We used an ED syndromic surveillance system to understand the factors driving respiratory ED attendances in England and how these can be characterised by the syndromic indicators available. Respiratory indicators were observed to peak at different points during winter, with further variation observed in the distribution of attendances by age. Multiple linear regression revealed acute respiratory infection and bronchitis were sensitive to increasing RSV activity in infants. A less specific all respiratory indicator was found to be sensitive to RSV, showing the ability for this ED system to make full use of data even from sites using basic diagnosis coding.

Seasonal respiratory infections place an increased burden on health services annually. We used a sentinel emergency department syndromic surveillance system to understand the factors driving respiratory attendances at emergency departments (EDs) in England. Trends in different respiratory indicators were observed to peak at different points during winter, with further variation observed in the distribution of attendances by age. Multiple linear regression analysis revealed acute respiratory infection and bronchitis/bronchiolitis ED attendances in patients aged 1-4 years were particularly sensitive indicators for increasing respiratory syncytial virus activity. Using near real-time surveillance of respiratory ED attendances may provide early warning of increased winter pressures in EDs, particularly driven by seasonal pathogens. This surveillance may provide additional intelligence about different categories of attendance, highlighting pressures in particular age groups, thereby aiding planning and preparation to respond to acute changes in EDs, and thus the health service in general.

This report describes the development of novel syndromic cold weather public health surveillance indicators for use in monitoring the impact of extreme cold weather on attendances at EDs, using data from the 2010-11 and 2011-12 winters.A number of new surveillance indicators were created specifically for the identification and monitoring of cold weather related ED attendances, using the diagnosis codes provided for each attendance in the Emergency Department Syndromic Surveillance System (EDSSS), the first national syndromic surveillance system of its kind in the UK. Using daily weather data for the local area, a time series analysis to test the sensitivity of each indicator to cold weather was undertaken.Diagnosis codes relating to a health outcome with a potential direct link to cold weather were identified and assigned to a number of 'cold weather surveillance indicators'. The time series analyses indicated strong correlations between low temperatures and cold indicators in nearly every case. The strongest fit with temperature was cold related fractures in females, and that of snowfall was cold related fractures in both sexes.Though currently limited to a small number of sentinel EDs, the EDSSS has the ability to give near real-time detail on the magnitude of the impact of weather events. EDSSS cold weather surveillance fits well with the aims of the Cold Weather Plan for England, providing information on those particularly vulnerable to cold related health outcomes severe enough to require emergency care. This timely information aids those responding to and managing the effects on human health, both. within the EDs themselves and in the community as a whole. Crown Copyright (C) 2014 Published by Elsevier Ltd on behalf of The Royal Society for Public Health. All rights reserved.

DREEAM: Department of Research and Education in Emergency Medicine, Acute Medicine and Major Trauma, Nottingham University Hospitals NHS Trust, Nottingham, UK Emergency Department, Royal Victoria Infirmary, Newcastle Upon Tyne, UK Emergency Department, Birmingham Children’s Hospital, Birmingham, West Midlands, UK Emergency Department, James Cook University Hospital, Middlesbrough, UK Emergency Department, Barnsley District General Hospital, Barnsley, UK Accident and Emergency Department, Colchester Hospital University Foundation NHS Trust, Colchester, UK

ObjectiveTo evaluate the short-term efficacy and safety of methoxyflurane for the treatment of acute pain in patients presenting to an emergency department (ED) with minor trauma.MethodsSTOP! was a randomised, double-blind, multicentre, placebo-controlled study conducted at six sites in the UK. A total of 300 patients, 90 of whom were adolescent patients (age 12–17 years), were randomised 150:150 to receive either methoxyflurane via a Penthrox inhaler or placebo. The primary end point of the study was the change in pain intensity as measured using the visual analogue scale (VAS) from baseline to 5, 10, 15 and 20 min after the start of study drug inhalation. Patients were supplied with one inhaler containing 3 mL methoxyflurane or 5 mL placebo after enrolment and initial assessments. Age group (adolescent/adult) and baseline VAS score were controlled for in the statistical analyses.ResultsA total of 149 patients received methoxyflurane, and 149 patients received placebo. Demographic and baseline characteristics were comparable between the groups. Methoxyflurane reduced pain severity significantly more than placebo (p<0.0001) at all time points tested, with the greatest estimated treatment effect of −18.5 mm (adjusted change from baseline) seen at 15 min after the start of treatment. Methoxyflurane was well tolerated, with the majority of adverse reactions being mild, transient and in line with anticipated pharmacological action.ConclusionThe results of this study suggest that methoxyflurane administered via the Penthrox inhaler is an efficacious, safe, and rapidly acting analgesic.Trial registration number:NCT01420159.

Background This study illustrates the potential of using emergency department attendance data, routinely accessed as part of a national syndromic surveillance system, to monitor the impact of thunderstorm asthma. Methods The Emergency Department Syndromic Surveillance System (EDSSS) routinely monitors anonymised attendance data on a daily basis across a sentinel network of 35 emergency departments. Attendance data for asthma, wheeze and difficulty breathing are analysed on a daily basis. Results A statistically significant spike in asthma attendances in two EDSSS emergency departments in London was detected on 23 July 2013, coinciding with a series of large violent thunderstorms across southern England. There was also an increase in the reported severity of these attendances. Conclusions This preliminary report illustrates the potential of the EDSSS to monitor the impact of thunderstorms on emergency department asthma attendances. Further work will focus on how this system can be used to quantify the impact on emergency departments, thus potentially improving resource planning and also adding to the thunderstorm asthma evidence-base.

OBJECTIVES:As a result of gaps in middle-grade cover in the emergency department it became necessary for consultants to work some night shifts. This study aimed to examine the effect of this change in practice on performance.METHODS:A prospective observational study was conducted. Staffing and workload variables were collected over a period of 6 months in a single district general emergency department. The outcomes assessed were process times, the proportion of patients admitted and the proportion of patients returning within 7 days.RESULTS:Consultants worked 26 of 182 night shifts during the period studied. There were no differences in the number of patients present in the department at the start of the middle-grade or consultant night shifts. Fewer patients presented per hour during middle-grade night shifts: 3.8 patients per hour versus 4.4 patients per hour during consultant nights. Compared with middle-grade night shifts, the median waiting time was on average 19.6 min less and the median emergency department length of stay was 20.5 min less during consultant night shifts. The proportion of patients admitted from the emergency department was on average 3.9% less than during middle-grade night shifts but there was no difference in the proportion returning within 7 days.CONCLUSION:In this small single-site study, a consultant working nights has been shown to reduce process times and the rate of admission. It remains unclear whether such improvements would be sustained in the longer term.

Mason et al1Mason S. Weber E.J. Coster J. et al.Time patients spend in the emergency department: England's 4-hour rule—a case of hitting the target but missing the point?.Ann Emerg Med. 2011; (Epub ahead of print)Google Scholar raise some important points in their article discussing England's 4-hour rule. The rule has its flaws, the major criticism being that it detracts from the clinical priorities of the patient. However, as the authors conclude, it has led to improvements in emergency department (ED) waiting times. The Department of Health in England has in fact recently replaced the 4-hour rule in favor of clinical quality indicators,2Department of HealthA&E clinical quality indicators: implementation guidance and data definitions.http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122868Google Scholar and many National Health Service trusts have reported increasing waiting times. In our own trust, between September 2009 and June 2010, there were 101,745 attendances to the ED, of which 98.6% of patients met the 4-hour rule. Mean length of stay in the ED was 3 hours 24 minutes for patients admitted to the medical admissions unit and 3 hours 19 minutes for those admitted to the elderly admissions unit. After the replacement of the target in April 2011, we reanalyzed our ED attendances. Between May 1 and November 30, 2011, there were 74,658 patient attendances to the ED, of which 92.6% (98.6% versus 92.6%; P<.001) met the 4-hour rule. Mean length of stay in the ED increased by 18 minutes for medical admissions unit patients and 10 minutes for elderly admissions unit patients. Although there is no evidence that the 4-hour rule led to improved quality of care, it did help resolve the chronic problem of crowding, which appeared to be endemic in England's EDs. Since the replacement of the 4-hour rule in England, there is a worrying trend of increasing waiting times, and the United States could do worse than adopting it to help resolve problems of crowding in its EDs. Time Patients Spend in the Emergency Department: England's 4-Hour Rule—A Case of Hitting the Target but Missing the Point?Annals of Emergency MedicineVol. 59Issue 5PreviewTo address concerns about prolonged emergency department (ED) stays from crowding, England mandated that the maximum length of ED stay for 98% of patients be no greater than 4 hours. We evaluate the effect of the mandated ED care intervals in England. Full-Text PDF In replyAnnals of Emergency MedicineVol. 60Issue 1PreviewThank you for responding to our article.1 The 4-hour target has been replaced by a dashboard of quality indicators aiming to better represent the patient journey and experience.2 Although we appreciate that this may be leading to increased emergency department (ED) waiting times and therefore contributing to more crowded EDs, our article sought to highlight that enforcing a shorter total ED waiting time was not sustainable, as evidenced by the increasing proportion of patients being moved out of the ED year after year in the last 20 minutes before the target time. Full-Text PDF

Objective Digit preference bias has previously been described in a number of different clinical settings including the emergency department. This study aimed to assess whether the implementation of a computerised recording system affects the digit preference bias in recording of times of arrival, assessment and departure at an emergency department. Methods A preintervention/postintervention study was undertaken in a type 1 district general hospital emergency department that receives approximately 70 000 attendances per annum. Consecutive 8-week samples were taken before and after the introduction of an electronic whiteboard/patient tracking system. Timings of arrival, nursing and medical assessment and departure were compared. Results Twelve thousand four hundred and ninety-three patients presented during the 8-week control period and 11 758 patients presented in the 8-week period after the introduction of electronic data capturing. Within the control group, over 80% of the nursing assessment (82.7%), medical examination (92.5%) and departure times (92.7%) ended in ‘0’ or ‘5’, compared with just over 20% after electronic recordings (22.0, 21.7 and 21.8% respectively). Conclusion The introduction of the patient tracking system eliminated the digit preference bias found in recording of the time of nursing assessment, examination and departure that was present in the preintervention data.

Study objective: To address concerns about prolonged emergency department (ED) stays from crowding, England mandated that the maximum length of ED stay for 98% of patients be no greater than 4 hours. We evaluate the effect of the mandated ED care intervals in England.Methods: This was a retrospective analysis of ED patient throughput before, during, and after implementation of the target. Fifteen acute hospital trusts' ED data were purposively sampled, including all patient visits during May and June of 2003 to 2006. We compared total time in ED and time to clinician across years, segregating for admitted versus discharged patients and young versus old patients, using a random-effects regression model and adjusting for hospital clustering.Results: We analyzed 735,588 ED visits. The proportion of patients seen and treated within 4 hours improved from 83.9% to 96.3%. Adjusted total length of ED stay from 2003 to 2006 increased by 8.6 minutes for all patients and 30 minutes for admissions; time to physician improved by 1 minute for all patients. The proportion of patients leaving the ED during the last 20 minutes before 4 hours increased from 4.7% of all patients in 2003 to 8.4% in 2006. Admitted patients were more likely than discharged ones to leave the ED in the last 20 minutes, and the relative likelihood increased each year after 2003, with incidence rate ratio 1.04 (95% confidence interval [Cl] 0.78 to 1.39), 1.39 (95% Cl 1.05 to 1.82), and 1.55 (95% Cl 1.19 to 2.20) for 2004, 2005, and 2006, respectively. An increasing proportion of elderly patients were in the last 20-minute departure interval each year compared with younger patients (in 2003 7.4% versus 4.1%; in 2006 17.3% versus 6.3%).Conclusion: The introduction of a time target reduced the proportion of patients staying greater than 4 hours. More patients departed within 20 minutes of the target 4-hour interval after the mandate, notably, the elderly. [Ann Emerg Med. 2012;59:341-349.]

Background The London 2012 Olympic and Paralympic Games is a mass gathering event that will present a major public health challenge. The Health Protection Agency, in collaboration with the College of Emergency Medicine, has established the Emergency Department Sentinel Syndromic Surveillance System (EDSSS) to support the public health surveillance requirements of the Games.Methods This feasibility study assesses the usefulness of EDSSS in monitoring indicators of disease in the community. Daily counts of anonymised attendance data from six emergency departments across England were analysed by patient demographics (age, gender, partial postcode), triage coding and diagnosis codes. Generic and specific syndromic indicators were developed using aggregations of diagnosis codes recorded during each attendance.Results Over 339 000 attendances were recorded (26 July 2010 to 25 July 2011). The highest attendances recorded on weekdays between 10:00 and 11:00 and on weekends between 12:00 and 13:00. The mean daily attendance per emergency department was 257 (range 38-435). Syndromic indicators were developed including: respiratory, gastrointestinal, cardiac, acute respiratory infection, gastroenteritis and myocardial ischaemia. Respiratory and acute respiratory infection indicators peaked during December 2010, concomitant with national influenza activity, as monitored through other influenza surveillance systems.Conclusions The EDSSS has been established to provide an enhanced surveillance system for the London 2012 Olympics. Further validation of the data will be required; however, the results from this initial descriptive study demonstrate the potential for identifying unusual and/or severe outbreaks of infectious disease, or other incidents with public health impact, within the community.

BACKGROUND:Information regarding waiting times has been shown to be a key determinant of patient satisfaction. This study aimed to examine the potential accuracy of predicted waiting times determined on the patient's arrival in the Emergency Department (ED).METHODS:A retrospective study of 50 000 consecutive patients attending a single ED was undertaken. A linear regression model was developed to predict waiting times, assessing a number of different measures derived from the waiting times of patients seen immediately prior to an individual patient's time of arrival. To assess the fit of the model, the mean absolute difference between the patient's actual and predicted waiting times was determined.RESULTS:6726 patients had incomplete data and were excluded from the analysis. The mean waiting time across all streams was 64.6 (SD 43.7) min. The best performing linear regression model used two variables to predict a patient's waiting time, calculated across the entire sample of patients. This model predicted 27% of the variability in waiting time. The mean absolute difference between actual and predicted waiting times across all streams was 29.0 (SD 23.5) min. The mean absolute difference in waiting times was similar across the streams.CONCLUSIONS:There is a considerable difference between predicted and actual waiting times using this method. Further investigation is required to determine whether such a degree of inaccuracy is acceptable to patients and improves satisfaction more than the provision of no information regarding waiting times.

The UK four hour standard for processing patients attending emergency departments was introduced at 90% in 2004 and has sat at 98% since 2005. We have shown that the effect of the target is not uniform—patients admitted to hospital from the emergency department were affected most by a “spike” in activity during the …

The introduction of targets within emergency medicine has led to numerous changes in the way care is delivered in the UK. These changes are largely based on local priorities and demands rather than evidence. However, staff within emergency departments (ED) do not operate in silos, but depend on strong relationships across organisational and professional boundaries to achieve their goals. This study …

OBJECTIVE:This study aimed to develop a definition of frequent use of an emergency department (ED) by comparing differences in the observed frequency distribution with that of a theoretical frequency distribution.METHODS:A retrospective analysis of attendance of ED and minor injury unit attendances in one city over 1 year was conducted. From these data, the expected frequency distribution was determined based upon a Poisson distribution.RESULTS:During the period studied, 75,141 people attended on 98,908 occasions. The theoretical frequency distribution showed that there were 2764 (3.7%) "frequent users" presenting repeatedly due to non-random events. These patients made 12,316 (12.4%) attendances. Frequent users were older than chance users (mean age 49.7 vs 44.5 years). A greater proportion arrived by ambulance (55.3% vs 27.5%), presented with psychiatric problems (5.8% vs 1.1%) or alcohol intoxication (1.3% vs 0.5%), and were admitted to hospital (37.4% vs 19.6%).CONCLUSION:We have identified that there is a group of patients who present repeatedly due to non-random events, confirming the existence of "frequent users". Their characteristics are clearly different to other patients in the ED. We propose that "frequent users" be defined as any patient who makes more than four attendances per year.

Objectives: To estimate the diagnostic accuracy of non-invasive tests for proximal deep vein thrombosis (DVT) and isolated calf DVT, in patients with clinically suspected DVT or high-risk asymptomatic patients, and identify factors associated with variation in diagnostic performance. Also to identify practical diagnostic algorithms for DVT, and estimate the diagnostic accuracy, clinical effectiveness and cost-effectiveness of each.Data sources: Electronic databases ( to April 2004). A postal survey of hospitals in the UK.Review methods: Selected studies were assessed against validated criteria. A postal survey of hospitals in the UK was undertaken to describe current practice and availability of tests, and identify additional diagnostic algorithms. Pooled estimates of sensitivity, specificity and likelihood ratios were obtained for each test using random effects meta-analysis. The effect of study-level covariates was explored using random effects metaregression. A decision-analytic model was used to combine estimates from the meta-analysis and estimate the diagnostic performance of each algorithm in a theoretical population of outpatients with suspected DVT. The net benefit of using each algorithm was estimated from a health service perspective, using cost - utility analysis, assuming thresholds of willingness to pay of pound 20,000 and pound 30,000 per quality-adjusted life-year ( QALY). The model was analysed probabilistically and cost-effectiveness acceptability curves were generated to reflect uncertainty in estimated cost-effectiveness.Results: Individual clinical features are of limited diagnostic value, with most likelihood ratios being close to 1. Wells clinical probability score stratifies proximal, but not distal, DVT into high-, intermediate- and low-risk categories. Unstructured clinical assessment by experienced clinicians may have similar performance to Wells score. In patients with clinically suspected DVT, D-dimer has 91% sensitivity and 55% specificity for DVT, although performance varies substantially between assays and populations. D-dimer specificity is dependent on pretest clinical probability, being higher in patients with a low clinical probability of DVT. Plethysmography and rheography techniques have modest sensitivity for proximal DVT, poor sensitivity for distal DVT, and modest specificity. Ultrasound has 94% sensitivity for proximal DVT, 64% sensitivity for distal DVT and 94% specificity. Computed tomography scanning has 95% sensitivity for all DVT ( proximal and distal combined) and 97% specificity. Magnetic resonance imaging has 92% sensitivity for all DVT and 95% specificity. The diagnostic performance of all tests is worse in asymptomatic patients. The most cost-effective algorithm discharged patients with a low Wells score and negative D-dimer without further testing, and then used plethysmography alongside ultrasound, with venography in selected cases, to diagnose the remaining patients. However, the cost-effectiveness of this algorithm was dependent on assumptions of test independence being met and the ability to provide plethysmography at relatively low cost. Availability of plethysmography and venography is currently limited at most UK hospitals, so implementation would involve considerable reorganisation of services. Two algorithms were identified that offered high net benefit and would be feasible in most hospitals without substantial reorganisation of services. Both involved using a combination of Wells score, D-dimer and above-knee ultrasound. For thresholds of willingness to pay of pound 10,000 or pound 20,000 per QALY the optimal strategy involved discharging patients with a low or intermediate Wells score and negative D-dimer, ultrasound for those with a high score or positive D-dimer, and repeat scanning for those with positive D-dimer and a high Wells score, but negative initial scan. For thresholds of pound 30,000 or more a similar strategy, but involving repeat ultrasound for all those with a negative initial scan, was optimal.Conclusions: Diagnostic algorithms based on a combination of Wells score, D-dimer and ultrasound ( with repeat if negative) are feasible at most UK hospitals and are among the most cost-effective. Use of repeat scanning depends on the threshold for willingness to pay for health gain. Further diagnostic testing for patients with a low Wells score and negative D-dimer is unlikely to represent a cost-effective use of resources. Recommendations for research include the evaluation of the costs and outcomes of using the optimal diagnostic algorithms in routine practice, the development and evaluation of algorithms appropriate for specific groups of patients with suspected DVT, such as intravenous drug abusers, pregnant patients and those with previous DVT, the evaluation of the role of plethysmography: interaction with other diagnostic tests, outcome of low-risk patients with negative plethysmography and measurement of the costs of providing plethysmography, and methodological research into the incorporation of meta-analytic data into decision-analytic modelling.

Objective Digit preference bias has previously been described in a number of different clinical settings. The paper aimed to assess whether digit preference bias affects the recording of the time patients arrive and leave emergency departments. Method An observational study of 137 emergency departments in England and Wales was conducted. Each department was asked to submit details of the time of arrival and time of departure from the emergency department for each patient attending during April 2004. In addition, interviews with the lead clinician were undertaken to determine the method used to record the time of departure. The degree of digit preference bias was assessed using a modification of Whipple's index. Results One hundred and twenty-three (86.9%) departments submitted data detailing 648 203 emergency department episodes. 114875 (18.0%) episodes had a recorded minute of departure of ‘0’ or ‘30’, with a further 2 81 890 (44.1%) having other values with a terminal digit of ‘0’ or ‘5’. The mean modified Whipple's index for time of departure was 316.9 (range 70.9–484.4). Linear regression demonstrates a small but significant inverse relationship between the modified Whipple's index and the mean total time in department (b=−0.05, 95% CIs −0.09 to −0.0004, P=0.048). Conclusion Some departments show considerable digit preference bias in the recording of time of departure from the emergency department. Such bias may cause difficulty in assessing changes in the performance of departments.

Objective: When patients present to an emergency department because of nontraumatic headache, they often present a diagnostic challenge. This study aimed to examine the utility of clinical features in detecting serious underlying causes of nontraumatic headache in adult patients presenting to an emergency department.Methods: A prospective observational study of alert adult patients presenting to 1 UK emergency department over a period of 14 months was conducted. Patients were excluded if their headache was related to trauma or they had been previously recruited into the study. A standardized data collection form was used to record details of the history and examination findings. Investigation and management were conducted according to the existing departmental protocols. Patients were followed up for 3 months following their initial presentation. Each factor in the history and examination was examined for its ability to predict a serious underlying cause of headache.Results: Five hundred and eighty-nine patients were included in the study with complete follow-up details obtained on 558 (94.7%) patients. Seventy-five (13.4%) patients were found to have a serious pathological cause of their headache. Four features were found to be significant independent predictors of serious pathology, these were age > 50 years (likelihood ratio (LR) = 2.34), sudden onset, (LR = 1.74), any abnormality on neurological examination (LR = 3.56), and presentation due to associated features (LR = 2.27). Taken in combination, the presence of any 1 of the first 3 features has a sensitivity of 98.6% and specificity of 34.4% (Positive LR = 1.50, Negative LR = 0.04).Conclusion: Three features, age greater than 50, sudden onset, and an abnormal neurological examination, are identified as significant independent predictors of serious pathology, which, in combination, can exclude the presence of such pathology in adult patients presenting with nontraumatic headache.