ObjectivesCollaboration between the orthopaedic and emergency medicine (ED) services has resulted in standardised treatment pathways, leaflet supported discharge and a virtual fracture clinic review. Patients with minor, stable fractures are discharged with no further follow-up arranged. We aimed to examine the time taken to assess and treat these patients in the ED along with the rate of unplanned reattendance.DesignA retrospective study was undertaken that covered 1 year before the change and 1 year after. Prospectively collected administrative data from the electronic patient record system were analysed and compared before and after the change.SettingAn ED and orthopaedic unit, serving a population of 300 000, in a publicly funded health system.Participants2840 patients treated with referral to a traditional fracture clinic and 3374 patients managed according to the newly redesigned protocol.Outcome measuresTime for assessment and treatment of patients with orthopaedic injuries not requiring immediate operative management, and 7-day unplanned reattendance.ResultsWhere plaster backslabs were replaced with removable splints, the consultation time was reduced. There was no change in treatment time for other injuries treated by the new discharge protocol. There was no increase in unplanned ED attendance, related to the injury, within 7 days (p=0.149). There was a decrease in patients reattending the ED due to a missed fracture clinic appointment.ConclusionsThis process did not require any new time resources from the ED staff. This process brought significant benefits to the ED as treatment pathways were agreed. The pathway reduced unnecessary reattendance of patients at face-to-face fracture clinics for a review of stable, self-limiting injuries.

ObjectivesAlcohol is responsible for a proportion of emergency admissions to hospital, with acute alcohol intoxication and chronic alcohol dependency (CAD) implicated. This study aims to quantify the proportion of hospital admissions through our emergency department (ED) which were thought by the admitting doctor to be (largely or partially) a result of alcohol consumption.SettingED of a UK tertiary referral hospital.ParticipantsAll ED admissions occurring over 14 weeks from 1 September to 8 December 2012. Data obtained for 5497 of 5746 admissions (95.67%).Primary outcome measuresProportion of emergency admissions related to alcohol as defined by the admitting ED clinician.Secondary outcome measuresProportion of emergency admissions due to alcohol diagnosed with acute alcohol intoxication or CAD according to ICD-10 criteria.Results1152 (21.0%, 95% CI 19.9% to 22.0%) of emergency admissions were thought to be due to alcohol. 74.6% of patients admitted due to alcohol had CAD, and significantly greater than the 26.4% with ‘Severe’ or ‘Very Severe’ acute alcohol intoxication (p<0.001). Admissions due to alcohol differed to admissions not due to alcohol being on average younger (45 vs 56 years, p<0.001) more often male (73.4% vs 45.1% males, p<0.001) and more likely to have a diagnosis synonymous with alcohol or related to recreational drug use, pancreatitis, deliberate self-harm, head injury, gastritis, suicidal ideation, upper gastrointestinal bleeds or seizures (p<0.001). An increase in admissions due to alcohol on Saturdays reflects a surge in admissions with acute alcohol intoxication above the weekly average (p=0.003).ConclusionsAlcohol was thought to be implicated in 21% of emergency admissions in this cohort. CAD is responsible for a significantly greater proportion of admissions due to alcohol than acute intoxication. Interventions designed to reduce alcohol-related admissions must incorporate measures to tackle CAD.

Objectives & Background The Redesigned Fracture Pathway has revolutionised fracture management, decreased orthopaedic workload and improved the patient journey. The Pathway consists of guideline driven treatment of patients with fractures. There is no follow up for many stable injuries, virtual review of other fractures and orthopaedic registrar referral for admission decisions. Many discharged patients never receive a clinic appointment necessitating the development of discharge information leaflets and a move from plaster casts to Velcro splints. Have orthopaedics simply passed their workload onto the Emergency Department? 1) Patients with fractures are discharged with no follow up, does this necessitate longer consultations in ED? 2) Without routine follow up do patients simply pitch back up to ED? 3) Has the admissions process actually improved? Methods We examined length of consultations, unplanned reattendances to ED within 7 days, number of Orthopaedic admissions and time from first assessment to admission before and after Fracture Clinic Redesign. Results 1) Length of consultation was unchanged for discharges without follow up, (p=0.316, 0.508, 0.571). Consultations were shorter when splints replaced casts, (p=0.046, 0.588, 0.032). 2) Unplanned reattendances within 7 days did not increase as a proportion of ED attendances, (p=0.779). 3) Orthopaedic admissions fell by 7.9% and time from first assessment to admission by 9.6% per annum (p=0.002, p=0.011). Orthopaedic breaches decreased significantly, (p<0.001). Conclusion Direct discharges from ED do not require longer consultations nor do they return to ED. Orthopaedic admission is increasingly efficient and breaches are down. Is Fracture Pathway Redesign good for the Emergency Department? Yes!

Aim Cerebrospinal fluid (CSF) analysis for xanthochromia is routinely used to exclude subarachnoid haemorrhage (SAH). In this study, we evaluated the sensitivity and specificity of xanthochromia (by NEQAS-spectrophotometry) in routine clinical practice in three acute hospitals, in patients with suspected SAH. We explored whether including CSF red cell count (RCC) with xanthochromia improved diagnostic accuracy. Methods In this retrospective analysis, all xanthochromia results were assessed over three consecutive years. Clinical information and Registry data were analysed to find all patients diagnosed with SAH. We correlated xanthochromia data with clinical and radiological findings. Results There were 1761 xanthochromia performed. Of these, 26 (1.5%) were positive, 1624 (92%) negative and 72 (4.1%) were inconclusive. Of the 26 tests that were positive, 9 (35%) had confirmed SAH, 17 (65%) were falsely positive, with no false negative tests in our series. Xanthochromia identified 6% of all SAH diagnosed in the study. Incorporating RCC <1000 with xanthochromia, reducing false positive tests by 38% and inconclusive test by 85%. Conclusion The positive yield of xanthochromia is low but identified 6% of SAH. NEQAS-spectrophotometry is an excellent diagnostic method with 100% sensitivity, 99% specificity. Incorporating RCC markedly reduces false positive and inconclusive tests reducing need for further imaging.