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Biomedical subjects

S W Goodacre

Publications and source records attributed to S W Goodacre.

8 recordsLinked to original sources
PubMed2000

Should we establish chest pain observation units in the UK? A systematic review and critical appraisal of the literature.

OBJECTIVES: The chest pain observation unit (CPOU) has been developed in the United States to allow rigorous assessment of patients presenting with chest pain, thus expediting their discharge if assessment is negative. This review aims to examine the evidence for effectiveness and economic efficiency of the CPOU and to explore whether data from the United States can be extrapolated to the UK. METHOD: Search of the literature using Medline and critical appraisal of the validity of the data. RESULTS: Five studies comparing outcomes of CPOU care with routine practice showed no significant difference in objective measures including mortality or missed pathology. Eleven studies described outcomes of a cohort of CPOU patients. Follow up was comprehensive and demonstrated no clinically significant evidence of missed pathology. Nine studies comparing CPOU costs with routine care demonstrated impressive cost savings that were more modest when randomised comparisons were made. CONCLUSION: CPOU care is safe and costs are well defined. There is no strong evidence that a CPOU will improve outcomes if routine practice is good. Cost savings have been shown when compared with routine care in the United States but may not be reproduced the UK.

Chest Pain↗
PubMed1999

Consistency of retrospective triage decisions as a standardised instrument for audit.

OBJECTIVES: To determine the level of agreement between senior medical staff when asked to perform retrospective case note review of nursing triage decisions, both before and after development of a consensus approach. METHODS: Four medical reviewers independently allocated triage categories to 50 emergency department patients after review of their case notes. They were blind to the identity of the triage nurse and their triage categorisation. The process was repeated twice, firstly after agreement on a consensus approach and then using formal guidelines. RESULTS: Agreement between reviewers was initially fair to moderate (kappa = 0.27 to 0.53). This failed to improve after development of a consensus approach (kappa = 0.29 to 0.57). There was a trend towards better agreement when guidelines were used but agreement was still only moderate (kappa = 0.31 to 0.63). CONCLUSIONS: Audit of nurse triage categorisation by senior medical staff performing case note review has only fair to moderate consistency between reviewers. Use of this technique will result in frustration among those whose performance is being audited if they recognise inconsistency in the standard they are compared against.

Australia↗
PubMed1998

Role of the short stay observation ward in accident and emergency departments in the United Kingdom.

OBJECTIVE: To define the role of the accident and emergency (A&E) short stay ward by a survey of departments in the United Kingdom and review of published reports. METHODS: A postal questionnaire with telephone follow up to all major A&E departments with short stay beds. RESULTS: 95 departments were found to have short stay beds. These units received between 19000 and 121000 new patients per year (mean 51000, median 50500) and had access to between two and 20 beds (mean 7.5, median 6). The level of provision varied from one bed per 2440 new attendances to one bed per 27250 new attendances (mean 8380, median 6625). Where data on admission rates were available the departments admitted between 0.1% and 13.3% of their new attendances (mean 2.62%, median 1.9%). Cover was typically provided by an A&E senior house officer with frequent senior ward rounds. While the casemix usually included minor head injuries and alcohol intoxicated patients, there was considerable variation in the cases admitted. CONCLUSIONS: Short stay provision is highly variable in the United Kingdom. While there are many reports of well run short stay units, consistent evidence of clinical value and cost-effectiveness compared to other methods of care is lacking. Further comparative studies are required to define the role of the A&E short stay ward.

Cost-Benefit Analysis↗
PubMed1997

Trauma triage: a comparison of CRAMS and TRTS in a UK population.

The CRAMS scale and the Triage Revised Trauma Score (TRTS) were compared to assess their potential use as a prehospital method of activating hospital trauma teams. We studied patients from the resuscitation room of Leeds General Infirmary who had enough data recorded to allow calculation of the admission TRTS and CRAMS scale. Patients were defined as having major injury if they died in hospital, were admitted to the ICU or had an Injury Severity Score (ISS) of > 15. Each triage scale was compared by calculating multiple sensitivity/specificity pairs and plotting the results on a receiver operator (ROC) curve. The optimal cut-offs on each scale were compared directly. Ninety-seven (46 per cent) of a total of 213 patients fulfilled the study criteria for major injury. The best cut-off points were a CRAMS of < 9 and a TRTS of < 12. The TRTS was significantly more specific (0.9 versus 0.75) but at a cost of poor sensitivity (0.6 versus 0.69, not significant). The performance of both scales was similar when compared on the ROC curve. CRAMS and the TRTS were unable to identify major injuries in our sample with sensitivity and specificity adequate to support their use as a tool to activate trauma teams in the UK.

Adult↗
PubMed1997

On-scene times for trauma patients in West Yorkshire.

OBJECTIVE: To assess whether length of time on-scene in patients with major injury was associated with severity of injury or with abnormal on-scene physiology. METHODS: A retrospective analysis of a convenience sample of patients in whom prehospital on-scene times were entered onto the regional major trauma database. On-scene times of patients were analysed to assess whether ultimate injury severity score or on scene physiology measurements affected times. This was undertaken by examining subgroups of patients with similar injury severity or physiological measurements by Wilcoxon-Mann-Whitney testing and comparing 95% confidence intervals of the mean on-scene times. RESULTS: The mean on-scene time for 111 non-entrapped patients was 26 minutes (95% confidence interval 23.5 to 28.6). Patients with injury severity score of > 15, with a Glasgow coma scale of < 13, and with an abnormal pulse spent significantly less time on-scene than less severely injured or physiologically deranged patients. CONCLUSIONS: Paramedics have the ability to recognise patients with severe injury and reduce on-scene times. On-scene times were consistently long throughout all subgroups of major trauma patients.

Adolescent↗
PubMed1997

How do individuals with diabetes use the accident and emergency department?

OBJECTIVE: To determine whether the frequency and pattern of use of the accident and emergency (A&E) department by individuals with diabetes is different from that of the general population. METHODS: A historical cohort of 696 individuals with diabetes from six randomly selected general practices and a non-diabetic comparison cohort matched on age, sex, and general practice were identified. The use of an urban A&E department by the two cohorts was compared for number of visits between 1984 and 1996 for injuries, diabetes related and non-diabetes related illness, proportion referred by a general practitioner, proportion arriving by ambulance, and proportion admitted. RESULTS: More visits were made by the diabetic cohort (1002 v 706, P = 0.0001); 121 visits were directly related to diabetes, including 52 for hypoglycaemia. The diabetic cohort also had more visits for medical illness unrelated to diabetes (357 v 231, P = 0.0001). The number of visits for injuries was similar (524 v 475, P = 0.3). Individuals with diabetes who attended A&E were not significantly more likely to be referred by a general practitioner (14% v 16%) or admitted (20% v 17%). CONCLUSIONS: Individuals with diabetes made more frequent visits than the general population to the A&E department. Since there was no excess of visits for injuries and the proportion requiring admission was similar, the hypothesis that they have a different threshold for attending is not supported.

Adolescent↗
PubMed1996

A protocol to improve analgesia use in the accident and emergency department.

OBJECTIVE: To assess the use of analgesia in an accident and emergency (A&E) department and identify shortcomings. SETTING: University teaching hospital. METHODS: An audit of patients referred from the A&E department to orthopaedic fracture clinic (n = 100) or for orthopaedic admission (n = 100) was carried out to document analgesia use. An analgesia protocol was introduced and analgesia use was reassessed on the same numbers of patients. RESULTS: Prescribing of analgesia was initially poor: 91% of fracture clinic referrals and 39% of admissions received no analgesia while in the A&E department; when given, it was often by inappropriate routes. Introduction of an analgesia protocol significantly improved analgesia use: fracture clinic referrals receiving unsatisfactory analgesia were reduced from 91% to 69% (P < 0.001). There was a marked increase in the use of intravenous analgesia, from 9% to 37% (P < 0.001). CONCLUSIONS: Large numbers of patients still receive no analgesia while in the A&E department. This seems to be a common problem requiring intervention at a national level. The absence of a coordinated approach to improving analgesia provision for acute trauma in the United Kingdom should be addressed urgently.

Analgesia↗