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Objective: To examine the relationship between hospital and emergency department (ED) occupancy, as indicators of hospital overcrowding, and mortality after emergency admission. Design: Retrospective analysis of 62 495 probabilistically linked emergency hospital admissions and death records. Setting: Three tertiary metropolitan hospitals between July 2000 and June 2003. Participants: All patients 18 years or older whose first ED attendance resulted in hospital admission during the study period. Main outcome measures: Deaths on days 2, 7 and 30 were evaluated against an Overcrowding Hazard Scale based on hospital and ED occupancy, after adjusting for age, diagnosis, referral source, urgency and mode of transport to hospital. Results: There was a linear relationship between the Overcrowding Hazard Scale and deaths on Day 7 (r = 0.98; 95% CI, 0.79–1.00). An Overcrowding Hazard Scale > 2 was associated with an increased Day 2, Day 7 and Day 30 hazard ratio for death of 1.3 (95% CI, 1.1–1.6), 1.3 (95% CI, 1.2–1.5) and 1.2 (95% CI, 1.1–1.3), respectively. Deaths at 30 days associated with an Overcrowding Hazard Scale > 2 compared with one of < 3 were undifferentiated with respect to age, diagnosis, urgency, transport mode, referral source or hospital length of stay, but had longer ED durations of stay (risk ratio per hour of ED stay, 1.1; 95% CI, 1.1–1.1; P < 0.001) and longer physician waiting times (risk ratio per hour of ED wait, 1.2; 95% CI, 1.1–1.3; P = 0.01). Conclusions: Hospital and ED overcrowding is associated with increased mortality. The Overcrowding Hazard Scale may be used to assess the hazard associated with hospital and ED overcrowding. Reducing overcrowding may improve outcomes for patients requiring emergency hospital admission.

Objective: To evaluate the efficacy of a missed radiological abnormality follow‐up system in a teaching hospital emergency department. Methods: Prospective audit of all reported radiological abnormalities missed by Fremantle Hospital Emergency Department medical staff from 1 January 1997 to 31 December 1998. Results: Of 29 724 radiological examination series, 459 abnormalities (1.5%) were not clearly documented as being identified in the medical record. The commonest missed abnormalities were incidental chest findings, distal wrist fractures with minimal or no displacement, radial head fractures and tibial plateau fractures. The most senior doctor undertaking initial film review was a junior medical officer in 242 cases (53%), a registrar in 96 cases (21%), and a consultant in 42 cases (9%). The most senior staff member was unknown in 79 cases (17%). One hundred and twenty‐four missed abnormalities required a change in patient management (0.41% of total examinations, CI 0.34–0.48%). Ninety patients (73%) were referred to the patient’s general practitioner for management. Seventeen patients (14%) returned to the emergency department for management. Thirteen patients (10%) were referred to a specialist clinic and in four cases (3%) the management of the patient was not recorded. No patient required re‐admission to hospital. Conclusions: Missed radiological abnormalities in an emergency department with extended‐hours emergency physician supervision can be managed non‐urgently on an outpatient basis. Same‐day reporting of radiographs is not required if adequate follow‐up mechanisms for missed abnormalities exist.

A structured surgical coaching template used in a surgical coaching program facilitated short-term self-perceived improvement in surgical skill and confidence. Participants also expressed an intention to introduce a more structured approach in their teaching. The structured programme using the encounter template may have a potential role in remediating a surgeon identified as an outlier by a credentialing body.