A Review of Diagnostic Frequency 1998 - 2014

Cognitive Bias

"When we attempt to understand past events, we implicitly test the hypotheses or rules we use both to interpret and to anticipate the world around us. If, in hindsight, we systematically underestimate the surprises that the past held and holds for us, we are subjecting those hypotheses to inordinately weak tests and, presumably, finding little reason to change them."

Fischhoff

ED Attendances by Age

EMERGENCY DEPARTMENT ATTENDANCES BY AGE: A 
WELSH EXPERIENCE 
E. Hassen, R. Bhalla 
Accident and Emergency Department 
Correspondence to E. Hassen; email doctor@drhassencom. 

ABSTRACT 
Introduction: 
There is a dearth of epidemiological research into paediatric attendances at Emergency Departments in the UK. This study looks at all types of ED attendances by children at a single site through one year. 

Data and methods: 
Routine data on all attendances by children aged 1-15 years were available (period: 1 January 2005 to 31 December 2005). The data were analysed by time of year (weekly) for each age cohort. 

Results: 
Attendances peaked at age 2 and decreased for each cohort to a minimum at age 8 before rising again to age 15. For all ages attendances were higher for males compared to females. For the year, paediatric attendances peaked in week 28 as did total ED attendances. However, as a proportion of the total, paediatric attendances peaked in week 27. 

Conclusions: 
This study has shown that paediatric attendances at our ED are activity dependant, age sex and population dependant. There is considerable variation in ED attendance rates across the country with many factors responsible and few published comprehensive audits to guide planning. It is to be hoped that others will answer the same questions as a basis for further much needed research in Emergency Medicine. 

Abbreviations: ED, emergency department 
Keywords: children; emergency department; epidemiology; paediatric 


There is a dearth of epidemiological research into paediatric attendances at Emergency 
Departments in the UK. Most Emergency Medicine research in the UK has looked at types of injuries although several have looked at all types of ED attendance. Only one 
study has looked at the epidemiology of ED attendances specifically. This latter study found that most attendances were due to injuries and that these varied by age and location and that the variations were not stable across sites. More information is needed from more sites for longer periods through the country in addition to the sentinel sites 
monitored by the DTI given the contingent and complex causes of ED attendances. 


The lack of research in Emergency Medicine is due to the fact that this is a new 
speciality, that Emergency Medicine lacks political capital, that no dedicated funding 
exists for Emergency Medicine research, that no dedicated organisation is responsible for 
Emergency Medicine research, that Emergency Medicine practitioners have an action 
focus rather than a research focus and that Emergency Departments are under-resourced 
for service provision without the ability to do research. The Joint Statement on Children’s 
Attendances at Accident & Emergency Departments was published in 1999 with its most important references from 1985. The Care Group Workforce Team Recommendations 2003 Report did not deal with Emergency Medicine. The most recent numbers published for NHS Direct referrals to Emergency Departments were for 1999-2000, the first year that NHS Direct was operating. 


Emergency Medicine is still an orphan speciality and needs research that proves the 
growing workload and the effectiveness (clinical, social and financial) of Emergency 
Departments. Towards that end we contribute this study. 
This study looks at all types of ED attendance at one hospital to report on the use of the 
Emergency Department by children to see how these vary by age, sex and season. 


DATA AND METHODS 


The Study Hospital is a district general hospital in North East Wales serving a 
population of 250,000. It is situated on the outskirts of the town (pop 70,000), 
which is near the Welsh/English border in North Wales. The catchment area extends 
beyond the county to include patients from Flintshire, Powys, south 
Gwynedd, as well as some from Cheshire, the Wirral and Shropshire. 


The Emergency Department is fully computerised and records information on every 
attendance made. Data on all new ED attendances by children aged under 16 years of age 
were available for the period 1 January 2005 to 31 December 2005 (12,443 records). 

RESULTS 

In 2005 ED attendances peaked at age 2 and then decreased to a minimum at age 8 before rising again. For all attendances the peak was reached in week 28, which was also the week in which paediatric attendances peaked; however, as a proportion paediatric 
attendances peaked in week 27. For all ages males presented more frequently than 
females with the smallest difference at age 2 and the largest difference at age 12. 







We have an advantage compared to the fragmented health services sector in America: 
most accidents and emergencies in the UK are dealt with by the NHS in the Accident & Emergency Department. Centralised data collection, analysis and dissemination are 
possible. We hope it happens; soon. 

ACKNOWLEDGEMENTS 
We would like to thank the ED staff at the Study Hospital 

FOOTNOTES 

Funding: None. 
 Competing interests: none declared 

REFERENCES 

1. Downing, A, Rudge, G. A study of childhood attendance at emergency 
departments in the West Midlands region. Emerg Med J 2006 23: 391-393. 

2. Scuffham, P, Chaplin, S, Legood, R. Incidence and costs of unintentional falls in 
older people in the United Kingdom. J Epidemiol Community Health 2003 57: 
740-744. 

3. Accident & Emergency Services for Children: Report of A Multidisciplinary 
Working Party. RCPCH. June 1999. 

4. Long Term Conditions Care Group Workforce Teams Recommendations - 2003 
Report to the Workforce Numbers Advisory Board. DHHRD Care Group 
Workforce Teams. Nov 2003. 

5. Outcomes of calls to NHS Direct, 1999-00: Social Trends 31. DoH 
www.statistics.gov.uk. 2002. (Last accessed 20 June 2006). 

6. Helen Cooper, Chris Smaje, Sara Arber. Use of health services by children and 
young people according to ethnicity and social class: secondary analysis of a 
national survey. BMJ 1998; 317:1047-1051. 

7. MacFaul R and Werneke U. Recent Trends in hospital use by children in England. 
Arch Dis Child 2001; 85:203207. 

8. Emergency Care for Children: Growing Pains (2006). Board on Health Care 
Services. 2006. 

Today...

After-action reflection means learning something everyday, but not all learning is noteworthy on short timescales. Perspective is important and time offers better perspectives.

 

Looking back at my day I find my emotionality an issue: part of that is fatigue and part is the nature of the work and part is that all those who interact with us do so with imperfect and incomplete information. Life is complex.

 

Many profound truths sound asinine stated baldly: they are too obvious. They get their meaning, their depth and breadth from the hearer’s interpretation: the mouths of babes yield only the words of babes; no more. Meaning is tenuous and personal.

 

And generosity is always welcome; as is compassion.

St. Emlyns Virtual Hospital

Here.

To my networks

What are you particularly good at?

 

What are you becoming particularly good at?

 

What would you want to be particularly good at?

 

 

How do you teach a child to begin with the end in mind?

How do you teach a child to begin with the end in mind? Keeping in mind that adults teach what they do, not what they say, and that learning needs feedback and doesn’t happen without it.

For children, beginning with the end in mind means beginning with an unmet desire; needs and drives are the responsibilities of their carers. And those desires are likelier to be impulsive than planned. Frustration is likelier to promote learning than easy and early success. All this suggests that teaching an awareness of ends will be very challenging.

Sometimes it is better to act before you think; most times it is better to think before you act.

So, these are the necessary conditions: an unmet desire that has been frustrated; a proximate non-malevolent desire that can be satisfied given some help and thought and the willingness and patience to teach something that can be taught.

An awareness of ends implies an awareness of ecology: how things fit together, how they relate, what the facilitators and obstructors are or are likely to be.

Friction and inertia are practically ubiquitous. They are easily taught and often forgotten. The motivations of others are difficult to ascertain and confirm and are always changeable. And it is natural and common to ascribe to others degrees of latitude that are greater than we are aware of having ourselves.

Knowing how to teach children would make teaching adults easy.

Problem Based Learning

A letter to my consultants:

I am committed to being better. This is not an occasional goal or aspiration: it is me. Kaizen. I am not in competition with my future self but I am driven by an ideal self that may not be realised.

I have a great deal to learn and my learning progresses day by day. Learning is what I do.

I understand that protocols exist to standardise safe practice. Both standardisation and safety are important severally and together for many reasons. Standardisation should not mean petrification.

Auditing my own practice more intensively over the past 6-9 months, one of my goals has been to reduce my admission rates and to do so safely. So, I have paid more attention to the numbers and been more aggressive with treatments: keeping in mind that more aggressive action needs finer feedback, more acute monitoring – time is a resource that acts.

I have said many times that I am not invested in specific acts; I am invested in process.

We agree that practice should be informed by evidence and that evidence is sparse; however, we do generate evidence and don’t use it to inform our practices. When evidence exists to change practice and you don’t, it would be helpful if you could say what (achievable) evidence would be necessary to change practice. As consultants, ultimately responsible for safe practice in the unit, it would be considerate if in changing the management of my patients you did so because you believed it necessary rather than preferable. Art is always arguable: your interventions should benefit me as well as the patient. If you don’t change my mind about my course you won’t change my practice – and so you do me and my future patients a disservice if a change in practice is necessary.

Medicine is experiential; no book learning can substitute for treating patients. And guided, moderated experience always beats trial-and-error learning.

Thanks!

Lean Learning

This is borrowed from Lean Manufacturing or just-in-time manufacturing: no inventory. It is just-in-time learning as opposed to just-in-case learning, the premise being that know-why (judgement) is most important and that know-how is next and that know-what can always be looked up.

Many years ago, I was surprised to learn that Einstein did not know the mass of the earth. It wasn’t necessary to know it because it was referenced. It took more time and effort then to look up something like that than it does today. Knowing it remains unnecessary.

In medicine practice is supposed to be informed by the evidence, but for most of medicine there is no evidence. Where cause and effect are proximate, common-sense serves; where they are not it does not. We have already picked all the low hanging fruit of proximate effects. We are in uncharted territory with huge numbers of patients and small effects and a severely constrained cognitive biology.

What is the solution? More data and more sophisticated data mining and a more pervasively statistical perspective. Never, of course, forgetting human and humane engagement.