Explore the vast range of titles available.

The Valsalva manoeuvre is an internationally recommended treatment for supraventricular tachycardia, but cardioversion is rare in practice (5–20%), necessitating the use of other treatments including adenosine, which patients often find unpleasant. We assessed whether a postural modification to the Valsalva manoeuvre could improve its effectiveness. We did a randomised controlled, parallel-group trial at emergency departments in England. We randomly allocated adults presenting with supraventricular tachycardia (excluding atrial fibrillation and flutter) in a 1:1 ratio to undergo a modified Valsalva manoeuvre (done semi-recumbent with supine repositioning and passive leg raise immediately after the Valsalva strain), or a standard semi-recumbent Valsalva manoeuvre. A 40 mm Hg pressure, 15 s standardised strain was used in both groups. Randomisation, stratified by centre, was done centrally and independently, with allocation with serially numbered, opaque, sealed, tamper-evident envelopes. Patients and treating clinicians were not masked to allocation. The primary outcome was return to sinus rhythm at 1 min after intervention, determined by the treating clinician and electrocardiogram and confirmed by an investigator masked to treatment allocation. This study is registered with Current Controlled Trials (ISRCTN67937027). We enrolled 433 participants between Jan 11, 2013, and Dec 29, 2014. Excluding second attendance by five participants, 214 participants in each group were included in the intention-to-treat analysis. 37 (17%) of 214 participants assigned to standard Valsalva manoeuvre achieved sinus rhythm compared with 93 (43%) of 214 in the modified Valsalva manoeuvre group (adjusted odds ratio 3·7 (95% CI 2·3–5·8; p<0·0001). We recorded no serious adverse events. In patients with supraventricular tachycardia, a modified Valsalva manoeuvre with leg elevation and supine positioning at the end of the strain should be considered as a routine first treatment, and can be taught to patients. National Institute for Health Research.

Conversely the new roles of nurse specialists (for heart failure, epilepsy, Parkinson's, and other conditions) and nurse practitioners (emergency nurse practitioners, advanced nurse practitioners, and advanced clinical practitioners) are differentiated and settled.Doctors provide continuity for services and patients, while nurse specialists and nurse practitioners are an invaluable addition to the urgent and emergency care workforce.Experience devalued Recognition of the value of these new roles is, belatedly, a welcome reaffirmation of the benefit of experience.Since the introduction of Modernising Medical Careers in 2005, experience has been devalued in medical roles, albeit unintentionally.

Consultants’ workloads have increased in recent years which challenges the “offer” implicitly advertised to doctors in training

While the paper has looked at both in-hospital and community deaths within 60 days to allow for this, the opportunity to study the effect of possible changes in same-day emergency care case mix and volumes is a notable omission. [...]this paper has shown no evidence of harms from this particular centralisation project but a lack of any evaluation of attendant resource changes or comparison with national baseline trend data creates a logical barrier to wider endorsement of the paper’s premise. Impact and sustainability of centralising acute stroke services in English metropolitan areas: retrospective analysis of hospital episode statistics and stroke national audit data.

[...]with attendances rising by 22% and admissions by 42% since 2008, closing EDs is at the very least counterintuitive, especially as the average number of attendances to EDs in England is already very high by international comparisons. [...]with overcrowding in English EDs endemic, the notion that further reducing the number of EDs and increasing the catchment area served by each seems perverse. [...]the analysis within the current paper demonstrates a ‘non-significant’ increase in deaths associated with ED closures of 2.5%, but with a CI that included a possible 10% increase. Currently 70% of acute admissions occur via EDs and emergency admissions account for more than 70% of bed days occupied. [...]the loss of the emergency department is likely to be of existential relevance for the remainder of the hospital with both short-term (positive) and long-term (negative) consequences.

Over the last decade, increasing numbers of emergency department attendances and an even greater increase in emergency admissions have placed severe strain on the bed capacity of the National Health Service (NHS) of the United Kingdom. The result has been overcrowded emergency departments with patients experiencing long wait times for admission to an appropriate hospital bed. Nevertheless, scheduling issues can still result in significant underutilization of bed capacity. Bed occupancy rates may not correlate well with bed availability. More accurate and reliable long-term prediction of bed requirements will help anticipate the future needs of a hospital's catchment population, thus resulting in greater efficiencies and better patient care. This study aimed to evaluate widely used automated time-series forecasting techniques to predict short-term daily nonelective bed occupancy at all trusts in the NHS. These techniques were used to develop a simple yet accurate national health system-level forecasting framework that can be utilized at a low cost and by health care administrators who do not have statistical modeling expertise. Bed occupancy models that accounted for patterns in occupancy were created for each trust in the NHS. Daily nonelective midnight trust occupancy data from April 2011 to March 2017 for 121 NHS trusts were utilized to generate these models. Forecasts were generated using the three most widely used automated forecasting techniques: exponential smoothing; Seasonal Autoregressive Integrated Moving Average; and Trigonometric, Box-Cox transform, autoregressive moving average errors, and Trend and Seasonal components. The NHS Modernisation Agency's recommended forecasting method prior to 2020 was also replicated. The accuracy of the models varied on the basis of the season during which occupancy was forecasted. For the summer season, percent root-mean-square error values for each model remained relatively stable across the 6 forecasted weeks. However, only the trend and seasonal components model (median error=2.45% for 6 weeks) outperformed the NHS Modernisation Agency's recommended method (median error=2.63% for 6 weeks). In contrast, during the winter season, the percent root-mean-square error values increased as we forecasted further into the future. Exponential smoothing generated the most accurate forecasts (median error=4.91% over 4 weeks), but all models outperformed the NHS Modernisation Agency's recommended method prior to 2020 (median error=8.5% over 4 weeks). It is possible to create automated models, similar to those recently published by the NHS, which can be used at a hospital level for a large national health care system to predict nonelective bed admissions and thus schedule elective procedures.

BackgroundDelays to timely admission from emergency departments (EDs) are known to harm patients.ObjectiveTo assess and quantify the increased risk of death resulting from delays to inpatient admission from EDs, using Hospital Episode Statistics and Office of National Statistics data in England.MethodsA cross-sectional, retrospective observational study was carried out of patients admitted from every type 1 (major) ED in England between April 2016 and March 2018. The primary outcome was death from all causes within 30 days of admission. Observed mortality was compared with expected mortality, as calculated using a logistic regression model to adjust for sex, age, deprivation, comorbidities, hour of day, month, previous ED attendances/emergency admissions and crowding in the department at the time of the attendance.ResultsBetween April 2016 and March 2018, 26 738 514 people attended an ED, with 7 472 480 patients admitted relating to 5 249 891 individual patients, who constituted the study’s dataset. A total of 433 962 deaths occurred within 30 days. The overall crude 30-day mortality rate was 8.71% (95% CI 8.69% to 8.74%). A statistically significant linear increase in mortality was found from 5 hours after time of arrival at the ED up to 12 hours (when accurate data collection ceased) (p<0.001). The greatest change in the 30-day standardised mortality ratio was an 8% increase, occurring in the patient cohort that waited in the ED for more than 6 to 8 hours from the time of arrival.ConclusionsDelays to hospital inpatient admission for patients in excess of 5 hours from time of arrival at the ED are associated with an increase in all-cause 30-day mortality. Between 5 and 12 hours, delays cause a predictable dose–response effect. For every 82 admitted patients whose time to inpatient bed transfer is delayed beyond 6 to 8 hours from time of arrival at the ED, there is one extra death.

The Royal College of Emergency Medicine is charged via its Royal Charter to 'preserve and protect good health and to relieve sickness by improving standards of health care'.

The drinks industry sees longer opening hours for the World Cup as a victory for common sense—but this sets an unwelcome precedent, says Clifford Mann