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1 A 12 week prospective survey of all patients of any age with confirmed or suspected poisoning presenting to six accident and emergency departments in the North East of England was performed to establish the local incidence and patterns of presentation of poisoning. 2 945 episodes of poisoning involving 852 patients were recorded representing approximately 1.2% of all A&E presentations and suggesting an annual attendance rate of 2.7 per 1000 persons per year. 3 Attendance rates varied threefold between hospitals and were similar in males and females overall; between the ages of five and 14 attendances were more common in females (1.9 vs 0.6/103/y) while between 0 and 4 y (3.1 vs 2.4) and 25 and 34 y (3.9 vs 2.9/103/y) they were more common in males. 4 The median interval between poisoning and presenta tion was 2 h (mean 4.1 h) and only 19% of cases presented within 1 h. Presentation was most common between Friday evening and Tuesday morning and in the late afternoon and evening. 5 6% of the patients presented more than once with poisoning during the study period and 37% had a past history of deliberate self-harm. The most common poisons involved were paracetamol (43%), opioids (15%) and benzodiazepines (15%). 6 The study illustrates the frequency of presentations of poisoning to A&E departments. The high rate of poisoning in young men and the increasing use of paracetamol are particular causes for concern.

Objective-To assess the diagnostic value of supine and upright carotid sinus massage in elderly patients. Design-Prospective controlled cohort study. Setting-Three inner city accident and emergency departments and a dedicated syncope facility. Patients-1375 consecutive patients aged > 55 years presenting with unexplained syncope and drop attacks; 25 healthy controls. Interventions-Bilateral supine carotid sinus massage, repeated in the 70°head up tilt position if the initial supine test was not diagnostic of cardioinhibitory and mixed carotid sinus hypersensitivity. Main outcome measures-Diagnosis of cardioinhibitory or mixed carotid sinus hypersensitivity; clinical characteristics of supine v upright positive groups. Results-226 patients were excluded for contraindications to carotid sinus massage. Of 1149 patients undergoing massage, 223 (19%) had cardioinhibitory or mixed carotid sinus hypersensitivity; 70 (31%) of these had a positive response to massage with head up tilt following negative supine massage (95% confidence interval, 25.3% to 37.5%). None of the healthy controls showed carotid sinus hypersensitivity on erect or supine massage. The initially positive supine test had 74% specificity and 100% sensitivity; these were both 100% for the upright positive test. The clinical characteristics of the supine v upright positive subgroups were similar. Conclusions-The diagnosis of carotid sinus hypersensitivity amenable to treatment by pacing may be missed in one third of cases if only supine massage is performed. Massage should be done routinely in the head up tilt position if the initial supine test is negative. (Heart 2000;83:22-23)

1 Poisoning is a common reason for presentation to hospital and hospital admission but there is no agreed policy for managing these patients. This study exam ined the management of patients presenting with poisoning and the factors affecting the probability of hospital admission and prolonged stay. 2 Data on all cases of poisoning presenting to six Accident and Emergency departments in the North East of England over 12 weeks in 1994 was collected prospectively from A&E notes. Length of stay and outcome were recorded from hospital computer records. 3 Overall, 73% of patients were admitted to a medical ward. Probability of admission was not independently affected by age or gender but was increased in those with intentional poisoning (Odds Ratio (OR) 3.3 [95% CI 1.8, 6.1]), a history of self harm (OR 1.7, [1.0, 2.9]) or potentially hazardous poisoning (OR 3.7 [2.1, 6.6]). There were significant variations between hospitals (50 - 80%) which could not be attributed to case mix. 4 Prolonged stay ( > 2 nights) was more common in patients over 65 years (OR 6.8 [2.9, 16.1]), those with intentional poisoning (OR 2.7 [1.1, 6.6]) and those with potentially hazardous poisoning (OR 2.6 [1.4, 4.9]). Mean hospital stay was 1.5 days and varied signifi cantly between hospitals from 0.8 to 2.1 days and this was independent of case mix. 5 There are appreciable variations in the management of poisoning between hospitals which are not explained by patient characteristics. Savings would occur if rates of admission and duration of stay were reduced by those hospitals where admission is more frequent or hospital stay is longer. However, the impact of this on long term morbidity is unknown.

Objective: To map the range and scope of emergency nurse practitioner (ENP) services in the Northern and Yorkshire Region as part one of a three phased study investigating the developing role of the ENP on a multi-professional context. Methods: A telephone survey was conducted in the 48 hospital trusts within the region. Semi-structured interviews were arranged with the senior nurses responsible for accident and emergency services in responding departments. Data collection entailed completion of a form comprising 14 open-ended questions designed to elicit information about the range and scope of ENP services (as defined by the Royal College of Nursing). Data were analysed using descriptive statistics. Results: Interviews were conducted at 35 (73%) of the sites, 22 (63%) of which had an ENP service as defined above. Wide variation was found in the range of services in relation to: hours/days of availability; age range and sources of referrals of patients accessing the service; clinical caseloads of ENPs and the referral pathways to other services. Conclusion: The findings from the survey highlight the organic, context specific nature of ENP role developments in response to national government initiatives, professional agendas, and local service needs. P rovision of accident and emergency services in the UK is undergoing transformation, with new models of service delivery.1 One of the initiatives is the development of emergency nurse practitioner (ENP) roles.2 A number of political, professional, and local issues have combined to accelerate the development of these roles. These include national government agendas such as the Audit Commission, which recognised the increase in numbers of patients attending accident and emergency (A&E) departments, problems with waiting times, reduction in doctors' hours, and shortage of doctors in A&E departments.3 The report highlighted the need for reconfiguration of existing services and an increased role for nurses. In the Accident and Emergency Modernisation Programme Interim Report 4 the government announced a £15 million investment in modernising A&E departments. As well as improvement in the physical resources, the programme aimed to identify and disseminate examples of good practice and new ways of working to ensure that the organisation of A&E services, and the environment in which they are provided, give the maximum benefit to patients and staff. However, according to a recent report there is still a long way to go to reform emergency care throughout the country.