Can nurses working in remote units accurately request and interpret radiographs?

Methods: In this prospective study the four qualified nurses working in a peripheral unit were permitted to request a defined set of radiographs after limb trauma. A written protocol for nurse requested radiographs was supported by individual teaching sessions. At the time that the radiograph was requested basic demographic details were recorded and the patient was also assessed by two senior doctors in emergency medicine, one in person and one via a telemedicine link, both of whom independently considered whether the radiograph requested by the nurse was appropriate in that patient. Nursing staff were also asked to provide a provisional interpretation of each film, and this was compared with a gold standard derived from the interpretations of the two emergency physicians who had seen the patient and the final radiologist's report.

Results: The first 300 patients who had a radiograph requested by a member of the nursing staff were studied over a period of 12 months. Altogether 93 radiographs (31%) were positive for recent bony trauma or radio-opaque foreign body. Eleven radiographs (3.7%) were judged by both emergency physicians to be inappropriate. Three radiographs (1%) were requested outside the limits of the protocol, but all three were judged to be appropriate and occurred within the first two months of the study. A total of 32 (10.7%) of the radiographs were incorrectly interpreted by nursing staff with 26 false positives, four false negatives and two cases where the nurse observed an abnormality but failed to identify it correctly. The sensitivity of nurse interpretation was therefore 96%, with a specificity of 87%.

Conclusion: Experienced nurses, working without continuous medical supervision in a remote unit, are able to request appropriate radiographs of the peripheral limbs. Nurses requesting radiographs in this way can also interpret these films to a high standard, though with a tendency to err on the side of caution, generating many more false positive results than false negatives.

     

How good are accident and emergency doctors in the evaluation of psychiatric patients?

The aim of this study was to find out the agreement between psychiatrists and emergency department (ED) doctors in the diagnosis and treatment of psychiatric emergencies. All patients presenting with a psychiatric complaint and who were subsequently referred to the psychiatrist were included. A standard form was used to collect demographic data, provisional diagnoses and initial treatment by ED doctors, diagnoses by psychiatrists, and compatibility of ED diagnoses and treatment as judged by consulting psychiatrists. The mean age of the 223 patients enrolled was 36.5 years and the distribution between males and females was roughly equal. The most frequent presentations were aggressive behaviour (27.9%), depressive mood (13.5%) and suicidal idea (12.1%). Schizophrenia (39%) was the most common diagnosis followed by depression (20%) and adjustment disorders (9.5%). The agreements between psychiatrists and ED doctors in diagnosis and treatment were 61.4% and 89.5% respectively. Schizophrenia and bipolar disorders were least likely to be mis-classified. It is concluded that ED doctors were deficient in the diagnosis of psychiatric conditions especially in the less common diagnostic categories.     

Reliability of ophthalmic accident and emergency referrals: a new role for the emergency nurse practitioner?

Background and objectives: Annual attendances at the accident and emergency (A&E) department of St Bartholomew''s and The Royal London NHS Trust exceed 100 000 people of which 6% are ophthalmic. This study evaluated the accuracy of eye referrals from A&E senior house officers (SHOs) and emergency nurse practitioners (ENPs) and the impact any inaccuracies may have had on out of hours work. Methods: Over a four week period a record of all referrals from the A&E department was made. The doctor receiving the referral made a note of clinical variables as reported by the referring clinician. When the patient was subsequently reviewed by an ophthalmologist, a record was again made of these findings. Any discrepancies were recorded. Results: A total of 67 patients were recruited. ENPs were found to be consistently more accurate than SHOs in every aspect of the assessment, most notably in visual acuity (p = 0.0029), and provisional diagnosis (p = 0.012). Furthermore, had the examination findings been accurate, 58% of all SHO referrals seen after hours would have been triaged to the next available clinic but only 10% of ENP referrals could have been seen at the next clinic session (p = 0.027). Conclusion: This study found ENPs to be more accurate than A&E SHOs in history taking, recording visual acuity, describing ocular anatomy, and making provisional diagnoses. A significant reduction in out of hours ophthalmic workload may be achieved in the authors'' unit if ENPs were to see all eye emergencies.     

Should nurses take a COVID-19 vaccine?

The issue as to whether health care professionals have a moral obligation to take a vaccine for a communicable disease is not new. Nonetheless, this issue takes on a fresh urgency within nursing practice in the context of the present COVID-19 pandemic, i.e., is there an ethical requirement for nurses to take a COVID-19 vaccine? This paper approaches the issue by using a hypothetical example of Nurse X who has inadvertently infected Patient Y. French's (1984a) Principle of Responsive Adjustment is adapted to claim that there would be a moral expectation that Nurse X takes a COVID-19 vaccine (unless there are justifiable reasons not to). The proposition is also made that, should Nurse X not take a COVID-19 vaccine, they could be morally associated with originally infecting Patient Y.     

Burns and scalds in pre-school children attending accident and emergency: accident or abuse?

Objectives—To assess how frequently and adequately information relating to the possibility of non-accidental injury (NAI) is documented and considered by doctors assessing pre-school children with burns and scalds in the accident and emergency (A&E) department, and to determine the effect of introducing a routine reminder mechanism into the A&E notes, coupled with an improved programme of NAI education and awareness.

Methods—The records of 100 pre-school children attending an A&E department with a burn or scald were reviewed against nine pre-determined standards. Changes in policy were instituted, through a programme of education and the use of a reminder checklist, and the next 100 cases re-audited against the same checklist.

Results—Groups one and two were similar in their demographic characteristics. The reminder checklist was included in 60% of group two notes, and when included was completed in 97%. The child protection register was rarely consulted. There was a statistically significant increase in recording the following: time that the injury had occurred, the consistency of the history, the compatibility of the injury with the history given, the consideration of the possibility of NAI, the general state and behaviour of the child and the presence or absence of any other injuries. The rate of referral for a further opinion regarding the possibility of NAI increased from 0 to 3%, but failed to reach statistical significance.

Conclusions—Prevailing awareness and documentation regarding the possibility of NAI was found to be poor, but a programme of intervention combining education and the use of a reminder checklist improved both awareness and documentation of NAI, as well as referral rates for further assessment. This strategy may prove applicable to children of all ages and injury types, reducing the number of cases of child abuse that are overlooked in the A&E department.

     

UK accident and emergency departments and emergency contraception: what do they think and do?

OBJECTIVES: A postal questionnaire survey was conducted to assess what staff in UK accident and emergency (A&E) departments thought of providing an emergency contraception service, the degree of enthusiasm in and level of provision of the service, and staff attitudes to the introduction or continuation of provision of the service. METHODS: A questionnaire was sent to all 560 departments providing A&E services in the UK. RESULTS: Of the 560 units sent questionnaires, 355 (63.4%) replied. Half the units were located in small county towns, and a quarter in large towns. Requests for emergency contraception were received by 96% of responding units, but only 57% provided treatment. Requests for emergency contraception in 84 of these units ranged between one and 50 per month. The A&E senior house officer (SHO) and the gynaecology SHO and registrar prescribed most of the pills. Nurses were more involved in nurse led or general practitioner (GP) led units. Initial treatment only was given by 77% of providing units while the remainder also discussed subsequent contraception. Follow up was arranged with GPs by 92 units, and with family planning clinics by 66 units. Information packs were available in only 37 providing units. A total of 155 of providing units felt it was worthwhile and 56% of respondents thought emergency contraception should be provided by A&E departments. However, 91 units could identify one or more groups within the hospital who were antagonistic to provision by A&E departments, of which non-A&E medical staff formed the largest group. Over the counter availability of emergency contraception was not supported by 62% of respondents. CONCLUSION: The results show that while the female population appears to see a need for emergency contraception services to be provided in A&E departments, there is some reluctance by UK A&E departments to provide the service. Given the current interest in approaches to reducing unplanned pregnancies, especially in teenagers, provision of emergency contraception by A&E departments requires a pragmatic approach to ensure their cooperation in providing the service when alternative sources of provision are not available.     

Presentation of severe haemophilia—A role for accident and emergency doctors?

Background—The management of haemophilia has changed dramatically over the years and is constantly being improved. This study set out to discover if the diagnosis of haemophilia was being made early enough in those with no family history and looked at the different modes of presentation.

Method—A questionnaire was sent to all patients with haemophilia under the age of 16 who had no family history before diagnosis.

Results—There were 28 replies from 34 patients contacted (82% response rate). Three were excluded because of a known family history. The mean number of attendances to a doctor before a diagnosis was considered was 4.13 (median = 3, interquartile range = 2.5). The mean age of diagnosis was 29.52 months (median = 14, interquartile range = 20. Most presentations were to the accident and emergency department and to the general practitioner. The most common presenting feature was easy bruising.

Conclusion—There is a variable delay in diagnosis despite predictable presenting features.

     

Is there a place for complementary therapies in the accident and emergency department?

This paper addressess the potential for complementary therapies in the Accident and Emergency (A & E) department. It is suggested that whilst there are a number of therapies which may be efficacious in emergency settings, nurses need to consider the broader implications of their use in the A & E department.The organisational context of the A & E department and the nature of such acute work means that complementary therapies will probably be used as therapeutic techniques rather than discrete therapeutic entities. It is suggested that this approach is not dissimilar to the use of complementary therapies in other nursing specialities. The use of complementary therapies as techniques enhancing therapeutic care may, in the short term, be beneficial, however nurses need to reflect and reappraise what it is they are actually doing and the extent to which they can reconcile two apparently opposite paradigms of health care.The use of complementary therapy techniques have considerable potential in the care of clients attending A & E departments and examples of therapies and conditions for which it could be used are given.     

Should nurses restrain violent and aggressive patients?

Violent and aggressive behaviour towards nurses is common, especially in mental health settings. This article explores the value and safety of existing approaches to dealing with violence and aggression, including the use of physical restraint and medication. It highlights the need for greater preventive and participatory measures, and the use of less reactive strategies, such as advance directives.