More than 50% of patients with suspected PTE may be subject to unwarranted use of CTPA in the absence of pre-test clinical prediction rules coupled with D-dimer assays.

While the reported incidence of heroin use in the UK has reduced, related hospital admissions and associated mortality have continued to increase. Prompt access to treatment (opiate replacement therapy (ORT) and counselling support) have been shown to reduce risk and offer clients the optimal route to recovery. The Specialist Drug and Alcohol Recovery Service (Osprey House) within National Health Service Highland had lengthy delays from referral to commencing ORT (median wait 56 days), which this project aimed to reduce.A rapid process improvement workshop (RPIW) was undertaken to redesign the patient pathway from referral to recovery. The RPIW consisted of three phases: phase I, planning and preparation (12 weeks before the workshop week); phase II, the workshop week; and phase III, the follow-up. Metrics included the lead time from referral to initiating ORT and other process measures at baseline, and then repeated at 30, 60, 90 and 180 days, respectively. Additionally, data were routinely collected on the percentage of clients treated within 3 weeks, as was weekly data on the new process of screening clients within 1 day of referral. Multiple lean tools and techniques, including Plan, Do, Study, Act cycles, were used to test and implement new ways of working.Results at 180 days found the median time from referral to initiating ORT improved from a baseline of 56 to 21 days (63% improvement), room usage improved from 49% to 65% (32% increase) and standard work improved from level 1 to level 3. Increases in the number of clients treated within 3 weeks were demonstrated. Other metrics remained static or reported fluctuations too inconsistent to claim improvement at this point.By applying the Lean principles of removing waste and increasing value, we have redesigned our service, reducing the length of time clients with drug problems wait from referral to commencing ORT.

PurposeTo assess the extent to which accelerated diagnostic protocols (ADPs), compared to traditional care, identify patients presenting to emergency departments (EDs) with chest pain who are at low cardiac risk and eligible for early ED discharge.Patients and methodsRetrospective study of 290 patients admitted to hospital for further evaluation of chest pain following negative ED workup (no acute ischemic electrocardiogram [ECG] changes or elevation of initial serum troponin assay). Demographic data, serial ECG and troponin results, Thrombolysis in Myocardial Infarction (TIMI) score, cardiac investigations, and outcomes (confirmed acute coronary syndrome [ACS] at discharge and major adverse cardiac events [MACEs]) over 6 months of follow-up were analyzed. A validated ADP (ADAPT-ADP) was retrospectively applied to the cohort, and processes and outcomes of ADP-guided care were compared with those of care actually received.ResultsPatients had mean (±SD) TIMI score of 1.8 (±1.7); six (2.0%) patients were diagnosed with ACS at discharge. At 6 months, one patient (0.3%) re-presented with ACS and two (0.6%) died of non-coronary causes. The ADAPT-ADP defined 97 (33.4%) patients as being at low risk and eligible for early ED discharge, but who instead incurred mean hospital stay of 1.5 days, with 40.2% in telemetry beds, and 21.6% subject to non-invasive testing with only one positive result for coronary artery disease. None had a discharge diagnosis of ACS or developed MACE at 6 months.ConclusionCompared to traditional care, application of the ADAPT-ADP would have allowed one-third of chest pain patients with initially negative investigations in ED to have been safely discharged from ED.