Nurse practitioners: the role in A&E and primary care

This article describes a recent evaluation of the work of nurse practitioners across a range of A&E departments and minor treatment centres in west London. Questionnaires, face-to-face interviews and focus groups were used to collect the data. The authors found that across the sites in the study, the provision of nurse practitioner services varied in scope but were well received by staff and patients. Issues surrounding training remained unresolved, but the role appeared to be developing in response to the reduction in junior doctors' hours and improved and extended opportunities in pre- and post-registration nurse education. The authors recommend that the cost effectiveness of nurse practitioners should be evaluated. The accompanying commentary suggests the nurse practitioner role should be explicitly defined.

Patients telephoning A&E for advice: a comparison of expectations and outcomes

OBJECTIVE

To investigate the expectations of patients when they phone the accident and emergency (A&E) department, how this relates to the advice they receive, the action they subsequently take, and their satisfaction with the service.

SETTING

The study was undertaken at an inner city hospital in south east London.

METHODS

597 calls to the department were documented during the study period, and callers for whom a phone number had been recorded were followed up by structured interviews carried out by a trained interviewer within 72 h of the call. Up to three attempts were made to contact each patient. The interviews were conducted at various times of the day to avoid excluding people with different work or social patterns.

RESULTS

The interviewer was able to contact 203 patients within 72 h of their call to the A&E department. Of these 197 (97%) agreed to participate. Almost two thirds stated that when they phoned A&E they anticipated receiving self care advice; 11% expected to be advised to see or contact their general practitioner. Only a quarter of callers stated that they had expected to be told to attend A&E. There was disagreement between the advice that nurses documented as having been given, the advice the caller recalled receiving, and the action the patient subsequently took. Even so, 107 (55%) callers were very satisfied and 62 (32%) were satisfied, while 11 (6%) were dissatisfied with the telephone consultation; 15 (8%) were unsure. In all, 170 (87%) thought the advice they received was helpful.

CONCLUSIONS

Understanding the reasons why patients phone A&E departments and their expectations should contribute to developing more responsive and effective services.

Piloting an A&E and practice nurse educational exchange

The accident and emergency (A&E) department acts as an interface between primary and secondary care. Traditionally, general practice has been viewed negatively by A&E nurses. This article explores some of the issues surrounding these views. The need to challenge the traditional view of A&E as simply a department within a hospital and replace it by one that identifies A&E within the broader community context is identified. This change in ethos requires nurses who work in the A&E department to challenge their beliefs about the specialty. There is a need to look at the educational preparation of A&E nurses. A pilot educational exchange scheme, developed to explore ways of improving the relationship between A&E nurses and nurses working in general practice, is described.

Simple clinical data are useful in predicting effect of exercise training after myocardial infarction

OBJECTIVES

The aim of the present study was to determine whether simple clinical variables can predict the effect of intensive exercise training in an unselected population early after myocardial infarction.

METHODS

Starting 5 weeks after the qualifying myocardial infarction, 105 patients, 68 years old or younger, completed a 4 week period of intensive exercise training. The training effect was defined as an absolute increase in cumulative work at bicycle ergometry. Using univariate and multivariate analysis, 28 variables were tested against the training effect.

RESULTS

The mean exercise capacity increased from 46.7 +/- 22.7 kJ to 69.5 +/- 31.1 kJ (P = 0.0001). Multivariate analysis identified five independent predictors of the training effect. Myocardial infarct size was associated with a better training effect (P = 0.0018), as was male gender (P = 0.0042) and ability to exercise to exhaustion at the baseline exercise test (P = 0.0124). Older age (P = 0.0017) and treatment with beta-adrenergic blocking agents (P = 0.0241) were associated with a lower effect from training. These five variables explained 33% of the variations in effect from training. Patients suffering in-hospital cardiac complications or congestive heart failure achieved a training effect at least as great as patients without cardiac complications.

CONCLUSIONS

Five simple clinical variables, including infarct size, can assist in the selection of patients for exercise training after myocardial infarction.

Paediatric calls to an inner city accident and emergency department: service demand and advice given

Patients routinely call both Accident and Emergency (A & E) departments and General Practice for advice. Many of these calls concern children. In the UK, telephone calls for advise made to A & E departments are usually dealt with by nursing staff in an informal manner. This paper focuses on telephone calls concerning children received in a busy inner city department. Data were collected using a Telephone Consultation Record proforma (TCR) developed to document all calls to the A & E department. There were a total of 597 calls to the A & E department documented during the study period of which 218 (37%) concerned paediatric patients. The majority of calls were concerning children under the age of 5. One-third of callers were given self-care advice. This paper reports on the volume of calls, the nature of patients' problems and the outcome in terms of the advice given to the caller. The implications of the findings are discussed. Given the current demand for telephone advice, A & E departments should examine the nature and demand for telephone advice and explore methods of providing training and support to staff carrying out this role.

Treatment of thyrotoxicosis resistant to carbimazole with corticosteroids

We report two patients whose thyrotoxicosis failed to respond to conventional treatment with carbimazole. The patients remained persistently hyperthyroid, both clinically and biochemically, despite several months of carbimazole therapy at the maximum recommended doses. Prednisolone 20 mg per day was then given in addition to the antithyroid drug and a dramatic response observed in both cases. They were then successfully treated with radioiodine. Prednisolone has not been previously used to treat patients with hyperthyroidism who have not responded to thionamide drugs. Our experience suggests that corticosteroids may be potentially useful for controlling thyrotoxicosis in combination with carbimazole before definite treatment can be instituted.

Do patients use minor injury units appropriately?

BACKGROUND

This study aimed to examine the extent to which patients make appropriate use of Accident and Emergency and Minor Injury Unit services. The outcomes used included the proportion of Minor Injury Unit patients referred to an Accident and Emergency department, comparison between the proportions admitted from patients attending Minor Injury Units and Accident and Emergency departments directly, and the diagnoses and lengths of stay of those requiring admissions from Minor Injury Units.

METHODS

Patients were identified who were resident in the vicinity of Deal and Folkestone and in January 1994 attended local Minor Injury Units in these towns or nearby Accident and Emergency departments at times when the Minor Injury Units were open. The following details were documented from their hospital notes: presenting problem, time and date of attendance, mode of arrival at/referral to the facility, postcode of residence, age, sex, diagnosis and referral/discharge. A sub-sample of 448 patients were interviewed while waiting to be seen at the Minor Injury Units.

RESULTS

The criteria for inclusion in the study were met by 1891 patients. Of these, 188 (9.9 per cent) were referred by a general practitioner (GP). A total of 1472 patients attended the Minor Injury Units without referral from a GP, of whom 28 [1.9 per cent; 95 per cent confidence interval (CI) 1.2-2.6 per cent] were referred for further assessment and care to a general hospital. Whereas 71 (29.5 per cent; 95 per cent CI 23.7-35.3 per cent) of the 241 who went directly to an Accident and Emergency department without GP referral required admission, this was true for only eight (0.5 per cent; 95 per cent CI 0.2-0.9 per cent) self-referred patients attending Minor Injury Units. Four of the latter admissions were for trauma-related problems and required stays of less than 24 hours. Of the patients attending the Deal and Folkestone Minor Injury Units who were interviewed, only 195 (47.0 per cent) said that they would have attended an Accident and Emergency department had the facility not been available; the remainder said that they would have either gone to their own GP or self treated. The latter were more likely to be female patients, to have problems of longer duration, and/or to have attended the facilities by public transport or taxi.

CONCLUSION

The results support the view that patients choose appropriately between attending a Minor Injury Unit or an Accident and Emergency department. However, there was evidence that the availability of an intermediate tier of health care for minor injuries appears likely to result in increased overall workload. This small-scale study leaves unanswered questions in terms of clinical outcomes and the quality of care provided by different facilities.

Prothrombin time: one tube or two

This study compares the prothrombin times (PTs) and calculated international normalized ratios (INRs) from first and second evacuation blood tubes to determine the clinical importance of using a second tube specimen for protime coagulation studies. The National Committee for Clinical Laboratory Standards (NCCLS) currently recommends that all coagulation studies be done on a second or later drawn blood tube. For patients on long-term anticoagulation therapy, this often requires that first blood tubes be drawn and discarded at each prothrombin evaluation. In this prospective study, a first and second evacuation blood tube was drawn from 343 outpatients who had a physician-ordered prothrombin time test performed. There was no statistically significant difference in the paired PT or calculated INR from any of the first and second tubes. The average difference in the INR from tube 1 to tube 2 was 2% (standard deviation [SD] 1.1%). In this sample of outpatients, the use of a second tube for PT testing was not clinically justified.

Cost effectiveness of treating primary care patients in accident and emergency: a comparison between general practitioners, senior house officers, and registrars

OBJECTIVES

To compare outcome and costs of general practitioners, senior house officers, and registrars treating patients who attended accident and emergency department with problems assessed at triage as being of primary care type.

DESIGN

Prospective intervention study which was later costed.

SETTING

Inner city accident and emergency department in south east London.

SUBJECTS

4641 patients presenting with primary care problems: 1702 were seen by general practitioners, 2382 by senior house officers, and 557 by registrars.

MAIN OUTCOME MEASURES

Satisfaction and outcome assessed in subsample of 565 patients 7-10 days after hospital attendance and aggregate costs of hospital care provided.

RESULTS

Most patients expressed high levels of satisfaction with clinical assessment (430/562 (77%)), treatment (418/557 (75%)), and consulting doctor's manner (434/492 (88%)). Patients' reported outcome and use of general practice in 7-10 days after attendance were similar: 206/241 (85%), 224/263 (85%), and 52/59 (88%) of those seen by general practitioners, senior house officers, and registrars respectively were fully recovered or improving (chi2 = 0.35, P = 0.840), while 48/240 (20%), 48/268 (18%), and 12/57 (21%) respectively consulted a general practitioner or practice nurse (chi2 = 0.51, P = 0.774). Excluding costs of admissions, the average costs per case were 19.30 pounds, 17.97 pounds, and 11.70 pounds for senior house officers, registrars, and general practitioners respectively. With cost of admissions included, these costs were 58.25 pounds, 44.68 pounds, and 32.30 pounds respectively.

CONCLUSION

Management of patients with primary care needs in accident and emergency department by general practitioners reduced costs with no apparent detrimental effect on outcome. These results support new role for general practitioners.

Creating a shared vision of out of hours care: using rapid appraisal methods to create an interagency, community oriented, approach to service development

OBJECTIVES

To undertake a district wide review of out of hours primary health care services and identify the views of users and providers about current arrangements and options for development.

DESIGN

A range of qualitative and quantitative survey methods based on rapid appraisal methods, modified to apply to an inner city district.

SETTING

Socially deprived, multiethnic district in south east London with a population of over 700,000.

MAIN OUTCOME MEASURES

Strengths and weaknesses of current out of hours services and suggestions for developments.

RESULTS

Widespread dissatisfaction with current arrangements was identified, with specific problems relating to access, availability, demand for services, and interagency communication. Several areas for development were identified, including the establishment of an out of hours cooperative, multiagency primary care emergency centres, and telephone advice-triage. Many of these are now being planned or piloted.

CONCLUSIONS

Rapid appraisal provided a helpful method, enabling partnerships to be established between local agencies and users in relation to service development. The shared understanding and commitment to improving services that resulted is now having a major impact on out of hours care in the district.

Postradiotherapy hypothyroidism: radiation dose response and chemotherapeutic radiosensitization at less than 40 Gy

To analyze our experience with iatrogenic hypothyroidism, we prospectively followed 84 patients, seen from 1984 to 1990, who had been diagnosed with either Hodgkin's disease (HD) or head and neck (H&N) carcinoma and subsequently treated with radiotherapy. Within these two diagnostic groups were subgroups whose treatment differed as to dose of therapeutic irradiation received or adjunctive use of chemotherapy. Approximately 50% of all patients and of each subgroup developed either clinical or subclinical hypothyroidism during follow-up. However, among the HD patients who received irradiation plus chemotherapy, a dose-response relationship below a threshold limit of dose received, probably 40 Gy, was observed.

Preoperative concurrent chemoradiotherapy for unresectable Stage III nonsmall cell lung cancer

PURPOSE

We carried out a Phase II trial in an attempt to improve resectability and survivability of inoperable Stage III A and III B nonsmall cell lung cancer (NSCLC) patients by implementing a neoadjuvant chemoradiotherapy treatment program.

METHODS AND MATERIALS

Thirty-six patients with locally advanced Stage III NSCLC received neoadjuvant therapy consisting of 50.4 Gy in 5.5 weeks concurrent with two cycles of chemotherapy, using cisplatin and etoposide. No postsurgical consolidation therapy was given.

RESULTS

Assessment at 3 to 6 weeks after treatment suggested that 26 (72%) patients had been rendered resectable. Toxicities were common but usually tolerable; however, one toxic death occurred. Of 24 patients who proceeded to thoracotomy, complete resection was achieved in 20 (56%). There were two surgically related deaths. Surgical-pathological staging showed downstaging in 18 patients, including complete sterilization of the tumor in 3 (8%). The median survival for all 36 patients is 15 months, but at the time of analysis, median survival of resectable patients had not been reached. The actuarial 2-year survival is 39% for all study groups, 57% for resectable patients, and 16% for the remaining (p < 0.005).

CONCLUSIONS

While this preoperative neoadjuvant appears to improve survival of patients with Stage III NSCLC, comparison with previous reports of other similar trials indicate a superior survival advantage in association with higher doses of radiotherapy.

The management of leg ulcers

Two algorithms are presented as aids to diagnosis and appropriate treatment decisions for leg ulcers

Replication slippage in the evolution of potyviruses

Recently published evidence for sequence repetition in potyvirus genomes prompted us to analyse the published complete genome sequences and coat protein gene sequences of viruses of this family for evidence of replication slippage. Five of nine complete genomic sequences and 17 of 32 coat protein genes had significant sequence repetitions. Most of these were in coat protein genes, although the 5' region of the turnip mosaic virus genome also showed evidence of slippage. The results suggest that replication slippage may be involved in the evolution of viruses, as well as prokaryotes and eukaryotes, and that slippage can occur in both RNA and DNA when it is being replicated.

Incidence of childhood lymphoma in northern Israel, 1973-1990

We retrospectively analyzed all 164 cases of pediatric lymphoma diagnosed in northern Israel during the 18-year period from 1973 to 1990. Our findings generally conformed to those of other studies with regard to annual incidence (24.7/million), age at diagnosis (5 to 9 years for Jewish males, later for others), histology (Hodgkin's disease most commonly), and male predominance. The northern Israeli pediatric lymphoma pattern of incidence is similar to the Asian-African-South American pattern and unlike that of Europe or North America; in Israel, lymphoma rather than brain tumor is the second most common childhood malignancy. The nodular sclerosing variant was the most common histology seen in Hodgkin's lymphoma (especially in females), followed by mixed cellularity. Malignancies are generally more common in Jewish children but lymphomas in particular were seen more often in Arabs (28.7/million), while the Ashkenasi (20.8/million) and Sephardi (21.6/million) Jewish populations had similar incidences. The high rate of consanguineous marriages among Arabs and their lower socioeconomic level may explain the high incidence of lymphomas in this group.

Providing health-care advice by telephone

Telephone advice systems can deliver a high-quality, responsive service. There is potential for development of the practice nurse role as telephone adviser in primary care. This study identifies a need for training nurses in the role of telephone adviser.

Primary care in the accident and emergency department: I. Prospective identification of patients

OBJECTIVE

To compare patient characteristics and consultation activities for attenders at accident and emergency departments assessed by nurse triage as presenting with "primary care" or "accident and emergency" type problems.

DESIGN

One year prospective study.

SETTING

A busy, inner city accident and emergency department in south London.

SUBJECTS

Of the 5658 patients treated for new problems during a stratified random sample of 204 three hour sessions between 10 am and 9 pm during June 1989 to May 1990, all "primary care" (2065 patients) and a 10% random sample of "accident and emergency" (291 patients) were included in the analysis.

MAIN OUTCOME MEASURES

Patient's age, sex, duration of presenting problem, diagnosis, laboratory and radiographic investigations, treatments, and referrals.

RESULTS

40.9% of attenders with new problems were classified by triage as presenting with "primary care" problems (95% confidence interval 39.6% to 42.2%). Primary care attenders were more likely than accident and emergency patients to be young adults, to have symptoms with a duration of longer than 24 hours, and to present problems not related to injury (all P < 0.001). Accident and emergency patients were considerably more likely to be referred to on call teams and to be admitted. Even so, 9.7% of primary care patients were referred to on call teams and a further 8.9% were referred to the fracture clinic or advised to return to the accident and emergency department for follow up.

CONCLUSION

Accident and emergency triage can be developed to identify patients with problems that are more likely to be of a primary care type, and these patients are less likely to receive an investigation, minor surgical procedure, or referral. Many patients in this category, however, receive interventions likely to support their decision to attend accident and emergency rather than general practice. This may reflect limitations in the sensitivity of triage practice or a clinical approach of junior medical staff that includes a propensity to intervene.

Primary care in the accident and emergency department: II. Comparison of general practitioners and hospital doctors

OBJECTIVE

To compare the process and outcome of "primary care" consultations undertaken by senior house officers, registrars, and general practitioners in an accident and emergency department.

DESIGN

Prospective, controlled intervention study.

SETTING

A busy, inner city accident and emergency department in south London.

SUBJECTS

Patients treated during a stratified random sample of 419 three hour sessions between June 1989 and May 1990 assessed at nurse triage as presenting with problems that could be treated in a primary care setting. 1702 of these patients were treated by sessionally employed local general practitioners, 2382 by senior house officers, and 557 by registrars.

MAIN OUTCOME MEASURES

Process variables: laboratory and radiographic investigations, prescriptions, and referrals; outcome variables: results of investigations.

RESULTS

Primary care consultations made by accident and emergency medical staff resulted in greater utilisation of investigative, outpatient, and specialist services than those made by general practitioners. For example, the odds ratios for patients receiving radiography were 2.78 (95% confidence interval 2.32 to 3.34) for senior house officer v general practitioner consultations and 2.37 (1.84 to 3.06) for registrars v general practitioners. For referral to hospital specialist on call teams or outpatient departments v discharge to the community the odds ratios were 2.88 (2.39 to 3.47) for senior house officers v general practitioners and 2.57 (1.98 to 3.35) for registrars v general practitioners.

CONCLUSION

Employing general practitioners in accident and emergency departments to manage patients with primary care needs seems to result in reduced rates of investigations, prescriptions, and referrals. This suggests important benefits in terms of resource utilisation, but the impact on patient outcome and satisfaction needs to be considered further.

Patient expectations: what do primary care patients want from the GP and how far does meeting expectations affect patient satisfaction?

There is growing recognition of the importance of patients' expectations in general practice. This study aimed to investigate the types of expectations adult primary care patients have prior to consulting the GP, and how far meeting expectations is associated with increased satisfaction. Patients (n = 504) attending general practitioners (n = 25) at 10 London general practices were included in the study. The Patients Intentions Questionnaire (PIQ) was administered prior to the consultation to investigate patients' expectations and the Expectations Met Questionnaire (EMQ) was administered after the consultation to find out what the patient reportedly obtained. Satisfaction with the consultation was also measured using the Medical Interview Satisfaction Scale (MISS). The results of a principal components analysis of PIQ item scores indicated that the most wanted items were for 'explanation of the problem'. There was less desire for 'support' or 'tests and diagnosis'. Many of the 'support' items could potentially be provided to all patients, yet a proportion of patients reported not receiving these items from the GP. The results of one-way ANOVAs revealed that patients with greater numbers of their expectations met reported significantly higher satisfaction with the consultation than those with lower numbers met. The PIQ and EMQ could be potentially useful self-audit tools for use by general practitioners and trainee GPs.

[Treatment of urinary bladder cancer--a retrospective analysis]

Data on 482 stage A-0--D2 bladder cancer patients referred between 1975-86 were analyzed. Prognosticators of survival were stage, histologic subtype and differentiation. 143 patients with disease localized to the pelvis (stage A-0--D1) received definitive radiotherapy with 60 Gy or more, and 25 underwent preoperative irradiation and cystectomy. Later, a group of 56 selected patients with stage B--D1, referred between 1988-1991, received neo-adjuvant MCV chemotherapy (methotrexate, cisplatin and vinblastine) preceding either definitive radiotherapy or surgery. The 2-year overall actuarial survival rates were similar: 63% for radiotherapy only, 72% for cystectomy and 68% for neo-adjuvant chemotherapy; they were also similar when broken down by stage and grade.