A survey of teaching and the use of clinical guidelines in accident and emergency departments.

OBJECTIVE: To investigate organised teaching in accident and emergency (A&E) departments in England and Wales. METHODS: A survey was carried out by postal questionnaire. Directed to senior house officers (SHOs), the questionnaire examined the nature and extent of departmental teaching, and measured the availability, suitability, and actual use made of guidelines. Of 231 questionnaires sent, 164 were returned (response rate 71%). RESULTS: The results show that most SHOs attended A&E induction courses at the beginning of their attachments, although the scope of these coursed varied widely. Most SHOs also received regular teaching, although the programmes were generally of less than 3 h in duration. The majority of respondents were well supported with written documentation in a variety of formats. However, a significant minority (29%) of SHOs requested more detailed clinical guidance, and these tended to be the respondents who received the most departmental teaching. CONCLUSIONS: More time could be allocated to structured teaching than at present, and greater use made of complementary educational methods such as practical skill teaching, case presentation, clinical audit, and involvement in journal clubs. More extensive departmental teaching should also be supported by making available more detailed and comprehensive clinical guidelines.

The psychosocial assessment of patients discharged from accident and emergency departments after deliberate self-poisoning.

One-third of accident and emergency (A & E) patients who deliberately take an overdose are not admitted to hospital, and this proportion is increasing. We conducted an audit of 300 case records of such patients from two different district health authorities in London. We found that only 4% of patients were assessed in the manner recommended by the Department of Health and 10% had no psychosocial assessment whatsoever. We recommend specific training, an assessment form, regular audit, and communication with the general practitioner.

Cannon Street rail disaster--lessons to be learned.

We studied the types and mechanisms of injury suffered by passengers involved in the Cannon Street rail crash, by a telephone and postal survey of all passengers attending St Bartholomew's Hospital for treatment of their injuries, and retrospective examination of their hospital records. There were 104 patients of whom 91 had complete data sets. Of the 91 patients included in the study, 63 (69 per cent) had suffered craniofacial trauma. Of the 63 patients with this type of injury, 50 had been standing at the time of impact and 48 of these were able to say exactly how they had sustained their injuries. Of these 48 passengers, 34 said that they had collided with the luggage racks (71 per cent). Of the 32 passengers who had been seated at the time of impact, only 13 sustained craniofacial injuries and none had hit the luggage racks (P = 0.0001). Craniofacial trauma was the commonest type of injury. Those patients who suffered these injuries were most likely to have been standing at the time of impact and to have sustained their injuries following collision with a luggage rack. The type of luggage racks on this train were particularly dangerous and we recommend that the internal design of new British Rail rolling stock addresses this problem. This specific recommendation is in support of the more general measures discussed in the recently published official report of the incident. In the meantime, we consider that passengers should be advised to remain seated until trains have come to a halt.

Planning for medical provision on-board ship.

This paper describes the medical provision on board a 76 m passenger vessel. It discusses the floor space necessary, together with essential equipment to provide a high level of medical care particularly in the event of major emergencies. It stresses the necessity for training and practice of simulated emergencies to ensure a high state of readiness.

Resuscitation training for cardiac patients and their relatives--its effect on anxiety.

It is feared by many doctors that teaching basic life support (BLS) to high risk cardiac patients or a member of the family increases their anxiety. We trained a group of patients with recurrent ventricular tachycardia in BLS together with a friend or family member. Measurement of anxiety before and three months after training demonstrated a reduction in anxiety in both groups. This suggests that basic life support training can be targeted to high risk groups without fear of increasing anxiety.

Effectiveness of the call-out system for a London Coronary Ambulance service.

St Bartholomew's Hospital, in the City of London, has for many years run a Coronary Ambulance service, called by the public via the 999 system. During a 9-month period only 55% of 214 cardiac emergencies arriving at St Bartholomew's Hospital came with Coronary Ambulance support, although the service was available if called. In cases where the Coronary Ambulance was summoned, the call-out was inappropriate in 57% of cases. In addition, 153 cardiac emergencies arrived at the Accident and Emergency Department during hours when the Coronary Ambulance was not available. Reasons for breakdowns in the call-out system are discussed and remedies involving the public and London Ambulance Control are suggested.