BackgroundFever is a common presenting complaint in the developing world, but there is a paucity of literature to guide investigation and treatment of the adult patient presenting with fever and no localizing symptoms.ObjectiveThe objective of this study was to devise a standardized protocol for the evaluation and treatment of febrile adult patients who have no localizing symptoms in order to reduce unnecessary testing and inappropriate antimicrobial use. After devising the protocol, a pilot study was performed to assess its feasibility in the emergency department.MethodsA protocol was formulated for adult patients presenting with fever who had no clinical evidence of sepsis and no localizing symptoms to suggest the etiology of their fever. Investigations were based on duration of fever with no investigations indicated prior to day 3. Treatment was guided by results of investigations. A pilot study was performed after protocol implementation, wherein data were collected on successive adult patients presenting with fever.ResultsDuring the 6-week study period, 342 patients presented with fever, 209 of whom fit the parameters of the protocol, with 113 of these patients presenting on the 1st or 2nd day of fever. All patients experienced defervescence of fever, with ten patients being lost to follow-up. Of the patients presenting on day 1 or 2 of fever, 75.2% (85/113) defervesced without the need for testing; 53.1% (60/113) experienced defervescence without the need for antimicrobial therapy.ConclusionImplementation of this rational, standardized protocol for the assessment and treatment of stable adult patients presenting with acute undifferentiated febrile illness can lead to reduced rates of testing and antimicrobial use. A prospective, controlled trial will be required to confirm these findings and to assess additional safety outcome measures.

BackgroundProviding discharge instructions to emergency department (ED) patients is not a standard practice and there is wide disparity in its implementation. There is evidence that ED discharge instructions, especially a pre- formatted one, complements verbal instructions and improves patient communication and management.AimsOur aim was to audit the practice of providing a discharge summary in a standardized pre-formatted form to patients visiting the ED at Sundaram Medical Foundation (SMF), Chennai, India.MethodsCase sheets of 200 patients who visited the ED from 1 July to 31 August 2007 were selected randomly and were assessed for the documentation of the demographic and clinical details in the retained copy of the discharge summary by three medical records personnel independently. Descriptive analysis was used to measure frequency and percentages.ResultsAll patients (100%) received a discharge summary and a carbon copy of the same was retained in the hospital. Demographic data, diagnosis, prescription and discharge instructions were written in > 80%. Legibility of the three important sections, namely diagnosis, prescription and discharge instructions, were 66, 76 and 65%, respectively. The diagnosis was written in an abbreviated form in 27%. The patient’s signature was obtained in 80%, while doctors signed in 89%. Investigation results and follow-up advice were not documented in 85 and 93%, respectively. ConclusionThe pre-formatted discharge summary provided more information than a prescription form in terms of the amount of information written by virtue of its structured nature. Deficiencies did reflect a resistance to change current practices in spite of having a structured data sheet. Physician and staff education could overcome this.

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