Background Alcohol, drugs and self-harm are important public health issues that often coincide with socioeconomic inequalities. While national policy frameworks highlight these as important issues, data describing their prevalence in unscheduled care are lacking.Aim To conduct the first national-level description of the number, demographic characteristics and routes of care involving alcohol, drugs or self-harm emergencies across all unscheduled care services in Scotland.Methods A retrospective cross-sectional study using linked data from all unscheduled care services in Scotland (NHS 24 telephone triage service; primary care out-of-hours; ambulance; emergency department (ED); acute admission and mental health admission). All continuous care episodes (defined as pathways) were analysed and within these, indicators for involvement of alcohol, drugs and/or self-harm were identified from service level 'flags' and clinical codes. Pathways from 1 April 2022 to 31 March 2023 were included. Descriptive analyses of characteristics, exploration of the top 30 most common pathways and top-down pathway-attributable-cost analyses were undertaken.Results Of 2 721 120 pathways, 2.7% involved alcohol, drugs and/or self-harm-indicating considerable overlaps and complexity of care episodes. In 1.9% of all pathways only one of these indicators was identified. For the top 30 pathways (reflecting 79.0% of pathways involving only one indicator), the most common patient journey was ambulance to ED to acute admission, with an overall directly attributable cost to the National Health Service of approximately 216.9 pound million.Conclusion Using current structured data, 1.9% of unscheduled care pathways in Scotland involve alcohol, drugs or self-harm and 2.7% involve one or several of these indicators. Ambulance services and EDs feature in most of these care pathways and are potential settings for intervention. Future work should explore these pathways in greater depth, refine case identification at service level and develop integrated care models within the ED to better serve this patient population and address health inequalities.
Purpose To evaluate the diagnostic accuracy of high-sensitivity point-of-care (hs-POC) cardiac troponin algorithms for rule-out and rule-in of acute myocardial infarction (AMI) in emergency departments.Methods This PROSPERO-registered systematic review (CRD420251170970) searched MEDLINE, CENTRAL and trial registries (2005-2025) for studies evaluating serial hs-POC troponin testing (0 hour/1 hour or 0 hour/2 hour algorithms) in adults with suspected AMI. Primary outcomes were sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool.Results Eight studies (19 datasets; 9384 patients; 1157 AMI cases) evaluated four hs-POC platforms: Siemens Atellica VTLi, PHC Pathfast, QuidelOrtho TriageTrue and BioM & eacute;rieux SPINCHIP. Rule-out algorithms achieved pooled sensitivity 98.0% (95% CI 96.0% to 99.0%) and NPV 99.9% at an assumed AMI prevalence of 10%, with no additional missed AMI events reported during follow-up among patients classified as rule-out. Rule-in algorithms achieved specificity 96.0% (94.0% to 97.0%) and PPV 68.5% assuming a disease prevalence of 10%. Complex multiparametric algorithms showed higher pooled sensitivity (99.3%, I & sup2;=0%) than simple cut-off approaches (96.9%). The 0 hour/1 hour protocol showed similar diagnostic accuracy to 0 hour/2 hour while potentially allowing clinical decisions approximately 1 hour earlier. All four evaluated platforms achieved rule-out sensitivities >= 97%. All evaluated platforms met contemporary high-sensitivity analytical criteria and reported turnaround times of 8-17 min enabling rapid clinical decision-making and high diagnostic accuracy for both rule-out and rule-in applications. Overall risk of bias was low in 75% of datasets.Conclusions hs-POC troponin algorithms demonstrated high diagnostic accuracy for both rule-out and rule-in of AMI. Validated serial testing pathways, including 0 hour/1 hour and 0 hour/2 hour strategies, showed favourable diagnostic performance across evaluated platforms. Further implementation studies are needed to define their impact on emergency department workflow and patient outcomes.PROSPERO registration number CRD420251170970.
