Doctor-staffed ambulance helicopters: to what extent can the general practitioner replace the anaesthesiologist?
(33/2311)
During two years, a rural ambulance helicopter programme saved 41 patients' lives. In 29 of these patients, the decisive medical interventions were carried out by the flight anaesthesiologist before reaching the hospital. We asked an expert panel to assess whether these interventions could have been carried out by a general practitioner (GP). This was the case for 17 (59%) of the 29 patients, while more advances skills, equipment or drugs were needed for 11 (38%). Among these 11, three patients would probably have died without the interventions. We conclude that GPs can manage a majority of life saving missions for a rural ambulance helicopter programme, but the lack of a flight anaesthesiologist may imply substantial health losses for a few patients. (+info)
Demand for and supply of out of hours care from general practitioners in England and Scotland: observational study based on routinely collected data.
(34/2311)
OBJECTIVES: To determine the level of demand and supply of out of hours care from a nationally representative sample of general practice cooperatives. DESIGN: Observational study based on routinely collected data on telephone calls, patient population data from general practices, and information about cooperatives from interviews with managers. SETTING: 20 cooperatives in England and Scotland selected after stratification by region and by size. SUBJECTS: 899 657 out of hours telephone calls over 12 months. MAIN OUTCOME MEASURES: Numbers and age and sex specific rates of calls; variation in demand and activity in relation to characteristics of the population; timing of calls; proportion of patients consulting at home, at a primary care centre, or on the telephone; response times; hospital admission rates. RESULTS: The out of hours call rate (excluding bank holidays) was 159 calls per 1000 patients/year, with rates in children aged under 5 years four times higher than for adults. Little variation occurred by day of the week or seasonally. Cooperatives in Scotland experienced higher demand than those in England. Patients living in deprived areas made 70% more calls than those in non-deprived areas, but this had little effect on the overall variation in demand. 45.4% (408 407) of calls were handled by telephone advice, 23.6% (212 550) by a home visit, and 29.8% (267 663) at a centre. Cooperatives responded to 60% of calls within 30 minutes and to 83% within one hour. Hospital admission followed 5.5% (30 743/554 179) of out of hours calls (8 admissions per 1000 patients/year). CONCLUSIONS: This project provides national baseline data for the planning of services and the analysis of future changes. (+info)
Comparison of conventional surgical versus Seldinger technique emergency cricothyrotomy performed by inexperienced clinicians.
(35/2311)
BACKGROUND: Cricothyrotomy is the ultimate option for a patient with a life-threatening airway problem. METHODS: The authors compared the first-time performance of surgical (group 1) versus Seldinger technique (group 2) cricothyrotomy in cadavers. Intensive care unit physicians (n = 20) performed each procedure on two adult human cadavers. Methods were compared with regard to ease of use and anatomy of the neck of the cadaver. Times to location of the cricothyroid membrane, to tracheal puncture, and to the first ventilation were recorded. Each participant was allowed only one attempt per procedure. A pathologist dissected the neck of each patient and assessed correctness of position of the tube and any injury inflicted. Subjective assessment of technique and cadaver on a visual analog scale from 1 (easiest) to 5 (worst) was conducted by the performer. RESULTS: Age, height, and weight of the cadavers were not different. Subjective assessment of both methods (2.2 in group 1 vs. 2.4 in group 2) and anatomy of the cadavers (2.2 in group 1 vs. 2.4 in group 2) showed no statistically significant difference between both groups. Tracheal placement of the tube was achieved in 70% (n = 14) in group 1 versus 60% (n = 12) in group 2 (P value not significant). Five attempts in group 2 had to be aborted because of kinking of the guide wire. Time intervals (mean +/- SD) were from start to location of the cricothyroid membrane 7 +/- 9 s (group 1) versus 8 +/- 7s (group 2), to tracheal puncture 46 +/- 37s (group 1) versus 30 +/- 28s (group 2), and to first ventilation 102 +/- 42s (group 1) versus 100 +/- 46s (group 2) (P value not significant). CONCLUSIONS: The two methods showed equally poor performance. (+info)
Prehospital care--a UK perspective.
(36/2311)
In the UK, emergency ambulances are responding to astonishing increases in levels of emergency calls, in the order of a 40% increase nationally in the last 5 years. Pressures in primary care service out-of-hours provision, and increasing community-based care of elderly patients, as well as increased expectation by the public are contributory causes. Services are also being pressed to improve response times, particularly to life-threatening cases. These various aspects are discussed below. (+info)
Cost analysis of nurse telephone consultation in out of hours primary care: evidence from a randomised controlled trial.
(37/2311)
OBJECTIVE: To undertake an economic evaluation of nurse telephone consultation using decision support software in comparison with usual general practice care provided by a general practice cooperative. DESIGN: Cost analysis from an NHS perspective using stochastic data from a randomised controlled trial. SETTING: General practice cooperative with 55 general practitioners serving 97 000 registered patients in Wiltshire, England. SUBJECTS: All patients contacting the service, or about whom the service was contacted during the trial year (January 1997 to January 1998). MAIN OUTCOME MEASURES: Costs and savings to the NHS during the trial year. RESULTS: The cost of providing nurse telephone consultation was 81 237 pound sterling per annum. This, however, determined a 94 422 pound sterling reduction of other costs for the NHS arising from reduced emergency admissions to hospital. Using point estimates for savings, the cost analysis, combined with the analysis of outcomes, showed a dominance situation for the intervention over general practice cooperative care alone. If a larger improvement in outcomes is assumed (upper 95% confidence limit) NHS savings increase to 123 824 pound sterling per annum. Savings of only 3728 pound sterling would, however, arise in a scenario where lower 95% confidence limits for outcome differences were observed. To break even, the intervention would have needed to save 138 emergency hospital admissions per year, around 90% of the effect achieved in the trial. Additional savings of 16 928 pound sterling for general practice arose from reduced travel to visit patients at home and fewer surgery appointments within three days of a call. CONCLUSIONS: Nurse telephone consultation in out of hours primary care may reduce NHS costs in the long term by reducing demand for emergency admission to hospital. General practitioners currently bear most of the cost of nurse telephone consultation and benefit least from the savings associated with it. This indicates that the service produces benefits in terms of service quality, which are beyond the reach of this cost analysis. (+info)
Epileptological emergencies in accident and emergency: a survey at St James's university hospital, Leeds.
(38/2311)
Many patients attending an Accident and Emergency (A&E) department with seizures never come into contact with a neurological service. This survey was designed to find out how many patients with epileptological emergencies come to A&E and how they are managed. Cases were identified using the computerized A&E database. The A&E records of all adult patients attending the casualty department at St James's University Hospital with emergencies related to epilepsy between 1 April and 30 September 1998 were reviewed retrospectively. Out of a total of 36 024 adults attending A&E, 190 were related to epileptological emergencies. A problem relating to a previously recognized seizure disorder was the commonest reason for attendance. Patient management was highly variable and often suboptimal. Descriptions of seizure semiology and examination findings were frequently deficient. Up to 37.5 mg of diazepam, in up to five boluses, was given. Twenty per cent of patients with a diagnosis of status epilepticus were discharged home after diazepam treatment. Neurologists only became involved in 24.2% of cases. Epileptological emergencies only make up a small proportion of cases seen in adult A&E departments. Treatment and referral guidelines should be agreed between A&E staff and neurologists. The communication between general, specialist and acute services needs to be improved. (+info)
Relationship of socioeconomic status to the incidence and prehospital, 28-day, and 1-year mortality rates of acute coronary events in the FINMONICA myocardial infarction register study.
(39/2311)
BACKGROUND: Low socioeconomic status (SES) is associated with increased coronary heart disease mortality rates. There are, however, very little data on the relation of SES to the incidence, recurrence, and prognosis of myocardial infarction (MI) events. METHODS AND RESULTS: The FINMONICA MI Register recorded detailed information on all MI events among men and women aged 35 to 64 years in 3 areas of Finland during the period of 1983 to 1992. We carried out a record linkage of the MI register data with files of Statistics Finland to obtain information on indicators of SES, such as taxable income and education, for each individual who is registered. In the analyses, income was grouped into 3 categories (low, middle, and high), and education was grouped into 2 categories (basic and secondary or higher). Among men with their first MI event (n=6485), the adjusted incidence rate ratios were 1.67 (95% CI 1.57 to 1.78) and 1.84 (95% CI 1.73 to 1.95) in the low- and middle-income categories compared with the high-income category. For 28-day mortality rates, the corresponding rate ratios were 3.18 (95% CI 2.82 to 3.58) and 2.33 (95% CI 2.03 to 2.68). Significant differentials were observed for prehospital mortality rates, and they remained similar up to 1 year after the MI. Findings among the women were consistent with those among the men. CONCLUSIONS: The excess coronary heart disease mortality and morbidity rates among persons with low SES are considerable in Finland. To bring the mortality rates of low- and middle-SES groups down to the level of that of the high-SES group constitutes a major public health challenge. (+info)
Asthma aggravation, combustion, and stagnant air.
(40/2311)
BACKGROUND: The relationship between current concentrations of ambient air pollution and adverse health effects is controversial. We report a meteorological index of air stagnation that is associated with daily visits to the emergency department for asthma in two urban areas. METHODS: Data on daily values of a stagnation persistence index and visits to the emergency department for asthma were collected for approximately two years in Spokane, Washington, USA and for 15 months in Seattle, Washington, USA. The stagnation persistence index represents the number of hours during the 24 hour day when surface wind speeds are less than the annual hourly median value, an index readily available for most urban areas. Associations between the daily stagnation persistence index and daily emergency department visits for asthma were tested using a generalised additive Poisson regression model. A factor analysis of particulate matter (PM(2.5)) composition was performed to identify the pollutants associated with increased asthma visits. RESULTS: The relative rate of the association between a visit to the emergency department for asthma and the stagnation persistence index was 1. 12 (95% CI 1.05 to 1.19) in Spokane and 1.21 (95% CI 1.09 to 1.35) in Seattle for an increase of 11 and 10 hours, respectively, of low wind speed in a given day. The stagnation persistence index was only correlated with one set of factor loadings; that cluster included the stagnation persistence index, carbon monoxide, and organic/elemental carbon. CONCLUSION: Increased air stagnation was shown to be a surrogate for accumulation of the products of incomplete combustion, including carbon monoxide and fine particulate levels of organic and elemental carbon, and was more strongly associated with asthma aggravation than any one of the measured pollutants. (+info)