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Objective: To investigate the potential impact for ambulance services of telephone assessment and triage for callers who present with non-serious problems (Category C calls) as classified by ambulance service call takers. Design: Pragmatic controlled trial. Calls identified using priority dispatch protocols as non-serious were allocated to intervention and control groups according to time of call. Ambulance dispatch occurred according to existing procedures. During intervention sessions, nurses or paramedics within the control room used a computerised decision support system to provide telephone assessment, triage and, if appropriate, offer advice to permit estimation of the potential impact on ambulance dispatch. Setting: Ambulance services in London and the West Midlands. Subjects: Patients for whom emergency calls were made to the ambulance services between April 1998 and May 1999 during four hour sessions sampled across all days of the week between 0700 and 2300. Main outcome measures: Triage decision, ambulance cancellation, attendance at an emergency department. Results: In total, there were 635 intervention calls and 611 controls. Of those in the intervention group, 330 (52.0%) were triaged as not requiring an emergency ambulance, and 119 (36.6%) of these did not attend an emergency department. This compares with 55 (18.1%) of those triaged by a nurse or paramedic as requiring an ambulance (odds ratio 2.62; 95% CI 1.78 to 3.85). Patients triaged as not requiring an emergency ambulance were less likely to be admitted to an inpatient bed (odds ratio 0.55; 95% CI 0.33 to 0.93), but even so 30 (9.2%) were admitted. Nurses were more likely than paramedics to triage calls into the groups classified as not requiring an ambulance. After controlling for age, case mix, time of day, day of week, season, and ambulance service, the results of a logistic regression analysis revealed that this difference was significant with an odds ratio for nurses:paramedics of 1.28 (95% CI 1.12 to 1.47). Conclusions:The findings indicate that telephone assessment of Category C calls identifies patients who are less likely to require emergency department care and that this could have a significant impact on emergency ambulance dispatch rates. Nurses were more likely than paramedics to assess calls as requiring an alternative response to emergency ambulance despatch, but the extent to which this relates to aspects of training and professional perspective is unclear. However, consideration should be given to the acceptability, reliability, and cost consequences of this intervention before it can be recommended for full evaluation. S tudies in several countries have shown the rate of unnecessary emergency ambulance call out and subsequent attendance at accident and emergency departments to be between 11% to 52%. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15] This contributes to inefficient, clinically inappropriate health care, and may delay the provision of emergency care to those with life threatening needs. 16 However, research e...

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Implications for practice included: exploring new and effective methods of education based on behavioural theories; involving staff in updating policies and procedures; formal assessment of staff during intravenous preparation and administration.

This review raises concerns about handovers at the interface between prehospital and hospital settings. The quality of existing research in this area is relatively poor and further high-quality research is required to understand this important part of emergency care. We need to understand the complexity of handover better to grasp the challenges of context and interprofessional relationships before we reach for tools and techniques to standardise part of the handover process.

on cumulative dose by introducing matching (at least partially) on dose.Breslow and Day have said: "Occasions arise in which the association of one factor with disease appears at least partially to be explained by a second factor (associated both with disease and with the first factor), but where the two factors are essentially measuring the same thing, or where the second factor is a consequence of the first." 1 Although over-matching is mentioned in textbooks, substantive examples are not common. We have presented an example in which results from other studies were different. This difference indicated that over-matching was likely to be a problem.We thank BNFL, which allowed its data to be used in the study, and the Office for National Statistics for information on mortality. We also thank David McGeoghegan of Westlakes Scientific Consulting for his important contribution to the design, the data collection, and the examination of the matching factors; and Steve Whaley, also of Westlakes Scientific Consulting, whose work on the nested case-control analysis identified date of entry as the likely factor causing the over-matching.Funding: The Engineering and Physical Sciences Research Council (EPSRC), Westlakes Scientific Consulting (CASE studentship).Competing interests: JLH was an investigator on the EPSRC CASE award, which funded JLM; the CASE partner was Westlakes Scientific Consulting. KB was also an investigator on the EPSRC CASE award and is employed by Westlakes Scientific Consulting, which receives research funding from British Nuclear Fuels to support KB, DMcG, and SW in their work on the case-control study. The number of emergency (999) calls received by ambulance services in the United Kingdom has risen consistently over recent years. Ambulance services must respond to calls immediately by sending vehicles staffed by paramedics, with flashing lights and sirens. All patients have to be taken to an accident and emergency department. This response is not always appropriate, and it can result in inefficient use of resources and unnecessary risks to the general public, patients, and paramedics.The NHS Plan and the recent consultation document Reforming Emergency Care have emphasised the importance of trying new approaches to deliver appropriate care. 1 2 They highlight the need to consider new ways to integrate the ambulance response to 999 calls into the overall system that deals with emergencies.

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The adverse pulmonary effects of asbestos are well accepted in scientific circles. However, the extrapulmonary consequences of asbestos exposure are not as clearly defined. In this review the potential for asbestos to produce diseases of the peritoneum, immune, gastrointestinal (GIT), and reproductive systems are explored as evidenced in published, peer-reviewed literature. Several hundred epidemiological, in vivo, and in vitro publications analyzing the extrapulmonary effects of asbestos were used as sources to arrive at the conclusions and to establish areas needing further study. In order to be considered, each study had to monitor extrapulmonary outcomes following exposure to asbestos. The literature supports a strong association between asbestos exposure and peritoneal neoplasms. Correlations between asbestos exposure and immune-related disease are less conclusive; nevertheless, it was concluded from the combined autoimmune studies that there is a possibility for a higher-than-expected risk of systemic autoimmune disease among asbestos-exposed populations. In general, the GIT effects of asbestos exposure appear to be minimal, with the most likely outcome being development of stomach cancer. However, IARC recently concluded the evidence to support asbestos-induced stomach cancer to be “limited.” The strongest evidence for reproductive disease due to asbestos is in regard to ovarian cancer. Unfortunately, effects on fertility and the developing fetus are under-studied. The possibility of other asbestos-induced health effects does exist. These include brain-related tumors, blood disorders due to the mutagenic and hemolytic properties of asbestos, and peritoneal fibrosis. It is clear from the literature that the adverse properties of asbestos are not confined to the pulmonary system.