The Reality of Pain Scoring in the Emergency Department: Findings From a Multiple Case Study Design.

STUDY OBJECTIVE: Documentation of pain severity with pain scores is recommended within emergency departments (EDs) to improve consistency of assessment and management of pain. Pain scores are used in treatment guidelines and triage algorithms to determine pain management and in audit and research to evaluate pain management practices. Despite significant debate of their benefits, there has been limited evaluation of their use in practice. We use naturalistic, qualitative methods to understand how pain scores are used in practice and the mechanisms by which pain scoring may influence pain management. METHODS: We undertook a multiple case study design, using qualitative research in 3 EDs in England (the cases). Case studies incorporated 143 hours of nonparticipant observation, documentary analysis, and semistructured interviews with 36 staff and 19 patients. Data were analyzed with thematic analysis. RESULTS: Analysis identified that ED staff used the pain score for 2 conflicting purposes: as an auditable tool for guiding patient management and as a tool for monitoring patient experience. This led to ED staff's facing conflict between reporting their own judgment of what the pain score ought to be and what the patient said it was. Staff justified recording their own judgment according to concerns of accountability and appropriateness of management decisions. Staff thought that pain scoring had value in raising awareness and prompting action. CONCLUSION: In practice, pain scoring may not accurately reflect patient experience. Using pain scoring to determine the appropriateness of triage and treatment decisions reduces its validity as a measure of patient experience. Pain scoring should not be central to audit and systems of accountability for pain management.

Effectiveness of EDACS Versus ADAPT Accelerated Diagnostic Pathways for Chest Pain: A Pragmatic Randomized Controlled Trial Embedded Within Practice.

STUDY OBJECTIVE: A 2-hour accelerated diagnostic pathway based on the Thrombolysis in Myocardial Infarction score, ECG, and troponin measures (ADAPT-ADP) increased early discharge of patients with suspected acute myocardial infarction presenting to the emergency department compared with standard care (from 11% to 19.3%). Observational studies suggest that an accelerated diagnostic pathway using the Emergency Department Assessment of Chest Pain Score (EDACS-ADP) may further increase this proportion. This trial tests for the existence and size of any beneficial effect of using the EDACS-ADP in routine clinical care. METHODS: This was a pragmatic randomized controlled trial of adults with suspected acute myocardial infarction, comparing the ADAPT-ADP and the EDACS-ADP. The primary outcome was the proportion of patients discharged to outpatient care within 6 hours of attendance, without subsequent major adverse cardiac event within 30 days. RESULTS: Five hundred fifty-eight patients were recruited, 279 in each arm. Sixty-six patients (11.8%) had a major adverse cardiac event within 30 days (ADAPT-ADP 29; EDACS-ADP 37); 11.1% more patients (95% confidence interval 2.8% to 19.4%) were identified as low risk in EDACS-ADP (41.6%) than in ADAPT-ADP (30.5%). No low-risk patients had a major adverse cardiac event within 30 days (0.0% [0.0% to 1.9%]). There was no difference in the primary outcome of proportion discharged within 6 hours (EDACS-ADP 32.3%; ADAPT-ADP 34.4%; difference -2.1% [-10.3% to 6.0%], P=.65). CONCLUSION: There was no difference in the proportion of patients discharged early despite more patients being classified as low risk by the EDACS-ADP than the ADAPT-ADP. Both accelerated diagnostic pathways are effective strategies for chest pain assessment and resulted in an increased rate of early discharges compared with previously reported rates.

Comparison of conventional and high-sensitivity troponin in patients with chest pain: a collaborative meta-analysis.

BACKGROUND: Multiple studies have evaluated the diagnostic and prognostic performance of conventional troponin (cTn) and high-sensitivity troponin (hs-cTn). We performed a collaborative meta-analysis comparing cTn and hs-cTn for diagnosis of acute myocardial infarction (AMI) and assessment of prognosis in patients with chest pain. METHODS: MEDLINE/PubMed, Cochrane CENTRAL, and EMBASE were searched for studies assessing both cTn and hs-cTn in patients with chest pain. Study authors were contacted and many provided previously unpublished data. RESULTS: From 17 included studies, there were 8,644 patients. Compared with baseline cTn, baseline hs-cTn had significantly greater sensitivity (0.884 vs 0.749, P < .001) and negative predictive value (NPV; 0.964 vs 0.935, P < .001), whereas specificity (0.816 vs 0.938, P < .001) and positive predictive value (0.558 vs 0.759, P < .001) were significantly reduced. Based on summary receiver operating characteristic curves, test performance for the diagnosis of AMI was not significantly different between baseline cTn and hs-cTn (0.90 [95% CI 0.85-0.95] vs 0.92 [95% CI 0.90-0.94]). In a subanalysis of 6 studies that alternatively defined AMI based on hs-cTn, cTn had lower sensitivity (0.666, P < .001) and NPV (0.906, P < .001). Elevation of baseline hs-cTn, but negative baseline cTn, was associated with increased risk of death or nonfatal myocardial infarction during follow-up (P < .001) compared with both negative. CONCLUSION: High-sensitivity troponin has significantly greater early sensitivity and NPV for the diagnosis of AMI at the cost of specificity and positive predictive value, which may enable early rule in/out of AMI in patients with chest pain. Baseline hs-cTn elevation in the setting of negative cTn is also associated with increased nonfatal myocardial infarction or death during follow-up.

Evaluation of the DAVROS (Development And Validation of Risk-adjusted Outcomes for Systems of emergency care) risk-adjustment model as a quality indicator for healthcare.

BACKGROUND AND OBJECTIVE: Risk-adjusted mortality rates can be used as a quality indicator if it is assumed that the discrepancy between predicted and actual mortality can be attributed to the quality of healthcare (ie, the model has attributional validity). The Development And Validation of Risk-adjusted Outcomes for Systems of emergency care (DAVROS) model predicts 7-day mortality in emergency medical admissions. We aimed to test this assumption by evaluating the attributional validity of the DAVROS risk-adjustment model. METHODS: We selected cases that had the greatest discrepancy between observed mortality and predicted probability of mortality from seven hospitals involved in validation of the DAVROS risk-adjustment model. Reviewers at each hospital assessed hospital records to determine whether the discrepancy between predicted and actual mortality could be explained by the healthcare provided. RESULTS: We received 232/280 (83%) completed review forms relating to 179 unexpected deaths and 53 unexpected survivors. The healthcare system was judged to have potentially contributed to 10/179 (8%) of the unexpected deaths and 26/53 (49%) of the unexpected survivors. Failure of the model to appropriately predict risk was judged to be responsible for 135/179 (75%) of the unexpected deaths and 2/53 (4%) of the unexpected survivors. Some 10/53 (19%) of the unexpected survivors died within a few months of the 7-day period of model prediction. CONCLUSIONS: We found little evidence that deaths occurring in patients with a low predicted mortality from risk-adjustment could be attributed to the quality of healthcare provided.

Influence of adaptive analysis on unnecessary patient recruitment: reanalysis of the RATPAC trial.

STUDY OBJECTIVE: Recruitment to clinical trials is a challenging but essential activity in emergency medicine. Conventional fixed-sample trials may continue to recruit patients after efficacy has been demonstrated or when further recruitment is futile. Adaptive trials make use of emerging information to modify aspects of a trial or terminate it prematurely, potentially resulting in savings in terms of sample size, time, and cost. We aim to use sequential testing procedures to reanalyze data from a fixed-sample trial, the Randomised Assessment of Treatment Using Panel Assay of Cardiac Markers (RATPAC) trial, and investigate the potential for adaptive designs to reduce unnecessary recruitment. METHODS: The trial was reanalyzed with a triangular group sequential design, with interim analyses planned every 3 months. Patients were analyzed in the order in which they entered the original trial. RESULTS: We found that the RATPAC trial could potentially have stopped 1 year earlier, with 722 patients enrolled compared with 2,243 patients in the original trial, making a potential saving of approximately $390,000. Estimates of effect were similar, and the qualitative conclusions of the original and group sequential RATPAC trials were in agreement. However, the group sequential approach is not without limitations and would have resulted in less precise estimates of effect and less information available for the subsequent evaluation of secondary endpoints. CONCLUSION: Sequential designs are well suited in emergency medicine because of the rapidly obtained outcomes and the need to avoid unnecessary recruitment. We recommend that group sequential designs be considered for clinical trials in emergency medicine.

Health utility after emergency medical admission: a cross-sectional survey.

OBJECTIVES: Health utility combines health related quality of life and mortality to produce a generic outcome measure reflecting both morbidity and mortality. It has not been widely used as an outcome measure in evaluations of emergency care and little is known about the feasibility of measurement, typical values obtained or baseline factors that predict health utility. We aimed to measure health utility after emergency medical admission, to compare health utility to age, gender and regional population norms, and identify independent predictors of health utility. METHODS: We selected 5760 patients across three hospitals who were admitted to hospital by ambulance as a medical emergency. The EQ-5D questionnaire was mailed to all who were still alive 30 days after admission. Health utility was estimated by applying tariff values to the EQ-5D responses or imputing a value of zero for those who had died. Multivariable analysis was used to identify independent predictors of health utility at 30 days. RESULTS: Responses were received from 2488 (47.7%) patients, while 541 (9.4%) had died. Most respondents reported some or severe problems with each aspect of health. Mean health utility was 0.49 (standard deviation 0.35) in survivors and 0.45 (0.36) including non-survivors. Some 75% had health utility below their expected value (mean loss 0.32, 95% confidence interval 0.31 to 0.33) and 11% had health utility below zero (worse than death). On multivariable modelling, reduced health utility was associated with increased age and lower GCS, varied according to ICD10 code and was lower among females, patients with recent hospital admission, steroid therapy, or history of chronic respiratory disease, malignancy, diabetes or epilepsy. CONCLUSIONS: Health utility can be measured after emergency medical admission, although responder bias may be significant. Health utility after emergency medical admission is poor compared to population norms. We have identified independent predictors or health utility that need to be measured and taken into account in non-randomized evaluations of emergency care.

Evaluation of Global Registry of Acute Cardiac Events and Thrombolysis in Myocardial Infarction scores in patients with suspected acute coronary syndrome.

PURPOSES: We aimed to evaluate the Global Registry of Acute Cardiac Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) scores in patients with suspected but not proven acute coronary syndrome (ACS). BASIC PROCEDURES: We conducted a secondary analysis of data from the RATPAC trial. Standardized data were collected from 2263 patients presenting to 6 emergency departments with suspected but not proven ACS. Patients were followed up by record review and postal questionnaire at 30 and 90 days after recruitment to identify major adverse events, defined as death, emergency revascularization, life-threatening arrhythmia, hospitalization for ACS, or nonfatal acute myocardial infarction (AMI). MAIN FINDINGS: Data were available for 2243 patients (mean age, 54.5 years; 58% male). The major adverse event rate was 43 (2%) of 2243 after 30 days and 62 (3%) of 2243 after 90 days. The c statistics for 30-day events were 0.717 (95% confidence interval [CI], 0.698-0.735) for GRACE and 0.682 (95% CI, 0.662-0.701) for TIMI. The corresponding 90-day c statistics were 0.726 (95% CI, 0.707-0.745) for GRACE and 0.693 (95% CI, 0.674-0.712) for TIMI. The c statistic for patient age alone was 0.656 for 30-day events and 0.689 for 90-day events. PRINCIPAL CONCLUSIONS: The GRACE and TIMI scores are little better than age alone as predictors of major adverse events in patients with suspected but not proven ACS, and thus add little to prognostic assessment of such patients.

Where is the evidence for emergency planning: a scoping review.

BACKGROUND: Recent terrorist attacks and natural disasters have led to an increased awareness of the importance of emergency planning. However, the extent to which emergency planners can access or use evidence remains unclear. The aim of this study was to identify, analyse and assess the location, source and quality of emergency planning publications in the academic and UK grey literature. METHODS: We conducted a scoping review, using as data sources for academic literature Embase, Medline, Medline in Process, Psychinfo, Biosis, Science Citation Index, Cinahl, Cochrane library and Clinicaltrials.gov. For grey literature identification we used databases at the Health Protection Agency, NHS Evidence, British Association of Immediate Care Schemes, Emergency Planning College and the Health and Safety Executive, and the websites of UK Department of Health Emergency Planning Division and UK Resilience.Aggregative synthesis was used to analyse papers and documents against a framework based on a modified FEMA Emergency Planning cycle. RESULTS: Of 2736 titles identified from the academic literature, 1603 were relevant. 45% were from North America, 27% were commentaries or editorials and 22% were event reports.Of 192 documents from the grey literature, 97 were relevant. 76% of these were event reports.The majority of documents addressed emergency planning and response. Very few documents related to hazard analysis, mitigation or capability assessment. CONCLUSIONS: Although a large body of literature exists, its validity and generalisability is unclear There is little evidence that this potential evidence base has been exploited through synthesis to inform policy and practice. The type and structure of evidence that would be of most value of emergency planners and policymakers has yet to be identified.

Evaluation of triage methods used to select patients with suspected pandemic influenza for hospital admission.

OBJECTIVES: Prepandemic projections anticipated huge excess attendances and mortality in an influenza pandemic. A number of tools had been suggested for triaging patients with influenza for inpatient and critical care admission, but none had been validated in these patients. The authors aimed to evaluate three potential triage tools--CURB-65, PMEWS and the Department of Health community assessment tool (CAT)--in patients in the first waves of the 2009 H1N1 pandemic. SETTING: Prospective cohort study in three urban emergency departments (one adult, one paediatric, one mixed) in two cities. PARTICIPANTS: All patients presenting to the three emergency departments fulfilling the national definition of suspected pandemic influenza. OUTCOME MEASURES: 30-day follow-up identified patients who had died or had required advanced respiratory, cardiovascular or renal support. RESULTS: The pandemic was much less severe than expected. A total of 481 patients (347 children) were recruited, of which only five adults fulfilled the outcome criteria for severe illness. The c-statistics for CURB-65, PMEWS and CAT in adults in terms of discriminating between those admitted and discharged were 0.65 (95% CI 0.54 to 0.76), 0.76 (95% CI 0.66 to 0.86) and 0.62 (95% CI 0.51 to 0.72), respectively. In detecting adverse outcome, sensitivities were 20% (95% CI 4% to 62%), 80% (95% CI 38% to 96%) and 60% (95% CI 23% to 88%), and specificities were 94% (95% CI 88% to 97%), 40% (95% CI 32% to 49%) and 81% (95% CI 73% to 87%) for CURB-65, PMEWS and CAT, respectively. CONCLUSIONS: Although limited by a paucity of cases, this research shows that current triage methods for suspected pandemic influenza did not reliably discriminate between patients with good and poor outcomes.

Interhospital variation in the RATPAC trial (Randomised Assessment of Treatment using Panel Assay of Cardiac markers).

BACKGROUND: The RATPAC trial showed that using a point-of-care panel of CK-MB(mass), myoglobin and troponin at baseline and 90 min increased the proportion of patients successfully discharged home, leading to reduced median length of initial hospital stay. However, it did not change mean hospital stay and may have increased mean costs per patient. The aim of this study was to explore variation in outcome and costs between participating hospitals. METHODS: RATPAC was a pragmatic multicentre randomised controlled trial (N=2243) and economic analysis comparing diagnostic assessment using the panel to standard care for patients with acute chest pain due to suspected myocardial infarction at six hospitals. The difference in the proportion of patients successfully discharged (primary outcome) and mean costs per patient between the participating hospitals was compared. RESULTS: Point-of-care assessment led to a higher proportion of successful discharges in four hospitals, a lower proportion in one and was equivocal in another. The OR (95% CI) for the primary outcome varied from 0.12 (0.01 to 1.03) to 11.07 (6.23 to 19.66) with significant heterogeneity between the centres (p<0.001). The mean cost per patient for the intervention group ranged from being £214.49 less than the control group (-132.56 to 657.10) to £646.57 more expensive (73.12 to 1612.71), with weak evidence of heterogeneity between the centres (p=0.0803). CONCLUSION: The effect of point-of-care panel assessment on successful discharge and costs per patient varied markedly between hospitals and may depend on local protocols, staff practices and available facilities.

Clinical decision rules for adults with minor head injury: a systematic review.

BACKGROUND: There are many clinical decision rules for adults with minor head injury, but it is unclear how they compare in terms of diagnostic accuracy. This study aimed to systematically identify clinical decision rules for adults with minor head injury and compare the estimated diagnostic accuracies for any intracranial injury and injury requiring neurosurgical intervention. METHODS: Several electronic bibliographic databases covering biomedical, scientific, and gray literature were searched from inception to March 2010. At least two independent reviewers determined the eligibility of cohort studies that described a clinical decision rule to identify adults with minor head injury (Glasgow Coma Scale score, 13-15) at risk of intracranial injury or injury requiring neurosurgical intervention. RESULTS: Twenty-two relevant studies were identified. Differences existed in patient selection, outcome definition, and reference standards used. Nine rules stratified patients into high- and moderate-risk categories (to identify neurosurgical or nonsurgical intracranial lesions). The Canadian Computed Tomography Head Rule (CCHR) high-risk criteria have sensitivity of 99% to 100% with specificity of 48% to 77% for injury requiring neurosurgical intervention. Other rules such as New Orleans criteria, National Emergency X-Radiography Utilization Study II, Neurotraumatology Committee of the World Federation of Neurosurgical Societies, Scandinavian, and Scottish Intercollegiate Guidelines Network produce similar sensitivities for injury requiring neurosurgical intervention but with lower and more variable specificity values. DISCUSSION: The most widely researched decision rule is the CCHR, which has consistently shown high sensitivity for identifying injury requiring neurosurgical intervention with an acceptable specificity to allow considered use of cranial computed tomography. No other decision rule has been as widely validated or demonstrated as acceptable results, but its exclusion criteria make it difficult to apply universally.

Predictive scoring in non-trauma emergency patients: a scoping review.

This study is an inclusive scoping review of the literature relating to outcome prediction in adult non-trauma emergency patients, in order to identify the number and range of risk scores developed for acutely ill adults and to identify the outcomes these scores predict. The data source used was Medline 1950-2009. To be eligible for inclusion, papers had to detail an assessment tool, wholly or predominantly clinical, applied at the point of patient presentation to unscheduled healthcare services with outcome measures up to 30 days after presentation. Papers detailing trauma, paediatrics, purely obstetric or psychiatric presentations, tools wholly applied in a critical care setting, tools requiring an algorithm not freely available, biomarkers or tests not routinely available in an Emergency Department (ED) setting were excluded. 192 papers were reviewed. Within 17 broad disease categories, 80 inclusion criteria were used, 119 tools were assessed (25 of which were non-disease specific), and 51 outcome measures were used (30 of which were disease-specific). The areas under the receiver-operator characteristic curve (AUROCs) varied from 0.44 to 0.984. The multiplicity of tools available presents a challenge in itself to the acute clinician. Many tools require a specific diagnosis, which is not immediately available, and the authors advocate ED development of tools for case-mix adjustment and clinical risk stratification.

Management of isolated minor head injury in the UK.

BACKGROUND: Recent guidelines and service developments may have changed the management of isolated minor head injuries in the UK. The authors aimed to review current practice and national statistics, and determine whether methods of service delivery are associated with differences in admission rates. METHODS: The authors surveyed management of minor head injuries in all acute hospitals in the UK and then correlated these responses with Hospital Episodes Statistics (HES) emergency department data relating to head injury. RESULTS: Responses relating to children were received from 174/250 hospitals and adults from 181/250. Nearly all hospitals had unrestricted access to CT scanning (adults 96%, children 94.5%). Most hospitals (70.1%) admitted adults under the emergency department staff, usually (61.4%) to an observation ward or clinical decision unit. Children were usually formally admitted to a ward (86.7%) under an inpatient team (78.5%). The median proportion of attendances admitted was higher for adults (18%) than for children (9%). There was no evidence of any association between the proportion admitted and the admission team, location or requirement for senior or specialist approval (all p>0.1). CONCLUSION: Minor head injury admission, especially for adults, is increasingly the responsibility of the emergency department. Admission policies had no significant effect on the proportion admitted, although improved HES data are required to confirm this.

Do emergency department attendances by homeless people increase in cold weather?

BACKGROUND: Little is known about how and when homeless people use the emergency department. It might be anticipated that attendances would increase in cold weather as homeless people seek possible shelter. The authors aimed to describe emergency department attendances by homeless people and determine whether ambient temperatures affect attendance rates. METHODS: The authors undertook a retrospective study of routine data from the Northern General Hospital Emergency Department and Weston Park Weather Station from 2003 to 2008. RESULTS: There were 528 573 emergency department attendances between 2003 and 2008, including 2930 by homeless people (5.5 per 1000 attendances). Total attendances increased steadily over the study period, while attendances by homeless people peaked in 2005 and 2006. Attendances by homeless people were more frequent in the evening and at night, and a relatively high proportion (17.4%) left without being seen. There was a small positive correlation between daily attendances by homeless people and minimum (r=0.061, p=0.004) or maximum (r=0.049, p=0.022) daily temperature. CONCLUSION: We found no evidence to suggest that homeless people are more likely to attend the emergency department in cold weather. If anything, there was a small positive correlation between rate of attendances and daily temperature.

Meta-analysis of ischemia-modified albumin to rule out acute coronary syndromes in the emergency department.

BACKGROUND: Because of possible adverse outcomes, many of the >6 million annual emergency department (ED) patients with suspected acute coronary syndromes (ACS) undergo extensive evaluations. To minimize medical errors, chest pain evaluations are structured to identify accurately nearly 100% of patients with ACS. This is at a cost of negative evaluation rates that can exceed 90%. Ischemia-modified albumin (IMA), a serum biomarker with a high negative predictive value (NPV) at ED presentation, may exclude ACS. Our objective was to perform a meta-analysis of IMA use for ACS risk stratification. METHODS: By computer literature search and communication with authors of unpublished information, all IMA data were considered. This analysis included studies if they reported IMA results from an ED presentation for suspected ACS. We defined a negative triple prediction test (TPT) as a nondiagnostic electrocardiogram, negative troponin, and negative IMA. RESULTS: Eight studies of >1800 patients met the entry criteria. The TPT sensitivity and NPV for acute ACS were 94.4% and 97.1% and, for longer-term outcomes, were 89.2% and 94.5%, respectively. CONCLUSIONS: A negative TPT of a nondiagnostic electrocardiogram, negative troponin, and negative IMA has a high NPV for excluding ACS in the ED.

Development and validation of a score to identify in the Emergency Department patients who may benefit from a time-critical intervention: a cohort study.

BACKGROUND: Risk stratification methods developed on the basis of predicting illness severity are often used to prioritise patients on the basis of urgency. Illness severity and urgency may not be interchangeable. Severe illness places patients at risk of adverse outcome, but treatment is only urgent if adverse outcome can be prevented by time-sensitive treatment. We aimed to develop a score to identify patients in need of urgent treatment, on the basis of potential to benefit from time-sensitive intervention, and to compare this with a severity score identifying patients at high risk of death. METHODS: A sequential cohort of adults presenting to one Emergency Department by ambulance and admitted to hospital was prospectively collected (2437 derivation, 2322 validation). Data on outcomes representing potential to benefit was collected retrospectively on a random subset (398 derivation, 227 validation). Logistic regression identified variables predictive of death and potential to benefit from urgent treatment. RESULTS: Death was predicted using age, respiratory rate, diastolic blood pressure, oxygen saturations, temperature, GCS and respiratory disease (AUROC 0.84 (95 % CI 0.8-0.89) derivation and 0.74 (0.69-0.81) validation), while potential to benefit was predicted by pulse, systolic blood pressure and GCS (AUROC 0.74 (0.67-0.80) derivation and 0.71 (0.59-0.82) validation). CONCLUSIONS: A score developed to predict the need for urgent treatment has a different composition to a score developed to predict illness severity, suggesting that triage methods based on predicting severity could lead to inappropriate prioritisation on the intended basis of urgency.

Patient and primary care physician satisfaction with chest pain unit and routine care.

OBJECTIVES: The chest pain unit (CPU) has been developed to improve care for patients with acute, undifferentiated chest pain. The authors aimed to measure patient and primary care physician (PCP) satisfaction with CPU care and routine care and to determine whether patient satisfaction predicted PCP satisfaction. METHODS: A CPU was established, and 442 days were randomly allocated to either CPU care or routine care. Consenting patients presenting with acute, undifferentiated chest pain were recruited and followed at two days and one month. All were given a self-completed patient satisfaction questionnaire two days after attendance (N = 972). Each patient's PCP was sent a self-completed satisfaction questionnaire during days 171-442 of the trial (N = 601). Analysis determined whether CPU care was associated with improved patient or PCP satisfaction and whether patient satisfaction predicted PCP satisfaction for three questions relating to diagnosis, treatment, and overall care. RESULTS: CPU care was consistently associated with higher scores across all patient satisfaction questions, from the perceived thoroughness of examination to care received to an overall assessment of the service received. However, CPU care achieved small improvements in only two of ten PCP satisfaction questions, concerning overall management of the patient and the amount of information about investigations performed. Furthermore, patient satisfaction did not predict PCP satisfaction in relation to diagnosis (p = 0.456), treatment (p = 0.256), or overall care (p = 0.085). CONCLUSIONS: CPU care is associated with substantial improvements in all dimensions of patient satisfaction but only minimal improvements in PCP satisfaction. Patient satisfaction was not a strong predictor of PCP satisfaction with emergency care.