Should we test for tetanus immunity in all emergency department patients with wounds?

BACKGROUND: People who present to the emergency department often do not know their tetanus immunisation status. The Protetanus test can determine whether a person is immune and can guide treatment decisions. OBJECTIVES: To examine whether testing all patients for immunity is clinically advisable and cost-effective. METHODS: 200 patients presenting to the emergency department with wounds were asked whether they were covered for tetanus, not covered or did not know. All had their tetanus immunity tested with the Protetanus kit and the result was compared with reported status. The number of unnecessary vaccinations which might have been given based on recall was calculated. The cost of testing and subsequent treatment versus vaccinations based on recall was calculated. RESULTS: 136 (68%) tested positive for tetanus immunity; 64 (32%) were negative. Age, sex and nationality were not associated with tetanus immunity. 151 (75.5%) did not know their status. Of these, 101 (66.9%) were positive and 50 (33.1%) negative. 49 (24.5%) were sure of their status. 36 said they were covered of whom 10 (27.8%) were wrong. 13 said they were not covered of whom 9 (69.2%) were wrong. If vaccination were based on recall status 38.8% of patients would receive incorrect treatment. Testing all 200 and treating appropriately would save £984, or £4.92 per patient compared with vaccination based on recall. CONCLUSION: On clinical grounds testing is advisable and it may produce significant cost savings.

Seizure First Aid Training For people with Epilepsy (SAFE) frequently attending emergency departments and their significant others: results of a UK multi-centre randomised controlled pilot trial.

OBJECTIVE: To determine the feasibility and optimal design of a randomised controlled trial (RCT) of Seizure First Aid Training For Epilepsy (SAFE). DESIGN: Pilot RCT with embedded microcosting. SETTING: Three English hospital emergency departments (EDs). PARTICIPANTS: Patients aged ≥16 with established epilepsy reporting ≥2 ED visits in the prior 12 months and their significant others (SOs). INTERVENTIONS: Patients (and their SOs) were randomly allocated (1:1) to SAFE plus treatment-as-usual (TAU) or TAU alone. SAFE is a 4-hour group course. MAIN OUTCOME MEASURES: Two criteria evaluated a definitive RCT's feasibility: (1) ≥20% of eligible patients needed to be consented into the pilot trial; (2) routine data on use of ED over the 12 months postrandomisation needed securing for ≥75%. Other measures included eligibility, ease of obtaining routine data, availability of self-report ED data and comparability, SAFE's effect and intervention cost. RESULTS: Of ED attendees with a suspected seizure, 424 (10.6%) patients were eligible; 53 (12.5%) patients and 38 SOs consented. Fifty-one patients (and 37 SOs) were randomised. Routine data on ED use at 12 months were secured for 94.1% patients. Self-report ED data were available for 66.7% patients. Patients reported more visits compared with routine data. Most (76.9%) patients randomised to SAFE received it and no related serious adverse events occurred. ED use at 12 months was lower in the SAFE+TAU arm compared with TAU alone, but not significantly (rate ratio=0.62, 95% CI 0.33 to 1.17). A definitive trial would need ~674 patient participants and ~39 recruitment sites. Obtaining routine data was challenging, taking ~8.5 months. CONCLUSIONS: In satisfying only one predetermined 'stop/go' criterion, a definitive RCT is not feasible. The low consent rate in the pilot trial raises concerns about a definitive trial's finding's external validity and means it would be expensive to conduct. Research is required into how to optimise recruitment from the target population. TRIAL REGISTRATION NUMBER: ISRCTN13871327.