Can the Ottawa knee rule be applied to children? A systematic review and meta-analysis of observational studies.

BACKGROUND: The Ottawa knee rule (OKR), a clinical decision aid is used to reduce unnecessary radiography. It is not clear whether this rule can be applied to children. OBJECTIVE: To establish whether the OKR had adequate sensitivity and acceptable specificity in children to advocate widespread use. METHODS: A systematic review and meta-analysis was conducted of observational studies that examined the diagnostic characteristics of the OKR in children. DATA SOURCES: Relevant English language articles were identified from Medline (1950 to date), EMBASE (1974 to date), CINAHL (1982 to date), the Cochrane Library, Google Scholar and a hand search of bibliographies. STUDY SELECTION: Observational studies that included children and have used the OKR for ruling out fractures in children either radiologically or in combination with follow-up. RESULTS: Four relevant studies were identified. Three studies were suitable for inclusion in the meta-analysis, representing 1130 children. The pooled negative likelihood ratio was 0.07 (95% CI 0.02 to 0.29), the pooled positive likelihood ratio was 1.94 (95% CI 1.60 to 2.36), the pooled sensitivity was 99% (CI 94.4 to 99.8) and the pooled specificity was 46% (CI 43.0 to 49.1). The reduction in radiography was between 30% and 40%. CONCLUSION: The OKR has high sensitivity and adequate specificity for children over the age of 5 years. There are not enough good data to advocate application of the OKR in children less than 5 years.

Integrated hospital emergency care improves efficiency.

BACKGROUND: There is uncertainty about the most efficient model of emergency care. An attempt has been made to improve the process of emergency care in one hospital by developing an integrated model. METHODS: The medical admissions unit was relocated into the existing emergency department and came under the 4-hour target. Medical case records were redesigned to provide a common assessment document for all patients presenting as an emergency. Medical, surgical and paediatric short-stay wards were opened next to the emergency department. A clinical decision unit replaced the more traditional observation unit. The process of patient assessment was streamlined so that a patient requiring admission was fully clerked by the first attending doctor to a level suitable for registrar or consultant review. Patients were allocated directly to specialty on arrival. The effectiveness of this approach was measured with routine data over the same 3-month periods in 2005 and 2006. RESULTS: There was a 16.3% decrease in emergency medical admissions and a 3.9% decrease in emergency surgical admissions. The median length of stay for emergency medical patients was reduced from 7 to 5 days. The efficiency of the elective surgical services was also improved. Performance against the 4-hour target declined but was still acceptable. The number of bed days for admitted surgical and medical cases rose slightly. There was an increase in the number of medical outliers on surgical wards, a reduction in the number of incident forms and formal complaints and a reduction in income for the hospital. CONCLUSIONS: Integrated emergency care has the ability to use spare capacity within emergency care. It offers significant advantages beyond the emergency department. However, improved efficiency in processing emergency patients placed the hospital at a financial disadvantage.

Emergency ultrasound of the abdominal aorta by UK emergency physicians: a prospective cohort study.

OBJECTIVE: To establish whether UK emergency physicians could reliably perform focused ultrasound of the abdominal aorta in patients with suspected abdominal aortic aneurysm (AAA). METHODS: A prospective cohort study was conducted in the emergency department of a tertiary level UK teaching hospital. All patients who underwent an abdominal aortic ultrasound by an emergency physician during a 12 month period from January to December 2005 were included. The principle outcomes were presence of an AAA (external wall diameter >3 cm) or death from ruptured AAA. Outcome data were obtained from paper and electronic patient records and primary care telephone follow up. RESULTS: 120 focused ultrasound scans looking for AAA were performed by 19 different UK emergency physicians of various grades. Of the 120 scans, 26 (22%) were positive for an AAA, of which 17 cases represented a new diagnosis. Ruptured aneurysms represented 46% (12/26) of all positive scans, of which four patients underwent emergency repair. In the remaining 14 patients the AAA was an incidental finding that was not the reason for their presentation to the emergency department. Emergency ultrasound had a sensitivity of 96.3% (95% confidence interval (CI) 81.0% to 99.9%); a specificity of 100% (95% CI 91.8% to 100%); a negative predictive value of 98.6% (95% CI 88.0% to 99.9%); and positive predictive value of 100% (95% CI 86.8% to 100%) for the detection of AAA. CONCLUSION: Emergency ultrasound scanning by UK emergency physicians has high sensitivity and specificity for identifying AAA, consistent with international experience.

Case of the month: Buffalo chest: a case of bilateral pneumothoraces due to pleuropleural communication.

Simultaneous spontaneous bilateral pneumothoraces, the presentation of separate right and left pneumothoraces together, is a rare event. The pleural cavities in humans are separated completely and the only previous reports of pleuropleural communication have been associated with major invasive thoracic procedures, specifically mediastinal surgery. The term "buffalo chest" has been coined for the condition on the basis that the buffalo or bison has a single pleural cavity, one of the few mammals to do so. We present the case of a woman with a past history of a single right sided spontaneous pneumothorax but no major thoracic surgery, who presented to the emergency department with a second spontaneous right pneumothorax that was under tension. After thoracostomy, she was found to have bilateral pneumothoraces which resolved with a unilateral chest drain demonstrating pleuropleural communication. We believe this to be the first reported case of such a presentation in the literature. The case demonstrates an unusual emergency presentation of a rare anatomical anomaly.