BackgroundThe re-engineering of emergency department (ED) processes in the UK since 2002 has produced significant reductions in waiting times.AimsWe aim to describe the generic themes contributory to this improvement in performance, which has led to progress not yet replicated elsewhere in the English-speaking world.MethodsWe reviewed the Emergency Services Collaborative (ESC) set up by the National Health Service (NHS) Modernisation Agency as well as our own departmental performance in order to identify key themes for discussion. In addition, we reviewed relevant information from the UK Department of Health website. We used the 4-h target of patient passage through the ED as our primary outcome measure.ResultsEarly results from the ESC showed improvements, which have been sustained and enhanced since inception. We use our hospital performance figures to demonstrate a pattern of progressive improvement in performance, with 99.1% of all new attenders in 2007–2008 being seen, treated and discharged or admitted within 4 h of presentation to the ED.ConclusionsThe whole systems approach to re-engineering emergency care has led to universal improvements in patient throughput in EDs in the UK. Several of the concepts found to be useful in the NHS are worthy of consideration and adoption by other health care systems. Long waits in the ED are a thing of the past in the UK.
A total of 519 patients presenting with carcinoma of the caecum in the Plymouth Health District between 1975 and 1987 were reviewed. The clinical course was determined in relation to patients with and without a history of previous appendicectomy. There was no difference in the incidence of previous appendicectomy between patients with carcinoma of the caecum and an age and sex matched control group. The presence of synchronous carcinomas and/or adenomas was unrelated to previous appendicectomy. Ten patients presented with appendicitis and 11 with a mucocele of the appendix as the first sign of carcinoma of the caecum. Previous appendicectomy was associated with a higher incidence of local fixity, invasion of the abdominal wall, metastatic spread and poor differentiation. These differences were reflected in a significantly lower resection rate for carcinomas in patients who had previously undergone appendicectomy. The survival of patients who had previously had appendicectomy was significantly reduced. Four independent prognostic factors for survival were identified using multivariate discriminant analysis. These were Dukes' classification, local invasion, tumour differentiation and previous appendicectomy. Local recurrence was more common in patients who had previously had appendicectomy and was often in the old appendicectomy wound itself. Appendicectomy does not increase the risk of carcinogenesis in the caecum. In this study a history of appendicectomy was an independent risk factor for survival and significantly worsened the prognosis for patients who subsequently developed carcinoma of the caecum.
Most circumcisions take place for religious rather than medical reasons. Geoff Hinchley argues that the practice is harmful and should be stopped but Kirsten Patrick believes that the future sexual health benefits justify parental choice
Indwelling shunts to divert CSF flow are essential in treating hydrocephalus. There is a high incidence of shunt malfunction, which accounts for the increasing popularity of endoscopic third ventriculostomy. Failure to recognize and act on symptoms and signs of shunt malfunction may lead to loss of life or to permanent neurological dysfunction. This review provides the basis for assessment and management based on updated clinical knowledge.
Urine testing for genital C trachomatis in the emergency department can identify asymptomatic men in the community who may otherwise remain undetected. It is suggested that this is a worthwhile screening test to offer in the emergency department, providing follow-up for treatment can be arranged locally. There is no requirement for increased emergency department input into these patients over and above introducing them to the screening programme.
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