National Confidential Enquiry into Patient Outcome and Death guidelines for urgent surgery recommend a fully staffed emergency operating theatre and restriction of 'after-midnight' operating to immediate life-, limb-or organ-threatening conditions. Audit performed in our institution demonstrated significant decreases in waiting times for urgent surgery and an increased seniority of medical care associated with overnight pre-operative assessment of patients by anaesthetic trainees. Nevertheless, urgent cases continued to be delayed unnecessarily. A classification of delays was developed from existing guidelines and their incidence was audited. The results were disseminated to involved directorates. A repeat of the audit demonstrated a significant decrease in delays (p = 0.001), a significant increase in the availability of surgeons (p = 0.001) and a significant decrease in the median waiting time for urgent surgery compared to the first audit cycle and a previous standard (p < 0.01). We conclude that auditing delays and disseminating the results of the audit significantly decreases delays and median waiting times for urgent surgery because of improved surgical availability. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD), the Association of Anaesthetists of Great Britain and Ireland and Royal Colleges of Anaesthesia and Surgery have published guidelines and recommendations on the provision of care for emergency and urgent surgical cases [1][2][3][4][5][6][7]. Implicit within these publications are targets for maximum allowable waits for surgery in different urgency categories [1] ( Table 1). The provision of a 24-h dedicated emergency theatre staffed by senior anaesthetic and surgical personnel is also recommended in order to aid the achievement of these targets, maximising emergency operating in 'daytime hours' and minimising the impact of emergency cases on elective operating [2][3][4][5][6][7][8]. These recommendations specifically include provision of adequate time for anaesthetic pre-assessment [5].Although these recommendations have been widely disseminated, their implementation is not universal. A recent report revealed that 18% of hospitals in England, Wales and Northern Ireland did not provide daytime emergency operating facilities [9]. Delays in emergency and urgent surgery, even where 24-h emergency theatre facilities exist, are commonplace, with authors noting poor daytime emergency theatre utilisation, high levels of out-of-hours operating and a consequent lack of consultant input into emergency cases [10][11][12].Our institution provides a 24-h emergency theatre for surgical specialties that include vascular, urological, colorectal, hepatobiliary, otolaryngological, renal and liver transplantation surgery. A consultant anaesthetist has led daytime weekday emergency anaesthesia provision from 08.30 hours since the late 1990s. Despite the availability of such an operating theatre, it was perceived that the time taken for pre-operative assessment of patients by the emergency a...

Because of allegations that the implantation of many permanent cardiac pacemakers has been unjustified, we reviewed the indications for all new pacemakers implanted at 30 hospitals in Philadelphia County between January 1 and June 30, 1983, and paid for by Medicare. Complete chart data were evaluated for 382 implants. We determined whether the indications for implantation were appropriate and adequately documented on the basis of standard clinical practice. Implants were classified as possibly indicated primarily because of inadequate diagnostic evaluation (63 percent) or inadequate documentation of an accepted indication (36 percent). Implants were classified as not indicated primarily because a rhythm abnormality was incorrectly identified as a justifiable indication (84 percent). We found that 168 implants (44 percent) were definitely indicated, 137 (36 percent) possibly indicated, and 77 (20 percent) not indicated. Unwarranted implantation was both prevalent (73 percent of hospitals had an incidence of 10 percent or more) and independent of the type of hospital (university teaching, university-affiliated, and community hospitals). The additional tests most often required to clarify the need for a pacemaker in inadequately evaluated cases included electrophysiologic studies (37 percent) and ambulatory monitoring (31 percent). We conclude that in a large medical population in 1983, the indications for a considerable number of permanent pacemakers were inadequate or incompletely documented.

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