Impact of senior clinical review on patient disposition from the emergency department.

INTRODUCTION: The delivery of high quality emergency medicine ideally involves input from senior doctors 24 h a day. This study aims to assess the influence of 'real-time' senior clinician supervision on patient disposition from a UK emergency department. METHODS: The study was set in a UK teaching hospital with 24 h senior cover. Patients were initially seen by a junior doctor who completed a plan for the patient before seeking senior advice. Primary outcome measures were a change in patient outcome of discharge, admit, telephone speciality for opinion or outpatient follow-up. RESULTS: 556 patients underwent senior review during the study period. Review reduced inpatient admissions by 11.9% (95% CI 7.2% to 18.2%) and specifically reduced admissions to the acute medical assessment unit by 21.2% (95% CI 13.5% to 30.8%). Inappropriate discharge was prevented in 9.4% (95% CI 6.2% to 13.7%) and appropriate use of outpatient facilities resulted in a rise of 34.6% in appointments. CONCLUSIONS: Senior doctor input in patient care in the ED adds accuracy to disposition decisions, impacting on patient safety and improving departmental flow.

Reduced productivity among junior trainees in the emergency department and the impact on senior clinicians.

UNLABELLED: Emergency medicine has recently undergone significant changes, with training, staffing and service delivery attracting particular attention. Senior doctors are under increased pressure to ensure the prompt delivery of service and to provide a smooth patient journey. It has been suggested that junior trainees see fewer patients than their predecessors, resulting in the burden of clinical work being transferred to senior clinicians, representing a shift away from the traditional model of service delivery. This study charts the work rate trends among junior doctors and the proportion of work performed by senior doctors over a 3-year period. RESULTS: The number of patients seen by junior trainees fell by 4% and was associated with a statistically significant 16.6% reduction in the mean number of patients seen per hour. The number of patients seen purely by senior clinicians increased to over 35%, in addition to reviewing those seen by junior trainees. This highlights reduced clinical exposure and productivity among juniors, but also shows the significant knock-on effect on the workload of senior clinicians. CONCLUSIONS: There will need to be an increase in the number of trained clinicians within emergency medicine to continue to deliver effective training and supervision and ensure a safe, good quality service to patients.

Severe hypoglycaemia in citalopram overdose.

We present two episodes of poisoning with citalopram in which the main feature was profound hypoglycaemia. Citalopram has been regarded as the most toxic of the selective serotonin reuptake inhibitors in overdose; however, hypoglycaemia is not one of the documented features of overdose. This is an important component of the toxicological profile of citalopram and a treatable cause of seizure activity that should be reported in poisoning information references.