Adolescents with Rett syndrome at critical care pathway junctures: Examining clinicians' decision to initiate invasive long-term ventilation.

BACKGROUND: The initiation of invasive long-term ventilation (I-LTV) for an adolescent with Rett Syndrome (RTT) involves many serious bioethical considerations. In moving towards a more inclusive model of patient participation, transparency surrounding the main influencing factors around this decision is important. OBJECTIVE: We aimed to identify the main drivers influencing a clinician's decision to support initiation of I-LTV for an adolescent with RTT. METHOD: We used an anonymous online vignette-based factorial survey. The survey was distributed internationally through eight professional multi-disciplinary organisations to reach clinicians working in paediatrics. RESULTS: We analysed 504 RTT vignettes completed by 246 clinicians using mixed effect regression modelling. The main three significant influencing factors identified were: parental agreement with the decision to support initiation, the family's support network, and proximity to a tertiary care centre. Additional comments from participants focused on family support, and the importance of on-going communication with the family. CONCLUSION: As the rights of those with disabilities improve and participation of adolescents in decision-making becomes more established, effective communications with the family around goals of care and particular sensitivity and reflective practice around methods of consensus building will likely contribute to a positive decision-making process at this difficult time.

The role of bioethics services in paediatric intensive care units: a qualitative descriptive study.

BACKGROUND: There is considerable variation in the functionality of bioethical services in different institutions and countries for children in hospital, despite new challenges due to increasing technology supports for children with serious illness and medical complexity. We aimed to understand how bioethics services address bioethical concerns that are increasingly encountered in paediatric intensive care. METHODS: A qualitative descriptive design was used to describe clinician's perspectives on the functionality of clinical bioethics services for paediatric intensive care units. Clinicians who were members of formal or informal clinical bioethics groups, or who were closely involved with the process of working through ethically challenging decisions, were interviewed. Interviews took place online. Resulting transcripts were analysed using thematic analysis. RESULTS: From 33 interviews, we identified four themes that described the functionality of bioethics services when a child requires technology to sustain life: striving for consensus; the importance of guidelines; a structure that facilitates a time-sensitive and relevant response; and strong leadership and teamwork. CONCLUSIONS: Clinical bioethics services have the potential to expand their role due to the challenges brought by advancing medical technology and the increasing options it brings for treatment. Further work is needed to identify where and how bioethics services can evolve and adapt to fully address the needs of the decision-makers in PICU.

The factorial survey as an approach to investigate clinical decision-making: examining influences on a clinician's decision to initiate life-sustaining clinical technology for a child with spinal muscular atrophy type 1.

Background: Spinal Muscular Atrophy (SMA) type 1 is a debilitating condition with a poor prognosis, though therapeutic advances are promising. Long-term ventilation is a common management strategy as respiratory function deteriorates. Without consensus on best practice respiratory management, the decision to initiate invasive LTV (I-LTV) for this group of young children involves many ethical considerations. Understanding the main influencing factors on a clinician's likelihood to initiative I-LTV for a child with chronic critical illness is important to maintain transparency and trust with the family during this challenging time. Methods: A factorial survey was used to identify the factors that influence a clinician to support initiation of I-LTV for children with SMA type 1. Factorial survey content was based on literature and evidence-based practice and the content was subject to extensive pretesting and pilot testing. An anonymous survey was disseminated (Oct 2021-Jan 2022), via eight international professional organisations, to clinicians with experience caring for children at the time of initiation of I-LTV. Results: 251 participants answered 514 vignettes on SMA type 1. The greatest influencing factor on clinician's likelihood to initiate I-LTV was parental agreement with the need to initiate I-LTV. Additional qualitative comments from participants support this finding. Clinicians also highlighted the important role of innovative therapies as well as the availability of supports for families when considering initiation however these findings were context based. Conclusions: The factorial survey approach provides a valuable way of identifying influencers on decision-making in sensitive situations. The findings demonstrate the acceptance of the centrality of parental influence in decisions on care delivery. Effective communication with the child's family is key to ensuring shared understanding and agreement of goals of care. More international research is needed on the long-term effects of novel treatments, as well as impact on quality of life and influence of geographical location, to inform decision-making.

Technology solutionism in paediatric intensive care: clinicians' perspectives of bioethical considerations.

BACKGROUND: The use of long-term life-sustaining technology for children improves survival rates in paediatric intensive care units (PICUs), but it may also increase long-term morbidity. One example of this is children who are dependent on invasive long-term ventilation. Clinicians caring for these children navigate an increasing array of ethical complexities. This study looks at the meaning clinicians give to the bioethical considerations associated with the availability of increasingly sophisticated technology. METHODS: A hermeneutic phenomenological exploration of the experiences of clinicians in deciding whether to initiate invasive long-term ventilation in children took place, via unstructured interviews. Data were analysed to gain insight into the lived experiences of clinicians. Participants were from PICUs, or closely allied to the care of children in PICUs, in four countries. RESULTS: Three themes developed from the data that portray the experiences of the clinicians: forming and managing relationships with parents and other clinicians considering, or using, life sustaining technology; the responsibility for moral and professional integrity in the use of technology; and keeping up with technological developments, and the resulting ethical and moral considerations. DISCUSSION: There are many benefits of the availability of long-term life-sustaining technology for a child, however, clinicians must also consider increasingly complex ethical dilemmas. Bioethical norms are adapting to aid clinicians, but challenges remain. CONCLUSION: During a time of technological solutionism, more needs to be understood about the influences on the initiation of invasive long-term ventilation for a child. Further research to better understand how clinicians, and bioethics services, support care delivery may positively impact this arena of health care.

Integrated care for children living with complex care needs: an evolutionary concept analysis.

Children with complex care needs (CCNs) are in need of improved access to healthcare services, communication, and support from healthcare professionals to ensure high-quality care is delivered to meet their needs. Integrated care is viewed as a key component of care delivery for children with CCNs, as it promotes the integration of healthcare systems to provide family and child-centred care across the entire health spectrum. There are many definitions and frameworks that support integrated care, but there is a lack of conceptual clarity around the term. Furthermore, it is often unclear how integrated care can be delivered to children with CCNs, therefore reinforcing the need for further clarification on how to define integrated care. An evolutionary concept analysis was conducted to clarify how integrated care for children with CCNs is defined within current literature. We found that integrated care for children with CCNs refers to highly specialised individualised care within or across services, that is co-produced by interdisciplinary teams, families, and children, supported by digital health technologies.  Conclusion: Given the variation in terms of study design, outcomes, and patient populations this paper highlights the need for further research into methods to measure integrated care. What is Known: • Children with complex care needs require long-term care, and are in need of improved services, communication, and information from healthcare professionals to provide them with the ongoing support they need to manage their condition. • Integrated care is a key component in healthcare delivery for children with complex care needs as it has the potential to improve access to family-centred care across the entire health spectrum. What is New: • Integrated care for children with CCNs refers to highly specialised individualised care within or across services, that is co-produced by interdisciplinary teams, families, and children, supported by digital health technologies. • There is a need for the development of measurement tools to effectively assess integrated care within practice.

Development of a factorial survey for use in an international study examining clinicians' likelihood to support the decision to initiate invasive long-term ventilation for a child (the TechChild study).

BACKGROUND: The decision to initiate invasive long-term ventilation for a child with complex medical needs can be extremely challenging. TechChild is a research programme that aims to explore the liminal space between initial consideration of such technology dependence and the final decision. This paper presents a best practice example of the development of a unique use of the factorial survey method to identify the main influencing factors in this critical juncture in a child's care. METHODS: We developed a within-subjects design factorial survey. In phase 1 (design) we defined the survey goal (dependent variable, mode and sample). We defined and constructed the factors and factor levels (independent variables) using previous qualitative research and existing scientific literature. We further refined these factors based on expert feedback from expert clinicians and a statistician. In phase two (pretesting), we subjected the survey tool to several iterations (cognitive interviewing, face validity testing, statistical review, usability testing). In phase three (piloting) testing focused on feasibility testing with members of the target population (n = 18). Ethical approval was obtained from the then host institution's Health Sciences Ethics Committee. RESULTS: Initial refinement of factors was guided by literature and interviews with clinicians and grouped into four broad categories: Clinical, Child and Family, Organisational, and Professional characteristics. Extensive iterative consultations with clinical and statistical experts, including analysis of cognitive interviews, identified best practice in terms of appropriate: inclusion and order of clinical content; cognitive load and number of factors; as well as language used to suit an international audience. The pilot study confirmed feasibility of the survey. The final survey comprised a 43-item online tool including two age-based sets of clinical vignettes, eight of which were randomly presented to each participant from a total vignette population of 480. CONCLUSIONS: This paper clearly explains the processes involved in the development of a factorial survey for the online environment that is internationally appropriate, relevant, and useful to research an increasingly important subject in modern healthcare. This paper provides a framework for researchers to apply a factorial survey approach in wider health research, making this underutilised approach more accessible to a wider audience.

The Meaning Given to Bioethics as a Source of Support by Physicians Who Care for Children Who Require Long-Term Ventilation.

The role and potential of bioethics input when a child requires the initiation of technology dependence to sustain life is relatively unknown. In particular, little is understood about the meaning physicians give to bioethics as a source of support during the care of children in pediatric intensive care who require long-term ventilation (LTV). We used a hermeneutic phenomenological approach to underpin the collection and analysis of data. Unstructured interviews of 40 physicians in four countries took place during 2020. We found that elements of trust, communication and acceptance informed the physicians' perceptions of the relationship with bioethics. These ranged from satisfaction to disappointment with their input into critical decisions. Bioethics services have potential to help physicians gain clarity over distressing and complex care decisions, yet physicians perceive the service inconsistently as a means of support. This research provides a sound basis to guide more beneficial interactions between clinicians and bioethics services.

Comorbidities in older patients with myasthenia gravis - Comparison between early- and late-onset disease.

BACKGROUND: Multimorbidity is an emerging challenge in older myasthenia gravis patients, which can have even greater impact on quality of life and outcome than symptoms of myasthenia. AIMS OF THE STUDY: We aimed to investigate comorbidities in older population and compare early-onset (EOMG) and late-onset (LOMG) myasthenia patients. METHODS: We investigated clinical information of patients from Oxford Myasthenia Centre age 50 or older. Data on 60 chronic disorders were extracted. RESULTS: We included 327 myasthenia patients (30.9% EOMG and 69.1% LOMG) with a median age of 70 years. Comorbidities were present in 94.5% of patients and accumulated with age. Hypertension (58.4% vs. 31.7%), hypercholesterolemia (41.2% vs. 23.8%), diabetes (24.8% vs. 11.9%), cataract (15.5% vs. 5.0%) and prostate disorders (15.0% vs. 2.0%) were more common in LOMG than EOMG, but there were no differences between 70 EOMG and 70 LOMG patients matched according to age and sex. CONCLUSIONS: Comorbidities in older patients with myasthenia are very common, increase with age, and do not differ between early- and late-onset disease.

Initiating technology dependence to sustain a child's life: a systematic review of reasons.

BACKGROUND: Decision-making in initiating life-sustaining health technology is complex and often conducted at time-critical junctures in clinical care. Many of these decisions have profound, often irreversible, consequences for the child and family, as well as potential benefits for functioning, health and quality of life. Yet little is known about what influences these decisions. A systematic review of reasoning identified the range of reasons clinicians give in the literature when initiating technology dependence in a child, and as a result helps determine the range of influences on these decisions. METHODS: Medline, EMBASE, CINAHL, PsychINFO, Web of Science, ASSIA and Global Health Library databases were searched to identify all reasons given for the initiation of technology dependence in a child. Each reason was coded as a broad and narrow reason type, and whether it supported or rejected technology dependence. RESULTS: 53 relevant papers were retained from 1604 publications, containing 116 broad reason types and 383 narrow reason types. These were grouped into broad thematic categories: clinical factors, quality of life factors, moral imperatives and duty and personal values; and whether they supported, rejected or described the initiation of technology dependence. The majority were conceptual or discussion papers, less than a third were empirical studies. Most discussed neonates and focused on end-of-life care. CONCLUSIONS: There is a lack of empirical studies on this topic, scant knowledge about the experience of older children and their families in particular; and little written on choices made outside 'end-of-life' care. This review provides a sound basis for empirical research into the important influences on a child's potential technology dependence.

Triggers and Interventions of Patients Who Require Medical Emergency Team Reviews: A Cross-Sectional Analysis of Single Versus Multiple Reviews.

BACKGROUND: Medical emergency teams constitute part of the escalation protocol of early warning systems in many hospitals. The literature indicates that medical emergency teams may reduce hospital mortality and cardiac arrest. A greater understanding of pathways of patients who experience multiple medical emergency team reviews will inform clinical decision-making. OBJECTIVES: To explore differences between patients who require a single medical emergency team review and those who require multiple reviews, and to identify any differences between patients who were reviewed only once during admission and patients who required multiple reviews. METHODS: Data for this retrospective cross-sectional review, including demographic data, call triggers, outcomes, and interventions, were routinely collected from January 2013 through December 2015. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) collaborative's cross-sectional studies checklist (version 4). RESULTS: Of 54 787 admitted patients, 1274 (2%) required a call to a medical emergency team; of those, 260 patients (20%) needed multiple calls. Patients requiring multiple calls demonstrated higher mortality (odds ratio, 1.49 [95% CI, 1.12-1.98]). A logistic regression model identified surgical patients and those receiving antibiotics and respiratory interventions at the first medical emergency team review as being more likely to require multiple reviews. Patients transferred to a higher level of care after the first review were less likely to require another review. CONCLUSIONS: Patients requiring multiple medical emergency team reviews have higher mortality. Surgical patients have a higher risk of requiring multiple reviews. Hospitals need to include more details on surgical patients when auditing medical emergency team activation.

Parents and health professionals' experiences and perceptions of blended feeding in tube-fed children: a qualitative systematic review protocol.

OBJECTIVE: The objective of this review is to identify and synthesize the best available evidence on parents' and health professionals' experiences and perceptions of blended feeding in tube-fed children in order to promote effective decision-making on its use. INTRODUCTION: Blended feeding is not a new concept, despite the fact that commercial formulas have displaced its use in recent years. As feeding is viewed as an intimate experience between a parent and child, the choice of individualized blended feeds is something to be considered; however, professionals find there is a lack of evidence and discussion to support the use of blended feeding in practice. Therefore, the findings of this review may be beneficial, especially for professionals, and inform or promote more effective decision-making on the use of blended feeding. INCLUSION CRITERIA: This review will consider studies that investigate parents and/or health professionals' experiences and perceptions of total or partial blended feeding in tube-fed children. Studies published in English that focus on qualitative data will be considered. There will be no restrictions on year or publication. METHODS: The key information sources to be searched are: CINAHL Complete, MEDLINE, PsycINFO, Embase, Web of Science, WHO Library Database (GIM), and Google Scholar, along with several sources of gray literature. Two reviewers will independently screen titles and abstracts against the inclusion criteria, and will retrieve full text studies, assess methodological quality, and extract data. Findings will be pooled using meta aggregation, and a ConQual Summary of Findings will be presented. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO (CRD42020160357).

A systematic concept analysis of 'technology dependent': challenging the terminology.

There are an increasing number of children who are dependent on medical technology to sustain their lives. Although significant research on this issue is taking place, the terminology used is variable and the concept of technology dependence is ill-defined. A systematic concept analysis was conducted examining the attributes, antecedents, and consequences of the concept of technology dependent, as portrayed in the literature. We found that this concept refers to a wide range of clinical technology to support biological functioning across a dependency continuum, for a range of clinical conditions. It is commonly initiated within a complex biopsychosocial context and has wide ranging sequelae for the child and family, and health and social care delivery.Conclusion: The term technology dependent is increasingly redundant. It objectifies a heterogenous group of children who are assisted by a myriad of technology and who adapt to, and function with, this assistance in numerous ways. What is Known: • There are an increasing number of children who require medical technology to sustain their life, commonly referred to as technology dependent. This concept analysis critically analyses the relevance of the term technology dependent which is in use for over 30 years. What is New: • Technology dependency refers to a wide range of clinical technology to support biological functioning across a dependency continuum, for a range of clinical conditions. It is commonly initiated within a complex biopsychosocial context and has wide-ranging sequelae for the child and family, and health and social care delivery. • The paper shows that the term technology dependent is generally portrayed in the literature in a problem-focused manner. • This term is increasingly redundant and does not serve the heterogenous group of children who are assisted by a myriad of technology and who adapt to, and function with, this assistance in numerous ways. More appropriate child-centred terminology will be determined within the TechChild project.

Patients' experiences of living with multiple myeloma.

BACKGROUND: Multiple myeloma is a B-cell haematological malignancy characterised by uncontrolled plasma cell proliferation. Patients with the disease often undergo periods of remission followed by multiple relapses. Understanding patients' experience of living with this chronic condition is key to providing effective patient-centred care. AIMS: This qualitative descriptive study explored the experiences of patients living with multiple myeloma. METHODS: A purposive sample of 6 patients was used. Data were collected using in-depth unstructured interviews and analysed using Colaizzi's (1978) thematic framework. FINDINGS: The emergent themes included: information and communication; treatment and symptom burden; the importance of support from family/friends and professional help; psychosocial elements of survivorship. CONCLUSION: The complex symptoms of multiple myeloma need to be treated holistically to manage the unpredictable nature of this disease.

Disclosure strategies in adults with epilepsy when telling, "I have epilepsy": The How2tell study.

OBJECTIVE: To generate evidence-based knowledge about the strategies that adult people with epilepsy (PWEs) use in the process of telling others about their epilepsy. METHODS: In-depth, one-to-one interviews explored PWEs' first-hand experiences of self-disclosure (or not), and grounded theory methods of inductive-deductive analysis were used to identify strategies used in disclosing. Interviews were audio-recorded, transcribed, coded, and independently recoded by two researchers using a coding framework specifically developed in this study. To account for maximum variation, PWEs (aged 18+ years) with different life experiences and situations relating to (1) gender, (2) age, (3) employment status, (4) personal relationships, (5) family relationship, (6) support group involvement, and (7) seizure frequency were included. Given the many variables and psychosocial issues associated with epilepsy, demographic details and validated measures including Quality of Life in Epilepsy-10-P, Coping Inventory of Stressful Situations-Adult, and Patient Health Questionnaire-9 were used to describe the characteristics of participants and to contextualize the results. RESULTS: Forty-nine adults with epilepsy participated. Data analysis revealed six interrelated categories (with subcategories) of the strategies that PWEs reported using in the process of disclosure: (1) concerns about disclosing; (2) weighing up who and when to tell; (3) opportunities for telling; (4) moment of disclosure-how to construct the message; (5) tailoring the message to audience needs-altering the message when telling family members, partner, friends, children, or employer and workplace colleagues; and (6) managing reactions by making it ordinary. SIGNIFICANCE: People with epilepsy use a range of different strategies during the process of disclosing their epilepsy. These strategies were used to inform the development of the How2tell multimedia self-management resource for PWEs on self-disclosure in everyday social and life situations. How2tell is designed to benefit PWEs by empowering them with practical information about the process of telling another person, "I have epilepsy."

Experiences and perceptions of emergency department nurses regarding people who present with mental health issues: a systematic review protocol.

OBJECTIVE: The objective of this review is to identify, appraise and synthesize available evidence related to the experiences and perceptions of emergency department (ED) nurses regarding people with any mental health issue who present at the ED. INTRODUCTION: The ED is often the first point of contact for patients with a mental health issue, due to a shortage of available mental health services. Nursing staff in the ED are involved in key clinical decision making and hands-on care for these patients, despite a lack of mental health specialist training. In order to improve patient outcomes in the ED setting, it is necessary to have a thorough understanding of how ED nurses' experiences with this population affect their clinical decision making. INCLUSION CRITERIA: This review will consider studies that include ED nurses, with or without mental health specialist training, working in urban and rural EDs in healthcare settings worldwide. Qualitative studies that explore the experiences and perceptions of ED nurses regarding people who present with mental health issues in the ED setting will be considered. Studies published in English will be considered, with no date limitations. METHODS: CINAHL complete, MEDLINE, PsycINFO, Embase, Scopus, Web of Science and Google Scholar will be searched, along with several sources of gray literature. Retrieval of full-text studies, assessment of methodological quality and data extraction will be performed independently by two reviewers. Findings will be pooled using meta-aggregation, and a ConQual Summary of Findings will be presented.

The introduction of the Early Warning Score in the Emergency Department: A retrospective cohort study.

BACKGROUND: The combined use of the Manchester Triage System (MTS) with the Early Warning Score (EWS) may be useful in ensuring both appropriate prioritisation and continued monitoring in the Emergency Department (ED) leading to early intervention for deteriorating patients thus improving patient outcomes especially in overcrowded EDs. PURPOSE: Determine the effect of the EWS and MTS on accuracy of the MTS and ED waiting times. METHODS: A retrospective cohort chart review of all adult patients who presented to the ED in one large hospital in Ireland (n = 10,048) at three time points between 1st September 2015-30th September 2016; 3 months prior to EWS introduction, implementation month and 9 months post-implementation. RESULTS: Patients were significantly more likely to be categorised as an MTS category 2 (rather than 3-5) after the EWS was introduced (p < 0.001). Waiting times between triage and clinician review (p < 0.05) increased as did total time in the ED (p > 0.001). A similar finding was observed for patients with an MTS of 3-5. CONCLUSION: Although positive in terms of patient outcomes, the effective and sustained combined use of the MTS and EWS requires increased bed capacity and experienced clinical staff to ensure that the ED journey time reduced rather than increased.

Thymus imaging in myasthenia gravis: The relevance in clinical practice.

INTRODUCTION: The ability to distinguish between normal thymus, thymic hyperplasia, and thymoma should aid clinical management and decision making in patients with myasthenia gravis (MG). We sought to determine the accuracy of routine imaging in predicting thymic pathology. METHODS: We retrospectively analyzed records of patients with MG from the Oxford Myasthenia Centre registry who had undergone thymectomy. Each patient received 1 radiological diagnosis and 1 histological diagnosis. RESULTS: We included 106 patients. Radiological and histological diagnoses agreed in 73 (68.9%) patients. Sensitivity and specificity, respectively, were calculated for each radiological diagnosis as follows: thymoma 90% and 95.5%, hyperplasia 17.6% and 98.6%, and normal 96.9% and 60.8%. DISCUSSION: Routine chest computed tomography and MRI can effectively identify thymoma. However, they are not reliable tools to differentiate between thymic hyperplasia and normal thymus in patients with MG. Muscle Nerve, 2018.

Barriers to effective, safe communication and workflow between nurses and non-consultant hospital doctors during out-of-hours.

OBJECTIVE: This study aimed to evaluate the nature and type of communication and workflow arrangements between nurses and doctors out-of-hours (OOH). Effective communication and workflow arrangements between nurses and doctors are essential to minimize risk in hospital settings, particularly in the out-of-hour's period. Timely patient flow is a priority for all healthcare organizations and the quality of communication and workflow arrangements influences patient safety. DESIGN: Qualitative descriptive design and data collection methods included focus groups and individual interviews. SETTING: A 500 bed tertiary referral acute hospital in Ireland. PARTICIPANTS: Junior and senior Non-Consultant Hospital Doctors, staff nurses and nurse managers. RESULTS: Both nurses and doctors acknowledged the importance of good interdisciplinary communication and collaborative working, in sustaining effective workflow and enabling a supportive working environment and patient safety. Indeed, issues of safety and missed care OOH were found to be primarily due to difficulties of communication and workflow. Medical workflow OOH is often dependent on cues and communication to/from nursing. However, communication systems and, in particular the bleep system, considered central to the process of communication between doctors and nurses OOH, can contribute to workflow challenges and increased staff stress. It was reported as commonplace for routine work, that should be completed during normal hours, to fall into OOH when resources were most limited, further compounding risk to patient safety. CONCLUSION: Enhancement of communication strategies between nurses and doctors has the potential to remove barriers to effective decision-making and patient flow.

Discharge of Non-Acute Coronary Syndrome Chest Pain Patients From Emergency Care to an Advanced Nurse Practitioner-Led Chest Pain Clinic: A Cross-Sectional Study of Referral Source and Final Diagnosis.

BACKGROUND: Chest pain is a common presentation to emergency departments (EDs). Pathways for patients with non-acute coronary syndrome (ACS) chest pain are not optimal. An advanced cardiology nurse-led chest pain service was commenced to address this. The aim of the study was to assess the outcomes of non-ACS patients discharged from ED to an advanced cardiology nurse-led chest pain clinic and compare by referral type (nurse or ED physician). METHODS: The service consisted of advanced cardiology nurse or ED physician consultation in the ED and discharge to advanced nurse-led chest pain clinic review less than 72 hours after discharge. Referrals were by the advanced nurses during consult hours and out-of-hours were by the ED physicians. Data were extracted from case notes. This was a 1-site cross-sectional study of patients attending the chest pain clinic over 2 years. RESULTS: Confirmed coronary disease was diagnosed in 24% of patients. Of the 1041 patients, 45% were referred by the advanced nurses, who referred significantly more patients who were older (56.5 years/52.3 years), had positive exercise stress test results (21%/12%), and were diagnosed with stable coronary artery disease (19%/11%) and less patients with musculoskeletal diagnosis (5%/13%) and other noncardiac pain (36%/45%). CONCLUSIONS: The study fills a gap in the literature on the follow up of non-ACS patients who present to ED and used advanced cardiology nursing expertise in the ED and chest pain clinic. The advanced nurse referred more patients who were diagnosed with coronary disease, reflecting the expertise, experience, and efficiency of the advanced cardiology nurse-led service.