Evaluation of nurse triage in a British accident and emergency department

OBJECTIVE

To compare formal nurse triage with an informal prioritisation process for waiting times and patient satisfaction.

SETTING

Accident and emergency department of a district general hospital in the midlands in 1990.

DESIGN

Patients attending between 8:00 am and 9:00 pm over six weeks were grouped for analysis according to whether triage was operating at time of presentation and by their degree of urgency as assessed retrospectively by an accident and emergency consultant.

PATIENTS

5954 patients presenting over six weeks.

MAIN OUTCOME MEASURES

Time waited between first attendance in the department and obtaining medical attention, and patient satisfaction measured by questionnaire.

RESULTS

Complete data on waiting time were collected on 5037 patients (85%). Only 1213 of the 2515 (48%) patients presenting during the triage period were seen by a triage nurse. Patients in the triage group waited longer than those in the no triage group in all four retrospective priority categories, though differences were significant for only the two most urgent categories (difference in median waiting time 10.5 (95% confidence interval 3.5 to 14) min for category 1 and 8.5 (3 to 12) min for category 2). Responses to the patient satisfaction questionnaire were similar in the two groups except for the question relating to anxiety relating to pain.

CONCLUSIONS

This study fails to show the benefits claimed for formal nurse triage. Nurse triage may impose additional delay for patient treatment, particularly among patients needing the most urgent attention.

Zidovudine for chemoprophylaxis after occupational exposure to HIV-infected blood: an economic evaluation

Three approaches to the management of health care workers (HCWs) following percutaneous exposure to blood of previously unknown serological status were compared using cost-effectiveness analysis. In strategy A, all HCWs are offered zidovudine as soon as possible after exposure. The decision is made within 72 hours to (1) continue therapy with the drug for 4 weeks if the patient's blood is positive for human immunodeficiency virus (HIV) on testing or (2) discontinue therapy and follow-up if the patient's blood is HIV-negative. Strategy B is similar to A except that zidovudine is not offered. In strategy C the patient's blood is not tested and zidovudine is not offered. The results indicate that for every 100 HCWs managed with strategies A, B, and C, the total costs in Canadian dollars (Can $1.00 = U.S. $0.85) are $47,910, $38,849, and $110,834, respectively. The incremental cost per case of AIDS prevented by A relative to B is $300,140, and that prevented by A relative to C is -$6,244,000 (i.e., A results in savings relative to C).

Cellular immunity of patients with recurrent or refractory vulvovaginal moniliasis

Cellular immunity was studied in 73 patients with recurrent vaginal moniliasis and 37 healthy controls, by skin testing with the multitest CMI kit and Candida antigen, with measurement of lymphoblastic transformation to phytohemagglutinin, antigens of Candida albicans, mumps, and streptokinase. Eighteen patients (24.7%) had a hypoergic or anergic response to Candida antigen on skin testing versus two controls (5.4%), p = 0.01. Overall, the patient's lymphoblastic proliferation to mitogen and various antigens was not significantly different from that of the controls. However, a subgroup of younger women (19 to 29 years old) had impaired responses to Candida antigen when compared with age-matched controls, 58% versus 17%, p less than 0.005. Most women with current vaginal moniliasis had normal cellular immunity.

Hepatitis B and human immunodeficiency virus infection in street youths in Toronto, Canada

Hepatitis B and human immunodeficiency virus are transmitted by venereal contact or by the sharing of used needles during drug use. A questionnaire was administered to street youths admitting to prostitution and to a group denying prostitution, as well as to sexually active adolescents who lived with their family and were attending an adolescent medical clinic. The age, gender, race, number of sexual partners, condom use, illicit drug use, anal intercourse and admission to prostitution were recorded for each of the subjects. Serology was obtained for hepatitis B markers and human immunodeficiency virus antibody. Multiple regression analysis was performed to determine the factors which might predict hepatitis B serologic status. A single subject, who admitted to prostitution, was found to be human immunodeficiency virus-seropositive. Seven of 43 (16%) admitted prostitutes compared with 1 of 44 (2%) other street youth and none of 27 controls demonstrated anti-hepatitis B surface antibodies. The higher rate of seropositivity in admitted prostitutes was statistically significant (P less than 0.0097). Two seropositive prostitutes had IgM hepatitis B core antibody suggesting recent infection. Two factors, number of partners (P less than 0.0007) and practice of anal intercourse (P less than 0.05), were identified in the multiple regression analysis as predictive of seropositivity. Thus adolescents who live on the street are at increased risk for becoming infected with hepatitis B virus. The difficulty in ensuring vaccine coverage in this population would support calls for including hepatitis B vaccination as part of childhood immunization.

Differences in red blood cell choline and lipid-bound choline between patients with Alzheimer disease and control subjects

The concentrations of red blood cell choline, glycerophosphocholine, phosphocholine and lipid-bound choline were measured in patients with Alzheimer disease (AD) and in normal elderly controls. Red blood cell choline in the Alzheimer group (41.4 +/- 9.2 nmol/ml) was significantly higher (p less than 0.023) than in the elderly controls (18.7 +/- 2.3 nmol/ml). Red blood cell lipid-bound choline (1387 +/- 58 nmol/ml) in the AD group was significantly lower (p less than 0.0022) than in the age-matched controls (1667 +/- 65), while there were no significant differences in glycerophosphocholine or phosphocholine. Plasma choline and lipid-bound choline did not differ significantly between the groups. The mechanisms for these changes still need further study, although the finding of decreased lipid-bound choline supports the concept of altered phospholipid metabolism in patients with AD.

Methodological considerations in cognitive disorders or: "the baby needs enough bath water"

Establishing treatment efficacy for neuropsychiatric disorders is an often protracted process due to vagaries of symptoms, course, and probably the inherent variability of the central nervous system. No single study design is likely to be definitive. Thorough evaluation of intracranial drug infusion for illnesses such as Alzheimer's Disease will require extended, multidisciplinary work before true evaluation can confidently be made.

Midlatency auditory evoked responses: differential abnormality of P1 in Alzheimer's disease

The human 'P1' middle latency evoked potential is postulated to be generated in the thalamus by a cholinergic component of the ascending reticular activating system. To test the hypothesis that P1 and its generator substrate are abnormal in Alzheimer's disease (AD), a disorder of marked cholinergic deficiency, recordings of middle latency responses to click stimuli were carried out. Comparisons between the AD and age-matched control groups indicated normal auditory brain-stem and Pa responses but a significant decrease in P1 amplitude. This P1 abnormality suggests that the midbrain cholinergic cells in AD may be dysfunctional.

Cyclosporine-induced deterioration in patients with AIDS

Eight patients with AIDS (acquired immune deficiency syndrome) but free of life-threatening infection were treated with the immunosuppressive drug cyclosporine for a mean of 53.9 days. The serum cyclosporine levels were maintained in the desired therapeutic range. All eight patients experienced severe toxic symptoms, which necessitated discontinuation of cyclosporine therapy in six. The serum levels of creatinine, urea and potassium rose during treatment and fell after therapy was stopped. The total leukocyte count, hemoglobin level, platelet count, total T-cell count, and T4- and T8-cell counts all fell markedly during treatment. The total leukocyte count, platelet count, and T4- and T8-cell counts rose after therapy was stopped, but the hemoglobin level remained low. No patient experienced resolution of symptoms during therapy, and the condition of all patients improved after treatment was stopped. The results of this pilot study indicate that cyclosporine does not alleviate, and may worsen, the symptoms and laboratory findings in patients with AIDS.

Factors influencing erythrocyte choline concentrations

Choline concentrations in human erythrocytes increase after freezing and thawing, during incubation in Krebs-phosphate for 30 min or on storage at 0 degrees C for 3-24 hr. The increase is prevented by protein precipitation by 10% perchloric acid, 10% zinc hydroxide, 10% sodium tungstate or boiling in water. It is not prevented by EDTA (10 mM) and is increased by oleate (5 mM). We suggest that the increase is due to the action of phospholipase D on erythrocyte phospholipids.

Proverb and idiom comprehension in Alzheimer disease

Twenty-nine patients diagnosed with Probable Alzheimer Disease were administered tests of word, familiar phrases (idioms and proverbs), and novel phrase comprehension. From the early stage of the disease, patients performed worse at understanding familiar phrases than single words or novel phrases. The results uphold common observations that AD patients have difficulty interpreting abstract meanings. Cognitive variables responsible for poor idiom/proverb comprehension and the clinical implications of this new protocol are discussed.

Abnormal erythrocyte choline and influx in Alzheimer's disease

Choline transport and levels were studied in erythrocytes from patients with Alzheimer's disease and age-matched controls using stable isotopic tracer techniques. The mean erythrocyte choline in the Alzheimer group was 50.1 nmol ml-1 compared to 15.5 nmol ml-1 in the controls. This was significant using a Student's t test at a P of less than 0.0005. Influx of choline into the erythrocyte correlated inversely with erythrocyte choline with high significance. This study suggests that erythrocyte choline is elevated in a subset of patients with Alzheimer's disease and that the low affinity transport system is also abnormal in these patients. This abnormality of choline transport may play a role in the pathogenesis of Alzheimer's disease in some patients.

Aphasia in dementia of the Alzheimer type

Speech and language assessment in 30 patients with dementia of the Alzheimer type and in 70 normal controls revealed that all Alzheimer patients were aphasic. Throughout most of the course, the language disorder resembled transcortical sensory aphasia, and increasing language impairment correlated with increasing severity of dementia. Aphasia was present regardless of age of onset or family history of dementia. Aphasia is an important diagnostic criterion of dementia of the Alzheimer type.

Amnesia with hippocampal lesions after cardiopulmonary arrest

A patient developed an amnesic syndrome after cardiopulmonary arrest. Neuropathologic examination revealed pronounced anoxic injury to both hippocampi with little damage to other hemisphere structures. The clinical and pathologic findings suggest that lesions limited to the hippocampus can cause profound amnesia.

Value of computerised tomography in children with non-specific mental subnormally

Seventy-six children had computerized tomography scans as part of an investigation of mental subnormality; most of them are severely retarded and all those over age 5 years attend special schools. Seventy-two per cent of the children had normal scans. Twenty per cent showed cerebral atrophy and in only 8% was there a specific abnormality (agenesis of corpus callosum, arachnoid cyst, communicating hydrocephalus). None of these findings had any positive prognostic implication. Sedation or general anaesthesia was required for all except one child. Injection pethidine compound was used for children under age 5 years or less than 30 kg in weight, and trimeprazine orally was used for older children. The radiation exposure was high--5.6 rad per scan, which is 100 times greater than that from a posteroanterior and lateral chest x-ray film. For these reasons computerised tomography scans cannot be recommended as a routine part of the investigation of children with non-specific mental subnormality.

Immunological and biochemical analysis of a null mutant of alpha-glycerolphosphate dehydrogenase from Drosophila melanogaster

A Drosophila null mutant(BO-1-4) of alpha-glycerolphosphate dehydrogenase induced by ethylmethane sulfonate(EMS) was analyzed by double immunodiffusion, enzyme immunoinactivation, immunoelectrophoresis and two-dimensional electrophoresis. Based on all the immunological evidence, this mutant appears to express no protein that can cross-react with the antiserum specific to alpha-glycerolphosphate dehydrogenase. A protein spot corresponding to alpha-glycerolphosphate dehydrogenase was identified on two-dimensional gels of the soluble fly homogenates. The absence of this protein spor on two-dimensional gels of this null mutant further supported the immunological data. The activities of seven other enzymes in the related metabolic pathways were determined for the mutant and the control Drosophila. The null mutant does not show significant alterations in activities of these enzymes. The relationship between the deficiency of this enzyme and the inability for the sustained flight of the null mutant was discussed in terms of cellular metabolic regulations.