Brian Williams

Use of non-orthodox and conventional health care in Great Britain.

OBJECTIVE--To describe the characteristics of patients using non-orthodox health care and their pattern of use of conventional health care with respect to a particular problem. DESIGN--Postal survey of all 2152 practitioners of acupuncture, chiropractic, homeopathy, naturopathy, and osteopathy identified from 11 national professional association registers. Patients attending a representative sample of 101 responding practitioners completed questionnaires covering demographic characteristics, presenting problems, and use of the health service. SETTING--Practices of practitioners of non-orthodox health care in England, Scotland, and Wales. SUBJECTS--Qualified, non-medical practitioners of non-orthodox health care working in Great Britain and 2473 patients who had attended one of the sampled practitioners in an allocated time period between August 1987 and July 1988. RESULTS--An estimated 1909 practitioners were actively practising one of the study treatments in Great Britain in 1987. Of the estimated 70,600 patients seen by this group of practitioners in an average week, most (78%) were attending with a musculoskeletal problem. Two thirds of the patients were women. Only 2% were aged under 16, but 15% were aged 65 or over. One in three patients had not received previous conventional care for their main problem; 18% were receiving concurrent non-orthodox and conventional care. Twenty two per cent of the patients reported having seen their general practitioner for any reason in the two weeks before the surveyed consultation. CONCLUSIONS--Patients of non-orthodox health care, as provided by this group of practitioners, had not turned their backs on conventional health care. Non-orthodox treatment was sought for a limited range of problems and used most frequently as a supplement to orthodox medicine.

Evaluation of nurse triage in a British accident and emergency department.

OBJECTIVE--To compare formal nurse triage with an informal prioritisation process for waiting times and patient satisfaction. SETTING--Accident and emergency department of a district general hospital in the midlands in 1990. DESIGN--Patients attending between 8:00 am and 9:00 pm over six weeks were grouped for analysis according to whether triage was operating at time of presentation and by their degree of urgency as assessed retrospectively by an accident and emergency consultant. PATIENTS--5954 patients presenting over six weeks. MAIN OUTCOME MEASURES--Time waited between first attendance in the department and obtaining medical attention, and patient satisfaction measured by questionnaire. RESULTS--Complete data on waiting time were collected on 5037 patients (85%). Only 1213 of the 2515 (48%) patients presenting during the triage period were seen by a triage nurse. Patients in the triage group waited longer than those in the no triage group in all four retrospective priority categories, though differences were significant for only the two most urgent categories (difference in median waiting time 10.5 (95% confidence interval 3.5 to 14) min for category 1 and 8.5 (3 to 12) min for category 2). Responses to the patient satisfaction questionnaire were similar in the two groups except for the question relating to anxiety relating to pain. CONCLUSIONS--This study fails to show the benefits claimed for formal nurse triage. Nurse triage may impose additional delay for patient treatment, particularly among patients needing the most urgent attention.

Nurse practitioners in accident and emergency departments: what do they do?

OBJECTIVE--To determine the distribution and scope of nurse practitioner schemes in accident and emergency departments in England and Wales; to describe the caseloads of doctors and nurse practitioners on two representative days; and to estimate the number of patients managed by nurse practitioners in the year to 31 March 1991. DESIGN--A postal survey of accident and emergency departments and a content analysis of case notes of new patients attending a representative sample of accident and emergency departments on two days. SETTING--All accident and emergency departments in England and Wales. PARTICIPANTS--Survey: 560 nurses in charge of accident and emergency departments. Census: case notes of 5814 patients in 37 accident and emergency departments. MAIN OUTCOME MEASURES--Survey: number of accident and emergency departments with nurse practitioner schemes. Census: demographic and clinical characteristics of new patients attending and whether nurse practitioner or doctor made diagnoses and ordered investigations, treatments, referrals, discharges. RESULTS--513 replies (92%) from 465 surveyed functioning accident and emergency departments and 48 departments recently closed. 27 (6%) departments used designated nurse practitioners and 159 (34%) unofficial nurse practitioners. Only 530 (9%) of the 5814 patients in the census were managed entirely or mainly by nurse practitioners, with higher proportions in ophthalmic departments (nearly 30%) and minor casualty departments (over 40%) than in major departments (3%). Most patients managed by nurse practitioners (86%) had minor trauma. In the year ending 31 March 1991 an estimated 390,000 (95% confidence interval 260,000 to 520,000) patients out of a total of 12.5 million (3.1%, 2.1% to 4.1%) were clinically managed by a nurse practitioner. CONCLUSIONS--Designated nurse practitioner schemes are rare. The volume and range of nurse practitioner work in major general accident and emergency departments is small compared with those in specialised and minor accident and emergency departments.

Differences in priorities assigned to patients by triage nurses and by consultant physicians in accident and emergency departments.

STUDY OBJECTIVES--To investigate whether the greater urgency assigned to accident and emergency patients by triage nurses than by accident and emergency doctors was uniform across all patient groups. DESIGN--Patients attending an accident and emergency department between 8.00 am and 9.00 pm over a six week period were assessed prospectively for degree of urgency by triage nurses, and retrospectively for urgency by one of two consultant accident and emergency doctors. Patients were grouped according to their clinical mode of presentation. SETTING--An accident and emergency department of a district general hospital in the Midlands, UK, in 1990. PATIENTS--1213 patients who presented over six weeks. MEASUREMENTS AND MAIN RESULTS--As might be expected, patients conditions were assessed as being more urgent prospectively than retrospectively. This finding, however, was not uniform across all patient groups. Nurses assessments of urgency tended to favour children and patients who presented with eye complaints and gave less priority to medical cases, particularly those with cardiorespiratory symptoms. CONCLUSIONS--These findings have implications for all those involved in the organisation of triage systems and in the training of nurses in accident and emergency departments. It is essential that judgements on how urgently patients need to be seen are made in a completely objective manner.

Measuring the incidence of injury among bicycle commuters on cycle networks and open roads: A pilot study

Background Government policy is to reduce motorised land travel. Nottingham has a system of segregated and unsegregated cycle pathways. Exposure to risk on these different types of cycle route and related injury rates are unknown. Objective To develop simple, accurate methods of measuring distances travelled on different cycle pathways; to estimate the number of incidents (unexpected occurrences) per unit distance on different pathways, and the number yielding injuries. Design Diary recording over two weeks by a random sample of cycle commuters. Setting Nottingham city cycle routes used by hospital workers between home and work. Method Four hundred bicycle storage area users at a National Health Service (NHS) hospital were asked to map their routes to and from work, to estimate the distance involved and to record the nature and location of any incidents occurring during cycle commuting over two weeks. Using a ruler, string and the map scale, the distances covered on each type of route were calculated. Calculated distances were compared with actual distances measured with a car mileometer. Incident rates were calculated for each type of pathway. The occurrence of any injuries sustained in these incidents was checked against Accident and Emergency (A&E) department records. Results Only 267 proved eligible; 155 replied by the deadline; 87 agreed to participate, 68 declined. Eighty (44 males, 36 females) returned complete data. Cyclists estimates of route distance, and the distances of the same routes calculated by measuring map lengths differed by 2.1 km on average (range -3.3 to +5.4 km). Distances calculated by measuring map lengths differed from actual distances measured by mileometer by only 0.5 km on average. We calculated that commuters covered 5368 km, averaging 4.6 km per journey (range 0.8 to 7.6 km), 57 per cent of it on roads. Twenty-eight cyclists reported 53 incidents (10 per 1000 km: 95%CI 7 to 13). Segregated cycle paths had the highest rates (43 per 1000 km: 95%CI 26 to 67). In 46 cases the incident involved taking action to avoid an obstacle, a pedestrian, another cyclist or a motor vehicle. No injuries were reported in these incidents and nobody involved in the incidents attended the hospital A&E department. Conclusions It is feasible to record accurately over two weeks the exposure of commuting cyclists to travel on various types of urban cycle route, and the number and nature of potentially harmful incidents experienced. It is likely that the higher rate of injury on off-road cycle paths reported in other countries would be confirmed.