissions were greater in short stay than long stay cases. Reasons for this may be both appropriate (increased use of clinical protocols and falling average length of stay) and detrimental (pressure to meet 4 h emergency department target, changing primary care provision). Further research is needed before generalising findings to other Trusts.
PMCID: PMC2660078  PMID: 17652676
4.  Emergency care for children—the next steps 
Recommended steps for improved medical services to children and those needing urgent medical attention
PMCID: PMC2083140  PMID: 17185441
5.  Use of intravenous cyclizine in cardiac chest pain 
PMCID: PMC2579569  PMID: 16794116
6.  Enhanced cell attachment using a novel cell culture surface presenting functional domains from extracellular matrix proteins 
Cytotechnology  2008;56(2):71-79.
Many factors contribute to the creation and maintenance of a realistic environment for cell growth in vitro, e.g. the consistency of the growth medium, the addition of supplements, and the surface on which the cells grow. The nature of the surface on which cells are cultured plays an important role in their ability to attach, proliferate, migrate and function. Components of the extracellular matrix (ECM) are often used to coat glass or plastic surfaces to enhance cell attachment in vitro. Fragments of ECM molecules can be immobilised on surfaces in order to mimic the effects seen by whole molecules. In this study we evaluate the application of a novel technology for the immobilisation of functional domains of known ECM proteins in a controlled manner on a surface. By examining the adherence of cultured PC12 cells to alternative growth surfaces, we show that surfaces coated with motifs from collagen I, collagen IV, fibronectin and laminin can mimic surfaces coated with the corresponding whole molecules. Furthermore, we show that the adherence of cells can be controlled by modifying the hydropathic properties of the surface to either enhance or inhibit cell attachment. Collectively, these data demonstrate the application of a new technology to enable optimisation of cell growth in the tissue culture laboratory.
PMCID: PMC2259265  PMID: 19002844
Cell attachment; Cell culture surface; Collagen; Fibronectin; Laminin; PC12 cells
7.  Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis 
BMJ : British Medical Journal  2007;336(7636):130-133.
Objective To evaluate the effectiveness of multifactorial assessment and intervention programmes to prevent falls and injuries among older adults recruited to trials in primary care, community, or emergency care settings.
Design Systematic review of randomised and quasi-randomised controlled trials, and meta-analysis.
Data sources Six electronic databases (Medline, Embase, CENTRAL, CINAHL, PsycINFO, Social Science Citation Index) to 22 March 2007, reference lists of included studies, and previous reviews.
Review methods Eligible studies were randomised or quasi-randomised trials that evaluated interventions to prevent falls that were based in emergency departments, primary care, or the community that assessed multiple risk factors for falling and provided or arranged for treatments to address these risk factors.
Data extraction Outcomes were number of fallers, fall related injuries, fall rate, death, admission to hospital, contacts with health services, move to institutional care, physical activity, and quality of life. Methodological quality assessment included allocation concealment, blinding, losses and exclusions, intention to treat analysis, and reliability of outcome measurement.
Results 19 studies, of variable methodological quality, were included. The combined risk ratio for the number of fallers during follow-up among 18 trials was 0.91 (95% confidence interval 0.82 to 1.02) and for fall related injuries (eight trials) was 0.90 (0.68 to 1.20). No differences were found in admissions to hospital, emergency department attendance, death, or move to institutional care. Subgroup analyses found no evidence of different effects between interventions in different locations, populations selected for high risk of falls or unselected, and multidisciplinary teams including a doctor, but interventions that actively provide treatments may be more effective than those that provide only knowledge and referral.
Conclusions Evidence that multifactorial fall prevention programmes in primary care, community, or emergency care settings are effective in reducing the number of fallers or fall related injuries is limited. Data were insufficient to assess fall and injury rates.
PMCID: PMC2206297  PMID: 18089892
8.  Total time in English accident and emergency departments is related to bed occupancy 
Emergency Medicine Journal : EMJ  2004;21(5):575-576.
PMCID: PMC1726451  PMID: 15333534
9.  A survey of current consultant practice of treatment of severe ankle sprains in emergency departments in the United Kingdom 
Emergency Medicine Journal : EMJ  2003;20(6):505-507.
Objective: To determine current consultant practice in larger UK emergency departments in the management of severe ankle sprains.
Design: Questionnaire study to all UK emergency departments seeing more than 50 000 new patients per year.
Results: 70% response rate. Most popular treatment was ice, elevation, Tubigrip, and exercise, each of which was reported as used in most cases by over 70% of respondents. Crutches, early weight bearing, and non-steroidal anti-inflammatory drugs were each reported as used in most cases at over half of responding departments. Physiotherapy was usually only used in selected cases. Rest was usually advised for one to three days (35%). Follow up was only recommended for selected patients.
Conclusions: The results of this survey suggest that there is considerable variation in some aspects of the clinical approach (including drug treatment, walking aids, periods of rest) taken to the management of severe ankle sprains in the UK, although in some areas (for example, not routinely immobilising, early weight bearing as pain permits, use of physiotherapy, use of rest, ice, and elevation) there was concordance.
PMCID: PMC1726246  PMID: 14623832
10.  Discharge from triage: modelling the potential in different types of emergency department 
Emergency Medicine Journal : EMJ  2003;20(2):131-133.
Objective: To assess the potential for patients to be assessed and discharged directly from triage in an emergency department (ED).
Methods: Modelling was undertaken by collection of retrospective electronic data from four different EDs. Serial removal of groups was undertaken using data from coding systems related to patients details of admission/treatment/investigations and procedure undertaken. The final group left were analysed for ambulance usage, prior primary care consultation, and age group.
Results: 29.4% patients were discharged after clinical assessment but without any specific treatment or investigation. It was seen that of the patients who can be considered for discharge from triage, 15.5% were brought to the ED by ambulance, 3.5% were patients who had already consulted primary care, and 11% were children.
Conclusions: This study suggests that a large percentage of patients seen in EDs may not require the extra facilities of that department. There is potential for a large number to be discharged within a few minutes of arrival if appropriate assessment skills are available at first contact. This may require more senior assessment than is currently used. This study has not assessed safety of such a system or the times of day when it is best deployed.
PMCID: PMC1726074  PMID: 12642524
11.  Reforming the UK emergency care system 
Emergency Medicine Journal : EMJ  2003;20(2):113-114.
PMCID: PMC1726073  PMID: 12642515
12.  Use of emergency observation and assessment wards: a systematic literature review 
Emergency Medicine Journal : EMJ  2003;20(2):138-142.
Introduction: Observation and assessment wards allow patients to be observed on a short-term basis and permit patient monitoring and/or treatment for an initial 24–48 hour period. They should permit concentration of emergency activity and resources in one area, and so improve efficiency and minimise disruption to other hospital services. These types of ward go under a variety of names, including observation, assessment, and admission wards. This review aims to evaluate the current literature and discuss assessment/admission ward functionality in terms of organisation, admission criteria, special patient care, and cost effectiveness.
Methods: Search of the literature using the Medline and BIDS databases, combined with searches of web based resources. Critical assessment of the literature and the data therein is presented.
Results: The advantages and disadvantages of the use of assessment/admission wards were assessed from the current literature. Most articles suggest that these wards improve patient satisfaction, are safe, decrease the length of stay, provide earlier senior involvement, reduce unnecessary admissions, and may be particularly useful in certain diagnostic groups. A number of studies summarise their organisational structure and have shown that strong management, staffing, organisation, size, and location are important factors for efficient running. There is wide variation in the recommended size of these wards. Observation wards may produce cost savings largely relating to the length of stay in such a unit.
Conclusion: All types of assessment/admission wards seem to have advantages over traditional admission to a general hospital ward. A successful ward needs proactive management and organisation, senior staff involvement, and access to diagnostics and is dependent on a clear set of policies in terms of admission and care. Many diagnostic groups benefit from this type of unit, excluding those who will inevitably need longer admission. Vigorous financial studies have yet to be undertaken in the UK. Definitions of observation, assessment, and admission ward are suggested.
PMCID: PMC1726054  PMID: 12642526
13.  One size does not fit all. View 2 
Emergency Medicine Journal : EMJ  2003;20(2):120-122.
PMCID: PMC1726045  PMID: 12642521
14.  The effect of a separate stream for minor injuries on accident and emergency department waiting times 
Introduction: To decrease waiting times within accident and emergency (A&E) departments, various initiatives have been suggested including the use of a separate stream of care for minor injuries ("fast track"). This study aimed to assess whether a separate stream of minor injuries care in a UK A&E department decreases the waiting time, without delaying the care of those with more serious injury.
Intervention: A doctor saw any ambulant patients with injuries not requiring an examination couch or an urgent intervention. Any patients requiring further treatment were returned to the sub-wait area until a nurse could see them in another cubicle.
Method: Data were retrospectively extracted from the routine hospital information systems for all patients attending the A&E department for five weeks before the institution of the separate stream system and for five weeks after.
Results: 13 918 new patients were seen during the 10 week study period; 7117 (51.1%) in the first five week period and 6801 (49.9%) in the second five week period when a separate stream was operational. Recorded time to see a doctor ranged from 0–850 minutes. Comparison of the two five week periods demonstrated that the proportion of patients waiting less than 30 and less than 60 minutes both improved (p<0.0001). The relative risk of waiting more than one hour decreased by 32%. The improvements in waiting times were not at the expense of patients with more urgent needs.
Conclusions: The introduction of a separate stream for minor injuries can produce an improvement in the number of trauma patients waiting over an hour of about 30%. If this is associated with an increase in consultant presence on the shop floor it may be possible to achieve a 50% improvement. It is recommended that departments use a separate stream for minor injuries to decrease the number of patients enduring long waits in A&E departments.
PMCID: PMC1725754  PMID: 11777867
15.  Minor injury services—the present state 
PMCID: PMC1725622
16.  Emergency care—in and out of hospital 
PMCID: PMC1725603  PMID: 11435352
17.  A major sporting event does not necessarily mean an increased workload for accident and emergency departments. Euro96 Group of Accident and Emergency Departments 
AIM: To determine whether there were any changes in attendance at accident and emergency departments that could be related to international football matches (Euro96 tournament). METHOD: Fourteen accident and emergency departments (seven adjacent to and seven distant from a Euro96 venue) provided their daily attendance figures for a nine week period: three weeks before, during, and after the tournament. The relation between daily attendance rates and Euro96 football matches was assessed using a generalised linear model and analysis of variance. The model took into account underlying trends in attendance rates including day of the week. RESULTS: The 14 hospitals contributed 172 366 attendances (mean number of daily attendances 195). No association was shown between the number of attendances at accident and emergency departments and the day of the football match, whether the departments were near to or distant from stadia or the occurrence of a home nation match. The only observed independent predictors of variation were day of the week and week of the year. Attendance rates were significantly higher on Sunday and/or Monday; Monday was about 9% busier than the daily average. Increasing attendance was observed over time for 86% of the hospitals. CONCLUSION: Large sports tournaments do not increase the number of patients attending accident and emergency departments. Special measures are not required for major sporting events over and above the capacity of an accident and emergency department to increase its throughput on other days. 

PMCID: PMC1756198  PMID: 10522636
19.  Questionnaires of accident and emergency departments: Are they reproducible? 
Background—Questionnaires are commonly sent to accident and emergency (A&E) departments to determine common practice and are often extrapolated to best practice.
Aims—To determine if questionnaire based studies have a defined population of A&E departments and whether studies are reproducible.
Methods—All questionnaires in the Journal of Accident and Emergency Medicine were reviewed and assessed for inclusion criteria, departments studied and study design.
Results—30 questionnaires were detected, 22 were postal, six telephone and two did not state method of contact. Sample sizes ranged from 15 to 740 and inclusion of A&E departments was highly variable according to geographical area, size of department or consultant status. Seventeen (54.8%) did not state the source of A&E department listings. Response rates ranged from 55–100%. Only three studies undertook subset analysis according to either size or locality.
Conclusions—Questionnaire studies of A&E departments have poor methodology descriptions, which means that many are not reproducible. Inclusion criteria are highly variable and failure to analyse important subsets may mean that individual departments cannot apply recommendations. Questionnaire studies relating to A&E do not use a consistent well defined population of A&E departments. Information in the studies is usually inadequate to allow them to be repeated.
PMCID: PMC1725442  PMID: 11005408
20.  Public understanding of medical terminology: non-English speakers may not receive optimal care 
Introduction—Many systems of telephone triage are being developed (including NHS Direct, general practitioner out of hours centres, ambulance services). These rely on the ability to determine key facts from the caller. Level of consciousness is an important indicator after head injury but also an indicator of severe illness.
Aims—To determine the general public's understanding of the term unconscious.
Methods—A total of 700 people were asked one of seven questions relating to their understanding of the term unconscious. All participants were adults who could speak sufficient English to give a history to a nurse.
Results—Correct understanding of the term unconscious varied from 46.5% to 87.0% for varying parameters. Those with English as their first language had a better understanding (p<0.01) and there was a significant variation with ethnicity (p<0.05).
Conclusions—Understanding of the term unconscious is poor and worse in those for whom English is not a first language. Decision making should not rely on the interpretation of questions using technical terms such as unconscious, which may have a different meaning between professional and lay people.
PMCID: PMC1725361  PMID: 10718234
21.  Study of choice between accident and emergency departments and general practice centres for out of hours primary care problems 
Objectives—To determine the reasons for choosing between primary care out of hours centres and accident and emergency (A&E) departments for patients with primary care problems.
Methods—Interviews using a semi-structured approach of samples of patients attending A&E departments and general practitioner (GP) out of hours centres for primary care problems.
Results—102 patient interviews were undertaken. Sixty two per cent of A&E attenders were unemployed compared with 41% of out of hours attenders. White people were more likely to attend A&E departments and Asians the out of hours centre (p<0.01) and unemployed were more likely to attend A&E departments (70% v 30%). Some 46.3% of A&E department attenders had not contacted their GP before attending; 81.3% of first time users of the out of hours centre found out about it on the day of interview. Those attending A&E thought waiting times at the out of hours centre would be 6.3 hours (median) compared with a median perceived time of 2.9 hours by those actually attending the out of hours centre. Actual time was actually much less.
Conclusion—Once patients have used the GP out of hours centre they are more likely to use it again. Education should be targeted at young adults, the unemployed and white people. Patients should be encouraged to contact their GP before A&E department attendance for non-life threatening conditions. Waiting time perception may be an important reason for choice of service.
PMCID: PMC1756266  PMID: 10658985
23.  Study of early warning of accident and emergency departments by ambulance services. 
OBJECTIVE: To determine the warning time given to accident and emergency (A&E) departments by the ambulance service before arrival of a critically ill or injured patient. To determine if this could be increased by ambulance personnel alerting within five minutes of arrival at scene. METHODS: Use of computerised ambulance control room data to find key times in process of attending a critically ill or injured patient. Modelling was undertaken with a scenario of the first responder alerting the A&E department five minutes after arrival on scene. RESULTS: The average alert warning time was 7 min (range 1-15 min). Mean time on scene was 22 min (range 4-59 min). In trauma patients alone, the average alert time was 7 min, range 2-15 min, with an average on scene time of 23 min, range 4-53 min. There was a potential earlier alert time averaging 25 min (SD 18.6, range 2-59 min) if the alert call was made five minutes after arrival on scene. CONCLUSIONS: A&E departments could be alerted much earlier by the ambulance service. This would allow staff to be assembled and preparations to be made. Disadvantages may be an increased "alert rate" and wastage of staff time while waiting the ambulance arrival.
PMCID: PMC1347052  PMID: 10505913
24.  Does the Manchester triage system detect the critically ill? 
BACKGROUND: The Manchester triage system (MTS) is now widely used in UK accident and emergency (A&E) departments. No clinical outcome studies have yet been published to validate the system. Safety of triage systems is related to the ability to detect the critically ill, which has to be balanced with resource implications of overtriage. OBJECTIVES: To determine whether the MTS can reliably detect those subsequently needing admission to critical care areas. METHODS: Analysis of emergency admissions to critical care areas and comparison with original A&E triage code by a nurse using the MTS at time of presentation. Retrospective coding of all cases according to the MTS by experts and case analysis to determine whether any non-urgent coding was due to the system or to incorrect coding. RESULTS: Sixty one (67%) of the patients admitted to a critical care area were given triage category 1 or 2 (that is, to be seen within 10 minutes of arrival). Eighteen cases given lower priority were due to incorrect coding by the triage nurse. Six cases were correctly coded by the MTS, of which five deteriorated after arrival in the A&E department. Only one case was critically ill on arrival and yet was coded as able to wait for up to one hour. CONCLUSIONS: The MTS is a sensitive tool for detecting those who subsequently need critical care and are ill on arrival in the A&E department. It did fail to detect some whom deteriorated after arrival in A&E. Most errors were due to training problems rather than the system of triage. Analysis of critically ill patients allows easy audit of sensitivity of the MTS but cannot be used to calculate specificity.
PMCID: PMC1343329  PMID: 10353042
25.  The largest mass gathering  
BMJ : British Medical Journal  1999;318(7189):957-958.
PMCID: PMC1115406  PMID: 10195952

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