Volume 178 Issue 3

We need a coordinated approach to address the underlying problems in the health system The effects of access block on acute hospital services are most disturbingly reflected by patients on trolleys queued in emergency department (ED) corridors and ambulances circling hospitals, waiting to deliver acutely ill patients. The Australasian College for Emergency Medicine and the Australian Council on Healthcare Standards (ACHS) have defined access block for emergency patients as the percentage of all patients admitted, transferred or dying in the ED where their total ED time exceeds eight hours.1 For elective patients, access block is reflected in ballooning elective waiting list numbers and length of time spent waiting. Access block has been with us since the 1980s, but in recent years, in Australia, it appears to have become both endemic and critical across all our major cities.2,3 There is now evidence that access block causes poor patient outcomes and interferes with efficient hospital functioning.4,5 In this issue of the Journal (page 103) the impact of access block across Australia and potential solutions are outlined. Causes of access blockThe causes for this untoward development are not straightforward, but appear to correlate with major decreases in hospital bed numbers, community residential care facilities, and with changes in workforce and community attitudes. Bed numbers: In Australia, the total number of acute hospital beds has decreased over the past two decades, with a 15% decrease in public hospital beds occurring from 1995 to 2000.6 There have been concomitant decreases in inpatient length of stay, but the number of hospital admissions have also increased.7 There are now more day procedures and day admissions. Although some of these replace multiday stays, others represent new work or multiple admissions replacing a multiday, single admission.8 Concurrent with decreasing acute hospital bed numbers, access to residential care beds in the community has decreased, especially beds designated for high-dependency patients.9 This has increased demand on acute hospital services as elderly inpatients wait for long term placement or are inappropriately sent back to the community to avoid pressure on an already congested residential care system. Community-based treatments: Many patients with complex and chronic illnesses are now treated as hospital outpatients or in the community. However, when serious complications occur, patients frequently present to EDs, particularly if access to community healthcare services is not available. This lack of community support increases patient load on the acute care system. Workforce: No single person can master the high-technology solutions and complicated treatment regimens prevalent in acute care hospitals. At the same time, many elderly or infirm patients need basic nursing care, which at times is considered too mundane for highly trained hospital staff. Increasingly, the workforce model required in healthcare is team-based, with multidisciplinary input and multiple levels of expertise, even within disciplines.10,11 Training programs for doctors, nurses and allied health workers do not yet reflect this need. This imbalance between career aspirations, systemic needs and actual working environments results in dissatisfied workers or insufficient staff with necessary skills. These factors contribute to low morale, which further reduces workforce flexibility. Social changes: The demise of the extended family and changes in the demographics of marriage and childbearing have led to more elderly people living alone, and with greater feminisation of the workforce fewer people can be carers.7,12 Population projections indicate that the number of informal carers in the community (largely middle-aged women) will decline sharply as the baby boomers age and require care themselves. The default solution for many partially dependent people is referral to an acute hospital. Funding models: Payments to hospitals and healthcare providers are rigid and reward rapid treatment of uncomplicated conditions. In the community setting, payment is for episodes of care rather than continuity of care. Complicated emergencies, time-consuming conditions involving multiple medical specialties, and social issues stretch the time and financial resources required, and are dealt with piecemeal. Patients with complex or multiple problems frequently have no alternative but to attend a public hospital ED.11 Casemix payments in the acute care setting and fee-for-service models of payment in the community setting usually disadvantage patients who require longer stays and supported post-hospital care. Rigid rules around definitions such as "inpatient" versus "outpatient" treatment create financial risk for hospitals introducing innovative treatment strategies. Furthermore, public ED workloads increase as GP consultation rates in older age groups decline, along with a reduction in GP bulk billing and availability after hours.13 Increasing indemnity insurance premiums for procedural GPs and private specialists also lead to greater public ED demand. Potential solutionsSystematic management of access block is only just beginning to be discussed at a policy level. The extent of the issue is now such that a more strategic Australia-wide approach is necessary. The experiences described in this issue of the Journal show that hospitals can improve their individual performance with organisational changes. But, despite the impressive changes achieved with the outlined approaches to access block, it is apparent that our healthcare system has serious underlying problems that need to be publicly acknowledged by politicians and appropriately addressed. Workforce: Historically, the major solution to hospital access issues was to spend money and increase bed numbers by employing more staff. Recently, in Victoria, money was allocated for increased bed numbers and services, but there were insufficient staff to open more beds (see the Royal Melbourne Hospital report, page 109). Reasons for rigidity in work practice and roles within the healthcare workforce need to be explored, and, where there is no evidence to support limitations in practice, rules should be changed. Universities, clinical colleges and hospitals must work together to train healthcare professionals for the tasks required rather than for roles based on historical models. Funding: The innovative practices described in the hospital experiences were partly enabled by incentives from federal, State/Territory and hospital initiatives. The funding method can help direct healthcare services toward community needs. For example, funding hospitals for procedures, whether provided on an inpatient or outpatient basis, might allow a hospital to provide those services even when beds are not available. Casemix payments tend to favour hospitals that provide uncomplicated elective services — perhaps alternative models that encourage healthcare services to look after elderly, complicated, medical patients should be trialled. Funding that allows a hospital to experiment with new clinical pathways and not be financially penalised, such as the National Demonstration Hospitals Project14 (aimed at improved hospital service efficiency and utilisation) and the Hospital Admission Risk Program15 (aimed at decreasing hospital bed utilisation), should be encouraged. The next round of Australian Health Care Agreements should ensure balance in financial incentives between elective and emergency services. There should also be recognition of the need to better remunerate GPs for providing complex care, perhaps involving a trial of a capitated payment or managed competition model.16 Healthcare delivery systems: The central message conveyed by the experiences described in this issue of the Journal is that changing internal processes can improve access to inpatient resources. Initiatives such as medihotels, placing patients in a transit lounge before discharge, day-of-surgery admission for elective surgery, short-stay wards, and centralised bed control can all save bed-days. Encouraging clinicians to trial treating patients in different ways and objectively analysing outcomes requires leadership from clinicians and administrators. For high-volume conditions and procedures, there should be standardised treatment pathways to expedite inpatient stay. Efficient use of beds also requires accurate, transparent data collection with rapid feedback to clinicians. Many hospitals are unable to accurately account for every patient and the purpose of their continued inpatient stay. Similarly, many hospitals do not have an accurate bed census that identifies the variability in the number of beds that are open from shift to shift, nor do all have the ability to accurately count nursing sick leave rates by shift and day of the week. Residential care: It is important that use of residential care facilities is tightly controlled and residents are allocated to the appropriate level of care. However, the current problem is that patients are unable to access long term residential care facilities and are instead filling acute care beds. Reform within the subacute and residential/community care sector is necessary to improve efficiencies within the acute care sector and to provide appropriate long term care to patients. Attention to more appropriate locations to care for the small group of long-stay patients is likely to be the most efficient strategy to improve patient flow through the subacute sector. Service prioritisation: The public must become involved in the debate about which healthcare services are essential. The present rationing method is in essence a lottery — whether your ambulance is allowed to arrive at a certain hospital, or whether your elective surgery is on or off, depends on the capricious availability of beds. The healthcare system cannot provide every service, but basic emergency and elective services could easily be provided within present budgetary constraints. A more transparent and educated debate may allow healthcare providers to work in a more satisfying environment where expectations are matched with necessary resources. There remains considerable pessimism about the ability of the acute healthcare sector to deliver an effective service in the face of increasing demand and limited resources. There are solutions. However, political leadership and a coordinated national approach are necessary to resolve underlying structural issues surrounding workforce, work practice and funding.

Peter A Cameron · Donald A Campbell

We need to derive absolute cardiovascular risk functions based on contemporary Australian data The accurate estimation of risk for future disease events is critical to the determination of the benefit–risk ratio and the most cost-effective use of preventive therapies (Box 1). This is particularly relevant for cardiovascular diseases (CVD), which are the leading cause of deaths in Australia (40% of total deaths), and in 1993–1994 accounted for the largest proportion (12%, or $3.9 billion) of total annual recurrent health expenditure.3 (This proportion is now almost certainly greater.) Expenditure on cardiovascular drugs under the Pharmaceutical Benefits Scheme totals $1.2 billion annually, $629 million of this on lipid-lowering drugs, especially statins.4 Accurate assessment of the likelihood of future events would optimise resource allocation by targeting patients at higher risk.5 In this context, the work of Simons et al, reported in this issue of the Journal (page 113),6 is very important. In their ongoing Dubbo Study (which commenced in 1988 and involved 2805 men and women aged 60 years and older when first assessed), the authors evaluated a risk function for coronary heart disease (CHD) prediction developed from a longitudinal cohort study in Framingham, Massachusetts — the Framingham Study. They also derived a risk function for future CVD events, including stroke as well as CHD, by modelling data from the Dubbo cohort. The Framingham risk functions7-9 are widely used and form the basis of a New Zealand cardiovascular risk calculator,10 itself proposed as the absolute risk measurement tool in the recent lipid guidelines of the National Heart Foundation/Cardiac Society of Australia and New Zealand.11 The Framingham cohort consists primarily of white, middle-class individuals. The equation was derived from calculations based on age, sex, cigarette smoking status, diabetes status, and blood pressure, cholesterol and HDL cholesterol levels only. The Framingham measurements were also made some time ago before the dramatic increase in the prevalence of diabetes,12 and indeed Framingham included low numbers of people with diabetes. In essence, the study by Simons et al determined the applicability of observations made in another time and another place to an Australian population. They showed that the Framingham equation accurately predicted overall 10-year incidence of "hard" CHD endpoints (myocardial infarction or coronary death). This supports previous validation work with the Framingham equation in the Busselton study.13 However, the Busselton study is now over 20 years old, while the Dubbo cohort included only older individuals. Therefore, while these validation studies are important, it would be more relevant to derive predictive equations from data obtained from a representative and contemporary Australian cohort. This would acknowledge the variety of ethnic groups in Australia and the current mix of known and unknown risk factors. As the Framingham equation correctly predicts risk in only about 80% of cases,14 there is considerable interest in "novel" risk factors (eg, high sensitivity C-reactive protein) and techniques for imaging the arterial wall. Future research must examine the degree to which these elements might improve the ability to correctly identify those at risk. With the shift of treatment guidelines from individual risk thresholds for treatment to decisions based on multivariable absolute risk, the logical extension of this is to estimate treatment efficacy or effectiveness in terms of absolute treatment benefit. For example, the benefits of cholesterol lowering in terms of improving average life expectancy have previously been estimated.15 This approach would provide more meaningful information to both patients and clinicians, as well as allowing the non-cardiovascular benefits of modifying risk factors such as tobacco smoking, physical inactivity, and unhealthy diet to be taken into account. Data such as those from the Dubbo study have important implications for current Australian guidelines and practice (Box 2). Treatment decisions based on individual risk-factor thresholds are inadequate. The Dubbo study assesses the validity of the Framingham risk prediction equations in the elderly and provides an Australian risk equation for the same age group. Further work should be done to validate these equations in a wider contemporary population and to determine the extent to which new risk factors may improve assessment of risk. This should not, however, preclude swift measures to implement the use of absolute risk, as well as consideration of absolute treatment benefit, as ways of guiding treatment decisions in clinical practice. 1: Why focus on absolute risk of cardiovascular disease? Individuals with levels which fall in the highest decile for systolic blood pressure, cholesterol and body mass index account for only 20%–30% of the total number of cases of stroke, ischaemic heart disease and diabetes.1 Interventions based on elevated levels of a single risk factor may allocate treatment to individuals with little chance of gain because of low absolute risk.2 Absolute risk is the likelihood of developing an event(s) over a particular time period. Absolute risk equations acknowledge the multifactorial causation of cardiovascular disease, the sex difference in risk and the steep increase in risk with ageing. Epidemiological studies have shown a continuum of risk for increasing levels of risk factors, such as blood pressure, total cholesterol and HDL cholesterol levels, which is acknowledged in absolute risk equations. 2: Recommendations for current guidelines, practice and research in cardiovascular disease Treatment guidelines should place greater emphasis on absolute risk estimation in those without manifest cardiovascular disease (CVD). Linking estimates of the likely absolute benefit of interventions with calculation of absolute risk should reinforce the rationale for lifestyle measure for all individuals and pharmacological treatment for those at higher risk. Prediction of overall CVD risk over 5 (or 10) years should be the endpoint, as opposed to risk of coronary heart disease alone. Components of a composite CVD endpoint should be re-examined and possibly restricted to "hard" outcomes such as CVD death, non-fatal myocardial infarction and non-fatal stroke. Agreement on and adoption of a standardised approach would facilitate implementing absolute risk prediction in Australia. Future studies should include variables that might further improve risk prediction (eg, waist circumference, microalbuminuria, high-sensitivity C-reactive protein). Absolute risk assessment is likely to be implemented most effectively using electronic tools which can link to other national initiatives. Absolute risk assessment will not only optimise health gains, but will result in more cost-effective treatment and prevention.

Andrew M Tonkin MB BS, MD, FRACP · Stephen S Lim BA, BSc · Henrik Schirmer MD, PhD

Access block began to affect hospitals in the Australian Capital Territory during the winter of 2000. Practice was seriously affected first at the Canberra Hospital, a 500-bed mixed adult/paediatric tertiary hospital, in 2000, and then in 2002 at Calvary Hospital (220 beds), the other hospital in the ACT with an emergency department (ED). Access block in the Canberra Hospital averaged 9.1% (Australasian College for Emergency Medicine/Australian Council for Healthcare Standards [ACEM/ACHS] definition: proportion of admissions with total time in the ED longer than eight hours) during 1999. For 14 days between May and September the rate exceeded 20%. During 2000, it averaged 16.3%, with 56 days in excess of 20% between May and September (Box). This trend continued in 2001, when the figures were 22.9% and 79, respectively. The major underlying cause was a reduction in hospital bed capacity from a monthly average of 533 staffed beds in January–August 1999 to 491 in January–August 2000. As a corollary, a marked reduction in access block occurred when additional beds were made available by cancellation of elective surgery during the Sydney Olympics in September 2000. Although access block had a measurable effect on ED waiting time performance in 1999,1 it began to affect overall ED function in the second half of 2000,2 when a significantly lower proportion of presentations achieved their desired ACEM/ACHS waiting time performance. InterventionsThe onset of access block prompted review of ED work practice, leading to some improvement in ED performance in the face of access block during 2000, but little change since. The continued severity of the problem has stimulated ongoing review of all hospital work practice, aiming to reduce the demand on overnight beds through improving overall patient flow, and to improve ED function. The changes have proven to be of variable effectiveness. Interventions to improve patient flowRestructuring and expansion of the Bed Management Unit (May 2001); Revision of admission, discharge and bed management policies (July 2001 to March 2002); Expansion and increased use of hospital in the home and day surgery services (ongoing); Off-site transitional care arrangements for elderly patients (ongoing increase in transitional care beds); Activation of real-time estimated date of departure notification system and daily estimates of occupancy over next 24 hours (May 2001); Containment of elective surgery, particularly during winter (ongoing since 2001); and Opening of a discharge lounge (relatively little effect on time of discharge). Interventions to reduce ED demand for overnight bedsIncreased use of overnight discharge from the ED followed by day surgery for orthopaedic, plastic surgical, and gynaecological presentations; and Improved links with community services to facilitate discharge, particularly of geriatric patients. ED changes to mitigate effects of access blockRearranging medical staff rosters (2001 and 2002); Increasing by one the number of nursing staff on each shift (winter 2001 and ongoing); Drawing additional nursing staff from the hospital pool at times of excessive inpatient care in ED (2002 and ongoing); Establishing formal policies and procedures on prioritisation of ED activity (2001 and 2002); Revising hospital policies on ambulance diversion, although the effect has been limited, as the Canberra Hospital offers the only acute inpatient service in the region for paediatrics, orthopaedics, and most tertiary services; and Providing additional Hospital Assistant and Wardsman staff to assist in the ED (ongoing). Interventions planned for 2002–2003Renovation of the ED to make better use of the available space; Construction of a Clinical Decision Unit/Observation Unit in the ED to manage short-stay patients; and Opening of a short-stay surgical unit close to the operating theatre to better manage short-stay surgical patients. OutcomeAccess block is the major issue facing EDs in the ACT. Despite the above measures, hospitals in the ACT have experienced a continued increase in access block and significant decline in ED waiting time performance. Access block at the Canberra Hospital, January 1999 to September 2002

Drew B Richardson

The Queen Elizabeth Hospital (QEH) is a 340–361-bed acute tertiary referral hospital in the western suburbs of Adelaide. Since 1999, the hospital has had difficulties coping with emergency admissions demand, especially during winter. Over the previous years, there has been a reduction in acute bed numbers from 476 to 361. Also, within the past two years, there has been the loss of 250 residential care facility (RCF) nursing home beds from the western region of Adelaide. At the same time, the activity of the hospital as measured by casemix activity has remained constant. The inpatient occupancy in winter has resulted in the emergency department (ED) requesting to go on ambulance diversion (bypass) almost daily, usually in late afternoon; however, on most occasions, this has not been either approved or possible. Waiting times in the ED for patients to be transferred to a ward are sometimes up to several days and QEH's waiting times in the ED are the longest of South Australian hospitals. Cancellation of elective surgical and medical patients has sometimes been necessary. InterventionsIn a progressive response to reducing access block, the hospital has adopted a range of strategies. In 1996, an Interface Unit based within the Division of Medicine was developed to coordinate and facilitate early discharge from the wards and avoid unnecessary admissions from the ED by initiating treatment/management for patients with conditions that may be managed at home but require additional support. The nurses in this unit "broker" or organise external therapy or services (such as subcutaneous heparin for the treatment of deep venous thrombosis, or home supports for someone who is frail and would otherwise have been admitted to hospital) in association with the patient's general practitioner. With the loss of nursing home beds from the western Adelaide region, a step-down unit was created in the hospital with a lower registered/enrolled nursing skill mix. An active multidisciplinary team facilitates placing patients in RCFs or at home, with additional resources provided through brokered community services or State-based programs, such as the Adelaide Transition Alliance (which provides respite beds in RCFs) or with the Division of Surgery's "Hospital in the Home" program (which provides post-acute home nursing services from within the division's nursing resources). A transit bay of six beds for incoming (ED) and outgoing (discharge) patients has been created. In addition, overcapacity beds (ie, accepting an additional patient into a ward before a patient has been discharged) have been used, and day beds have been used for non-same-day inpatients. Emphasis has been placed on promoting appropriate admission and appropriate day stay, with audits conducted by senior nurses from the Interface Unit based on accepted clinical criteria. Early discharge remains a priority, and is reinforced at medical handover meetings held each morning to review new admissions, facilitate transfer of care, and provide clinical inservice. Home care specialist nurses have also helped prevent admissions (eg, heart failure nurses, home cancer therapy and respiratory care nurses). A "medical flying squad" was established to assess nursing home patients and was clinically effective in reducing transfers from the RCF to the ED, but was too costly to sustain. A GP service located within the ED was unsuccessful because of low numbers of triage category level 4 and 5 patients. A further issue was that it sometimes involved a GP referring to another GP. OutcomeThe impact of these interventions is difficult to measure, as ambulance diversion has sometimes not been allowed in SA. However, without the introduction of the above initiatives, a substantial further reduction in elective activity would have been necessary. One measure of the success of these programs is that in 2001 the hospital had 50 long-stay patients awaiting placement, and this is now down to an average of 25 patients. There have been strategies undertaken to increase the capacity of the ED, but medical and nursing staffing levels have remained an issue. Changes in chronic disease management are required to minimise acute inpatient demand, especially during winter. Strategically reducing elective surgical activity during winter and subsequently increasing it during summer is difficult. The Division of Surgery has trialled weekend surgery, but this has not been widely accepted by the community. The management of long-stay patients remains central to improving patient access. The appropriate allocation of nursing home and respite beds is needed on a regional basis. The failure of nursing home beds to become available through licensing is a major issue that must be addressed at a State and Commonwealth level.

Richard E Ruffin MD, FRACP · Jan K Hooper RN, RM, BNursing

Royal North Shore Hospital (RNSH) is a 550-bed tertiary referral hospital serving a population of about 900 000 in the Northern Sydney Health Area. In 1999, the RNSH executive, to deal with ongoing restricted access (RA = ambulance bypass), decided to implement various changes to the structures, policies and practices of the hospital to alleviate the blockages to patients entering the emergency department (ED) by ambulance. The extent of RA at RNSH is shown in Box 1. As expected, RA was worse during winter, with more than 100 hours per month. InterventionsIn March 1999, the clinical heads of the hospital's divisions implemented a program aimed at improving utilisation of beds in the medical and surgical wards, in the belief that solutions to restricted access lay not within the ED, but within the rest of the hospital. The specific interventions were implemented by committed multidisciplinary teams, underpinned with significant senior medical staff involvement and executive support. Structural changesAdministrative responsibility for the ED was moved to the Division of Medicine so that the problems facing the ED were seen as belonging to the general ward areas. Clinical Supervisors, with responsibility for coordinating bed management, were appointed in the divisions of medicine and surgery, and a Clinical Bed Manager was appointed with responsibility for bed management across the entire hospital. Team-building initiativesDaily meetings with divisional nursing unit managers, the clinical supervisor and the bed manager. These meetings identified patients awaiting discharge, potential delays in treatment requiring attention, delays in consultation, inappropriate admissions, and patients suitable for treatment through ambulatory care or other outpatient services. Friday afternoon meetings with all medical registrars, divisional medical and nursing heads, the clinical supervisor, and the bed manager to ensure that all patients not requiring hospitalisation over weekends had appropriate discharge plans. Provision of data to medical staff regarding clinical practice variation (eg, variation in average length of stay for specific conditions). Clinical initiativesAmbulatory care ward open every day with extended after-hours service, with referrals from all medical teams and directly from the ED. This ward currently treats more than 1400 patients each month, and is available for patients who are well enough to be at home, but require in-hospital treatment as day patients. For example, patients who require blood transfusions, joint aspirations, lumbar punctures, chemotherapy or intravenous antibiotics were all moved from inpatient beds to the ambulatory care service. Similarly, rural patients referred for multiple specialist consultations or investigations are managed in this unit. Early-morning blood collection for patients awaiting results before discharge, with results available by 9: 00 am for discharge by 10: 00 am. Day-only angiography. Fax referral to rehabilitation beds to expedite transfer. Weekend discharge rounds by the divisional medical head and the clinical supervisor. Accommodation initiativesReconfiguration of beds to five-day short-stay to encourage management of elective activity from Monday to Friday. Use of off-site residential accommodation for patients not requiring inpatient beds for investigations. Provision of free transport (taxi vouchers, hospital transport) to patients to facilitate discharge. Nursing home liaison committee to improve communication with local residential care providers and facilitate appropriate transfer from the acute- to the residential-care sector. Leasing of 12 private hospital beds and attached clinical staff from Mater Misericordiae Hospital during winter. Policy initiativesRevision of the restricted access policy. Before activating RA, the ED Staff Specialist must contact inpatient managers to assess whether it is possible to avoid RA by hastening bed movements. Revision of the weekend leave policy. Ward leave greater than eight hours suggests the patient should be treated in the ambulatory centre. Development of an over-census bed policy. Wards to go one patient over census when the ED is considering RA and has no alternatives. This policy only needed implementation on two occasions between March 1999 and October 2000; on both occasions it prevented the hospital going onto RA. OutcomeThe effect of these interventions was dramatic. Within six months of commencing these initiatives, RNSH had effectively eliminated restricted access to the ED (Box 1, 2000), while maintaining elective surgical activity and significantly reducing the number of patients on the waiting list for admission (Box 2). These improvements occurred with bed occupancy rates in excess of 90%. The key contributors to the success of this program appear to be: significant medical leadership through visible operational roles for divisional heads and staff specialists/clinical supervisors in bed management processes; attention to discharge planning for ward patients; centralised bed management with a whole-hospital focus; team-building among senior nursing and medical staff; improved communication between ED and ward areas; engagement of junior medical staff in bed management processes; and a multifaceted implementation program that sought to correct process inefficiencies wherever they were identified. The outcomes of the program support the hypothesis that reducing ED ambulance bypass can be achieved by interventions that address upstream blockages in the hospital rather than specific ED interventions. Maintaining organisational focus on continually questioning the appropriateness of bed management practices is a challenge that must be met to ensure the sustainability of these sorts of improvements. 1: Restricted access (ambulance bypass) at Royal North Shore Hospital, 1997–2000 Interventions to reduce restricted access were implemented from March 1999, and had produced a dramatic decrease in restricted access by the end of 1999. 2: Proportion of patients experiencing a delay to treatment at Royal North Shore Hospital

Rohan J H Hammett MB BS, FRACP · Bruce G Robinson MSc, FRACP

In Queensland, access block was first observed in the peripheral urban hospitals in the Brisbane and Gold Coast area. As the absolute and relative bed capacity of public hospitals declined in the period 1999–2002, access block in Queensland's largest hospitals increased from a barely manageable average of less than 10% (Australasian College for Emergency Medicine/Australian Council on Healthcare Standards definition: proportion of admissions with total time in the emergency department longer than eight hours) to an average of about 14% in financial year 2001–02. Various administrative analyses have shown that the deleterious effects of access block start to become apparent at levels greater than 5%, and that these dysfunctional levels of access block occur when hospital occupancy consistently exceeds 95%. Other observations on Queensland data are that, generally speaking, access block is less of a problem in provincial centres than in metropolitan areas, and that hospitals with the best elective surgery performance tend to have the worst access block performance, and vice versa. The best-performing large hospital in Queensland in relation to access block is the Royal Brisbane Hospital (RBH), which had an average 6.2% in 2001–02. RBH is believed to be one of only two major hospitals in Australia that had no requests for ambulance bypass in 2001–02. This outcome has been achieved through considerable research and innovation and a management view that the RBH cannot go on ambulance bypass, as its emergency department (ED) is the sole department servicing a catchment area population of some 550 000, and because the other EDs in Brisbane do not have the capacity to absorb the additional workload if RBH ED closed its doors, even for a few hours. Over the past decade the hospital has implemented many strategies aimed at optimising the efficiency of the ED, the acute care process and discharge procedures. These are summarised in the Box. All of these strategies are believed to have had some benefit, but the most significant are the ED Short Stay Unit and the Medical Assessment and Planning Unit. It is known that small improvements in bed availability (ie, 5–10 beds) can cumulatively have a very substantial impact on access block, so RBH's current focus is on precision bed management through improved information systems and processes, including geographic information systems (which map the geography of the hospital against variables such as patient numbers, staff numbers, and nurse dependency). The objective is to maximise the identification of the relationships and correlations that exist in separate data sources within the hospital to precisely measure and predict demand and throughput in real time and to communicate that information throughout the organisation. Once this strategy has been exhausted, access block will only be able to be avoided through greater reductions in elective surgical throughput or an increase in system bed capacity, particularly during periods of peak demand. Strategies to improve bed management at Royal Brisbane Hospital, 1992–2002 Emergency department Increased consultants (from two to eight) Admission policy ED Short Stay Unit (18 beds: 24-hour stay for minor head injuries, overdoses, renal colic, etc.) ED Fast Track Zone (for Australasian Triage Scale Category 3 and 4 patients) ED Imaging Unit (computed tomography, ultrasound, picture archiving and communication system/radiology information system) ED Stat Lab Nurse-initiated X-rays (for peripheral skeletal X-rays, according to clinical pathways) Extended Hours Social Work (18 hours/day) ED Primary Care Unit Transit Lounge (a separate lounge for discharged patients awaiting transfer) Acute Mental Health Assessment Unit (6 beds) Inpatient departments Medical Assessment and Planning Unit Medical Day Procedure Unit Increased day-of-surgery admission Increased day-only procedural admission (no overnight stay) Interim Care Unit (inpatient facility for subacute and non-acute patients waiting for nursing home placement) Hospital-in-the-home program

Richard H Ashby

Royal Perth Hospital (RPH) is the largest hospital in Western Australia. The Wellington Street campus has about 600 beds and is located on the edge of the inner city. The emergency department (ED) has an annual census of around 55 000, with an admission rate of 44%. Forty-two per cent of all attendances arrive by ambulance, and data from the ambulance service indicate that RPH receives more priority one ambulances than the other major teaching hospitals combined. From 1996 to 2001, attendances increased by 14% and admissions by 16%. In the same time, inpatient bed numbers have been reduced by about a third. Before 1999, ambulance bypass was extremely rare. In October 2000, four WorkSafe orders were issued because the ED was contravening regulations of the Occupational Safety and Health Act 1984 (WA): employees were not able to move safely within the ED corridors because of obstruction from too many patient trolleys; patient trolleys and other equipment were blocking egress through corridors for evacuation in event of fire or other emergency; employees were exposed to violence hazards; and employees were suffering work-related stress because of excessive work demands. On 12 December 2000, all three major teaching hospitals in Perth were on simultaneous ambulance bypass. As a result, the then Health Minister appointed an Ambulance Bypass Coordinator to prevent this event recurring. On 17 November 2001, the cover story of the West Australian detailed the poor conditions for patients and staff in the ED. As a result, the Department of Health formed an Emergency Services Task Force, with broad representation from the emergency medicine and nursing community. The Box shows the extent of ambulance bypass at RPH from July 1999 to June 2002. Analysis of the first two years indicates that the most common reason for initiating ambulance bypass was entry block (30.4%). Entry block is a result of overwhelming numbers of patients attending the ED in a short period, resulting in a functional block to the entry of the ED and ED overcrowding. This necessitates ambulance bypass, even if there are sufficient inpatient beds available. InterventionsA transit lounge was established in July 1999, allowing ward patients who are being discharged to await discharge medications and collection, thus freeing up their beds earlier. In July 2000, an eight-bed holding bay was opened next to the ED. This is designed for patients who are ready for admission, but for whom the inpatient bed is unavailable, and to relieve the stacking of patients in the ED corridor. Nevertheless, stacking of patients in the corridor still occurs. Within the ED, a transfer coordinator has been appointed since July 2001. This is a senior nurse who readies patients for inpatient admission and organises transfer to the ward. This frees nurses for clinical duties. The transfer coordinator also identifies and coordinates admission of patients to other sites (eg, private hospitals), and can arrange direct admission to the ward, bypassing ED. Bed management within the hospital was changed from a divisional system to a centralised bed management mechanism, allowing for effective crisis management. The hospital now has well-defined criteria for initiating ambulance bypass (involving factors such as excess patient load, environmental, staff or resource issues, excessive number of high-acuity patients, or declared disaster situation). Other options to reduce ED overcrowding include sending trolley patients awaiting admission to wait in the ward corridor. ED medical staffing was increased to address the large patient volume. The ambulance communications room now has a computerised ED patient tracking system (EDIS) installed. EDIS is present in all EDs in Perth. This allows the ambulance service to distribute its workload between sites. Other recommendations of the Emergency Services Task Force that have been implemented are to: increase bed capacity by permanently opening some closed beds if nursing staff can be found (about 40 beds); increase aged care and rehabilitation beds at a regional secondary hospital to allow transfer of inpatients from RPH; increase the availability of care awaiting placement beds; and increase the bed and investigatory capacity of another secondary hospital in the region to allow for greater retention of patients, thus easing the burden on RPH. ED staffing was significantly increased. The above measures have had significant clinical input and are designed to increase the capacity of the system, but the most important outcome has been the recognition at all levels of government that the problem exists and needs to be addressed. The situation is under constant review. Episodes of ambulance bypass at Royal Perth Hospital, July 1999 to June 2002

Daniel M Fatovich MB BS, FACEM

Royal Melbourne Hospital (RMH), a 360–390-bed acute tertiary referral hospital in inner Melbourne, began to experience an acute increase in access block from early 2000. Over the previous few years, there had been a gradual reduction in acute bed numbers and a marked reduction in subacute and nursing home beds in the area serviced by the hospital. At the same time, patient throughput, as measured in weighted inlier equivalent separations (WEIS), had not decreased. The access block was manifest by ambulance bypass of up to 150 hours per month in 2001, worsening access of emergency patients to inpatient beds, and increasing and chaotic theatre cancellations for elective patients. InterventionsDuring 2001, in response to a Victorian government initiative, RMH formed a clinician-led taskforce that developed 51 interventions. These aimed to maximise efficient use of inpatient beds and improve access for elective and emergency patients, and were generally adapted from programs tried at other institutions. The interventions were developed over three months from April to June 2001, and were implemented over the following three months. The more important initiatives were: centralising bed management, introducing a 48-hour short-stay ward, employing care coordinators in the emergency department to improve discharge and avoid inpatient admission,1 monitoring inpatient length of stay, with alerts for patients staying longer than 14 days, and improving access and referral to subacute care. OutcomeFollowing the implementation of the taskforce recommendations, there was a significant improvement in access block indicators, even though hospital bed numbers actually decreased in acute and subacute sectors. The hospital's WEIS remained the same and emergency WEIS increased during the six months from implementation. Ambulance bypass was reduced to fewer than 10 episodes per month, emergency patients waiting more than 12 hours for inpatient beds were reduced by 40%, and same- or prior-day theatre cancellations were reduced to fewer than 10 per month. The elective waiting list remained static during the first six months of implementation. Although the hospital was funded to increase bed numbers, this was not possible because of nursing shortages and rigid workforce rules. Significant components of the success of the interventions appeared to be that clinicians were empowered to drive the changes and the focus was on maximising bed use rather than saving money. Individual interventions that had substantial effects on access block were the 48-hour short-stay ward, care coordination in the emergency department, centralised bed management, day-of-surgery admissions, and monitoring of patients staying as inpatients for more than 14 days. Using a similar strategy, hospitals similar to RMH could function with fewer beds or treat more patients with the same number of beds. It is not possible to determine from our experience whether this would result in cost savings.

Peter A Cameron · Donald A Campbell

The Alfred Hospital, in Melbourne, is a 350–390-bed tertiary referral hospital with acute medical, surgical and psychiatric services. It is one of three hospitals in Bayside Health, a major metropolitan health service, and is one of the two major adult trauma centres in Victoria. The hospital also provides a number of statewide services, including those for heart–lung transplantation, cystic fibrosis and major burns. In 2000 and early 2001, there was a considerable increase in the occasions that the Alfred's emergency department (ED) had to implement ambulance bypass, and there were difficulties in timely access for high priority elective admissions. Several initiatives had already improved access in the hospital, such as hospital-in-the-home, pre-admission and day-of-surgery admission strategies. In addition, an integrated approach to bed management was in place. This involved daily review of priorities for emergency and elective admission, through a centrally coordinated bed assignment process, overseen by senior medical and nursing managers. InterventionsIn financial year 2001–02, the Victorian Department of Human Services funded a number of initiatives under the Hospital Demand Management Strategy, which aimed to improve access for emergency and elective patients. The funded initiatives in the Alfred ED include increased senior medical staff cover after hours and the development of fast-track, an area of the ED where a doctor and a nurse work in partnership to fast-track the patients' care. Other hospital initiatives included a targeted length-of-stay strategy, involving strategies such as additional care coordination for patients admitted to specific clinical units, and the introduction of a weekly ward round by senior medical and nursing staff to facilitate early discharge planning. A third project focused on strategies to avoid patients' presenting to the ED, such as multidisciplinary mobile teams working in concert with nursing homes and general practitioners. Among the more successful strategies were the Medical Ambulatory Day Unit and the Medihotel. These were designed to meet the needs of patients who required inpatient interventions, but who did not need overnight stay in an inpatient bed. These might be rural patients, patients receiving treatment over a series of days, or patients for clinical review or investigation. Previously, there was no alternative but to admit these patients to multiday inpatient beds. The Medical Ambulatory Day Unit (MADU) and Medihotel are next to each other within the main part of the hospital's ward area. The MADU was designed to provide a range of medical interventions and consultation facilities, and patients may attend on consecutive days for their treatment or investigation. The Medihotel provides accommodation to patients of the Alfred who are ambulatory and independent who do not require clinical intervention overnight, but who need to be close to professional expertise if required. OutcomeA review of the outcomes in late 2001 and early 2002 showed a significant reduction in ambulance bypass, from 291 episodes in 2000–01 to 158 episodes in 2001–02. However, similar improvement was not achieved in the number of ED patients waiting for more than 12 hours for an inpatient bed. Hospital-in-the-home substitution rates, which estimate the resulting inpatient capacity, were around 11%, which compared well with similar hospitals. Up to June 2002, there had been more than 3500 occasions of service for patients of the MADU, and more than 1900 patient-nights in the Medihotel. Nearly all clinical units at the Alfred have used the MADU/Medihotel at least once. The ability to plan for elective medical admissions without the risk of cancellation has been well received by staff. The centralised bed allocation and coordination process is extremely effective in maximising access to multiday beds, although this requires a considerable senior medical, nursing and management commitment. Some of the improvements to bed management flows did not require extra resources, as they related to changes in process. An example was the decision to allocate the first five multiday beds that became available each morning to patients awaiting admission in the ED — this had a considerable impact on the ED, without a flow-on disadvantage elsewhere. Other initiatives with high impact on access were increasing the number of senior staff in the ED, care coordination and ED disposition nurses, and weekly ward rounds by clinical bed management staff to identify opportunities for redesign of the processes of discharge and bed management.

Kim N Hill MB BS, MHP, FRACMA

Objectives: To evaluate a Framingham risk function for coronary heart disease in an elderly Australian cohort and to derive a risk function for cardiovascular disease (CVD) in elderly Australians.Design and setting: Analysis of data from a prospective cohort study (the Dubbo Study) in a semi-urban town (population, 34 000).Participants: 2805 men and women 60 years and older living in the community, first assessed in 1988, and a subcohort of 2102 free of CVD at study entry.Main outcome measures: Incidence of CVD (myocardial infarction, coronary death or stroke) over 5 and 10 years.Results: A Framingham risk function assessing "hard" coronary heart disease (ie, myocardial infarction or coronary death) accurately predicted 10-year incidence in men and women aged 60–79 years who were free of prevalent CVD or diabetes at study entry. In a multiple logistic model, CVD incidence was significantly predicted by age, sex, taking antihypertensive medication, blood pressure, smoking, total cholesterol level and diabetes. For a given age and cholesterol level, CVD risk over 5 years was doubled in the presence of antihypertensive medication or diabetes, increased by 50% with cigarette smoking, and halved in women compared with men.Conclusions: We have derived a simple CVD risk function specifically for elderly Australians that employs risk factors readily accessible to all medical practitioners.

Leon A Simons MD, FRACP · Judith Simons MACS · Latha Palaniappan MD, FACP · Yechiel Friedlander PhD · John McCallum DPhil

Objectives: To estimate the appropriateness of transfusions of platelets, fresh frozen plasma (FFP) and cryoprecipitate using National Health and Medical Research Council and Australasian Society for Blood Transfusion guidelines (NHMRC/ASBT 2002).Design and setting: Three separate retrospective surveys of medical records from 1 January to 31 August 2000 (1147 transfused patients) from 14 hospitals selected randomly from all public hospitals that use these blood products in New South Wales: five tertiary referral, five major metropolitan, and four major rural (base) hospitals.Main outcome measures: Proportion of potentially inappropriate transfusions.Results: 33% (136/414) of platelet, 37% (248/669) of FFP and 62% (37/60) of cryoprecipitate transfusions were assessed as inappropriate. By hospital type, 29% (75/259) of platelet transfusions were inappropriate at tertiary referral hospitals, 51% (40/78) at major urban hospitals, and 27% (21/79) at major rural hospitals. For FFP, 36% (112/313), 37% (80/216) and 39% (55/140) were inappropriate for referral, urban and rural hospitals, respectively. Cryoprecipitate was used almost exclusively at tertiary referral hospitals.Conclusions: In terms of the NHMRC/ASBT guidelines on use of blood products, there is considerable inappropriate transfusion of platelets, FFP and cryoprecipitate in NSW public hospitals.

William N Schofield MA, DipEdPsych · George L Rubin FAFPHM, FACR · Mark G Dean FRACP, FRCPA

Objective: To describe the changes in bulk-billing and out-of-pocket costs for Australian general practice consultations over the period 1995–2001.Design: Retrospective analysis of 1996–2001 survey data from the Australian Longitudinal Study on Women's Health (ALSWH), linked with Medicare and Department of Veterans' Affairs (DVA) data on general practice consultations from 1995 to 2001.Participants: 22 633 women who gave consent to linkage of their ALSWH data with Medicare/DVA records. In 1996, women in the "young" cohort (n = 6219) were aged 18–23 years, those in the "mid-age" cohort (n = 8883) were aged 45–50 years, and those in the "older" cohort (n = 7531) were aged 70–75 years.Outcome measures: Out-of-pocket costs paid by patients for general practice consultations, by calendar year, urban/rural area of residence, age, frequency of attendance, self-rated health, and education level.Results: For each age group and year studied, the use of bulk-billing was lower in rural areas than in urban areas. For example, in 2000, the percentage of women in rural and urban areas, respectively, who had all their general practice consultations bulk-billed was 31% v 52% (young women), 24% v 45% (mid-age women) and 58% v 79% (older women). There has been a steady decline in bulk-billing for general practice consultations in rural areas since 1995. The average out-of-pocket cost per consultation for women in rural areas was higher than the cost for women living in urban areas. After adjusting for age, health and socioeconomic factors, women living in urban areas were more than twice as likely to have all their consultations bulk-billed as women living in rural areas: odds ratio (OR), 2.4 (95% CI, 2.1–2.7) (young women); OR, 2.5 (95% CI, 2.3–2.8) (mid-age women); OR, 2.6 (95% CI, 2.3–2.9) (older women).Conclusions: In Australia, the geographic differential in the cost of general practice consultations is widening. Policy changes are required to enable women in rural and remote areas to have access to affordable healthcare services.

Anne F Young BMath(Hons), DipMedStat, PhD · Annette J Dobson BSc, MSc, PhD

Objectives: To review the choices of couples relinquishing frozen embryos and the outcomes of embryo donation at a major in-vitro fertilisation (IVF) clinic.Design and setting: Retrospective audit of 11.5 years of data (1991–2002) from the Monash University IVF clinic, Melbourne.Participants: Couples who make decisions regarding the fate of their frozen embryos, and recipient couples taking part in embryo adoption.Main outcome measures: Couples' choices with regard to the fate of their frozen embryos, and the outcome of donated embryo treatment cycles.Results: Of 1246 couples relinquishing frozen embryos, 1116 (89.5%) opted to discard rather than donate their embryos. Sixty-six per cent of donated embryos survived thawing. From donated-embryo transfer to 50 women in 92 cycles, a 17.4% pregnancy rate per transfer cycle was achieved, and 10 women delivered 11 healthy babies at term. At the time of our audit there were 98 couples on the waiting list to adopt embryos.Conclusions: It is worth considering how couples can be encouraged to donate rather than discard their surplus frozen embryos. An educational program on relevant legal, social and clinical issues may facilitate this.

Gabor T Kovacs MD, FRANZCOG · Sue A Breheny BSc(Hons) · Melinda J Dear BAppSc

Certain social expectations of medicine combine with characteristics of subspecialised technological paediatrics to facilitate the form of child abuse labelled "Munchausen by proxy syndrome". Examining this form of child abuse highlights possible shortcomings of medical practice. The primary medical tasks of diagnosing and curing illness and of preventing suffering are sometimes overridden by other motivations of which doctors may not be fully aware. More open discussion of what motivates health professionals in their work may improve medical practice and lead to a reduced incidence of Munchausen by proxy syndrome.

Jon N Jureidini PhD, FRANZCP · Allan T Shafer MA (Clin Psych), D Litt et Phil · Terence G Donald MBBS FRACP

Much has been written about the motivation of perpetrators in Munchausen by proxy syndrome (MBPS), but little, as far as I know, about the motivation of doctors who "collude" with parents in these behaviours. In general, I have no quibble with the analysis by Jureidini and colleagues.1 It is interesting, as they have done, to put forward a theory as to why doctors who are motivated to make "the diagnosis" might fail to recognise invented illness; however, the motivation of the "relentless investigator" is not the only one that should be examined. Indeed, doctors do not practise in a vacuum and are subject to pressures, societal among others, which may change with the clinical setting, affecting their practice. As a result, we may make mistakes in aspects of the clinical encounter — whether in our assessment of the process, the history, the examination or our interpretation of tests. Thus, when dealing with children, persistent parents may force the hand of even-thinking doctors because of current medicolegal and societal pressures. I do agree that children are more at risk from doctors who are enthusiastic about making a medical diagnosis and who ignore the social aspects of the consultation. However, concentrating on the motivation of the parent in MBPS cases has not proven useful in practice because of the complex psychopathology underlying such behaviour,2-4 and I doubt that focusing on the motivation of doctors will improve practice for similar reasons. While the relentless investigator is a particular problem in these cases, factors such as being busy, stressed or forgetful may also account for failure to identify the problem sooner. My concern is that, for an understanding of motivation to be useful in preventing the phenomenon of MBPS, it would be necessary to both reliably identify doctors' motivations and intervene to change these, and I do not believe that either of these steps is feasible. As a practising paediatrician, I suggest that a more useful approach to this problem of paediatric diagnosis would be to establish guidelines for the problem of the unresolved clinical problem or "difficult diagnosis" (see Box). The unresolved clinical problem: a practical approach4 Always consider MBPS in the differential diagnosis when the pieces do not seem to fit. Pay attention to the process of the consultation (how does the patient present?), especially where there is a history of maternal psychological problems. If worried about missed disease, draw up a list of hypotheses that should be used to direct further testing. Include the process of consultation in these; consult a colleague. Do not order invasive tests to "reassure" parents. Consider the cost and harm of tests versus the benefits. Do not overinterpret test results in the clinically well child. Get corroboration of previous illness from independent sources. Do not accept at face value a history of severe illness in a well child. Consult with a colleague before doing invasive tests where there is a major and unexplained incongruity between the story and the assessment. This is particularly important in gastroenterology and neurology. If all appropriate treatments inexplicably fail, be very wary of invasive testing. Consult with a colleague.

Kieran T Moran FRACP

Meningococcal septicaemia has high mortality, especially when the diagnosis is delayed or missed. Early recognition is not always straightforward, as classic clinical features may be absent or overlooked at initial presentation. Septicaemia without focal infection accounts for 15%–20% of cases of meningococcal disease and is the most worrisome manifestation in terms of diagnosis and outcome; in contrast, meningococcal meningitis is usually straightforward to diagnose, with a relatively good prognosis. Useful early clinical clues to meningococcaemia include: – a haemorrhagic (petechial or purpuric) rash; – blanching macular or maculopapular rash that appears in first 24 hours of illness; – true rigors; – severe pain in extremities, neck or back; vomiting, especially in association with headache or abdominal pain; rapid evolution of the illness; – concern of parents, relatives or friends; – patient age (highest incidence at age 3–12 months, followed by 1–4 and then 15–19 years); and – contact with a patient with meningococcal disease. In addition to specific clues, clinicians should look at the whole pattern of the illness. Timely clinical review is essential if there is doubt about the diagnosis. In any acutely febrile patient, it is prudent to ask "Why is this patient seeking help now?", then "Could this patient have meningococcaemia?".

Allen P Yung FRACP · Malcolm I McDonald FRACP, FRCPA

To the Editor: Interpretation of the report describing the first death attributed to the Irukandji syndrome should be tempered by the fact that significant unstated assumptions have been made in attributing the cause of death to a jellyfish.1 While envenomation by a jellyfish remains the likely diagnostic possibility, no evidence is presented that unequivocally confirms a jellyfish as the lethal agent. Several methods could have been used to support or confirm the diagnosis of jellyfish envenomation, including sampling of nematocysts from the victim's skin (before or after death), jellyfish capture, or reports of other similar, but less severe, stings from the same beach around the time the victim was stung. In severe jellyfish envenomation, attempts are often made to harvest nematocysts from patients' skin, most commonly by skin scraping or by sticky tape sampling.2 Recovered nematocysts may help to identify the species, and confirm the diagnosis.3 Although successful nematocyst recovery is uncommon in Irukandji syndrome, it is disappointing that "no attempt was made to sample nematocysts"1 given the relative simplicity of the procedure and the importance of this case. The authors state that "no sting site was clearly delineated",1 but then go on to say that there were, in fact, areas of "skin flushing and intermittent diaphoresis"1 over a significant period of time. Sticky tape sampling of these areas may have yielded nematocysts, allowing positive species identification. Postmortem skin sections have also been employed in Chironex fleckeri fatalities, and have shown nematocyst barbs on the victim's skin.4 Postmortem examination may also have revealed other contributing factors. I am particularly interested in the assertion that almost every Irukandji syndrome patient in the Whitsundays develops a "rise in cardiac troponin levels".1 In fact, the cited article makes no mention of troponin, simply stating that CK-MB (creatine kinase isoenzyme) levels "can be abnormal",5 and that "some severe cases [of Irukandji syndrome] may have a CK-MB [level] well above the normal range".5 Many aspects of the diagnosis and treatment of jellyfish envenoming remain controversial. Accurate reporting of unusual cases is thus of the utmost importance.

Paul M Bailey

To the Editor: In their Notable Case on jellyfish envenomation causing Irukandji syndrome,1 Fenner and Hadok suggest that similar deaths may have occurred in the past, with the relationship to Irukandji syndrome not being recognised. However, their call for urgent research into developing an antivenom needs to be based on a clear understanding about the risk of death. Unfortunately, they have not presented data that clearly establish causation or support their conclusions about treatment and the need for further research. While they reported a history that supports envenomation, there was no confirmation by detection of nematocysts or autopsy to examine for other causes of death. An alternative explanation could be that the patient was overcoagulated and died from complications of an intracerebral haemorrhage. While it is clear that blood pressure must be monitored, to suggest that it must be treated with phentolamine is not supported by this case report. Clearly, supportive management and, in particular, the optimal treatment of cardiovascular complications needs to be defined and may obviate the need for antivenom.

Andrew H Dawson

In reply: While overcoagulation causing intracerebral haemorrhage could have caused the death of the patient we described,1 he was normotensive until developing signs and symptoms of Irukandji syndrome some 20 minutes after being stung. The Irukandji syndrome is, and always has been, a clinical diagnosis only. Biochemical and pathological test results become abnormal later, but are not diagnostic — actual cause and effect have been described only once, with the experiment unlikely to be repeated!2 Nematocyst studies, while established for Chironex fleckeri,3,4 have never identified species associated with Irukandji syndrome, except Carukia barnesi, which appears to occur in the Cairns area only. Other species probably cause the more severe syndrome seen in the Whitsundays and on the Great Barrier Reef, where these deaths occurred.5 One of us (P J F) is possibly the only person to have captured specimens likely responsible for causing Irukandji syndrome from the Whitsundays, and the species remain unidentified, as they are a new species and not described to date. Also, when the moribund patient was admitted, no obvious sting site was visible, and a negative skin scraping would not rule out a jellyfish sting. Phentolamine has previously proved effective for relieving distressing autonomic symptoms,6 and not just for cardiovascular complications, although it appeared ineffective at the lower doses used in our patient. However, nothing appears to prevent toxic cardiac dilatation occasionally occurring later in the syndrome.7 Further research is currently under way. Antivenom development may prevent some (possibly all) major symptoms of Irukandji syndrome. However, production is impossible until sufficient specimens of all species (some six to 10) causing the syndrome are caught and their venom assessed. Such advances are many years away and may never be achieved with current poor levels of funding. Cardiac markers for jellyfish envenomation have previously been identified.5,8 Since 1999 troponin level has replaced creatine kinase isoenzyme (CK-MB) level, and both are invariably raised in patients stung by the Whitsunday jellyfish. Thus, the words "cardiac markers" should have been used in the article and for not doing so I apologise. Despite C. barnesi stings being common at north Cairns beaches, it has taken six years of dragging the beaches, with nets to catch jellyfish of this species. The thought of trying to catch a 12 mm jellyfish that makes erratic and irregular appearances in several hundred square kilometres of ocean around the Whitsunday Islands is totally daunting, but the possibility is being assessed. Such a venture will depend on funding becoming available. Other stings were reported in the area at the time of our patient's death and are well known at the resorts where people who have been stung in surrounding areas are taken for treatment. However, stings remain erratic; they have no predictable patterns of appearance, and unfortunately prophecy is currently impossible.

Peter J Fenner · John C Hadok

To the Editor: The article by Tan and Fitzgerald1 raises numerous concerns. The authors report that their recommended personal protective equipment (PPE) conforms to standards "in a hospital environment where the chemical vapour concentration will not be high". At the same time, the authors acknowledge data indicating most patients from a disaster will present to the local hospital by private transport (ie, without triage, decontamination, or prehospital care). These two considerations are incompatible and further ignore the possibility of the hospital as a direct terrorist target. The authors' assertion that their three decontamination lines "allow mass casualties, as well as trolleys and equipment, to be decontaminated quickly, efficiently, and in an orderly fashion" is simply not evidence based. Of greater concern, the authors report "major considerations were policies and plans [referring to the hospital External Disaster Committee] and the emergency department response". Although this bottom-up approach to disaster planning is typical, it pays inadequate attention to interdisciplinary issues of proper hazard identification and management, environmental health, syndromic surveillance, and field outbreak investigation. Readers seeking robust emergency department templates are better referred to other sources for guidance.2,3 Of greatest concern, the authors report "our recommendations are similar to systems in the US and Israel, but much less intensive, as the threat of a terrorist attack here is perceived to be much lower". The three references cited for that statement date back to 1994, with none more recent than 1999. Moreover, the logic of the unreferenced threat assertion confuses hazard and risk. Although the absolute probability of a given hazard may be low, the risk attending that hazard encompasses vulnerability of the exposed population. With weapons of mass destruction, the conditional probability of catastrophic public health consequences is high — one event is the only number you will ever need. The current public health context of chemical–biological–radiological (CBR) incident management in Victoria is one of limited experience, performance improvement indicators, and budgetary support from public health authorities. Public health is at risk when authorities report that "faced with dozens of requests each day to attend sites to assess white powder, the stretch capacity did not exist and nor should it".4 As a result, the leading trauma centre in Australia extracts $20 000 from its existing operations budget to discharge its CBR responsibilities. This is not good enough. Nevertheless, the authors deserve credit for their initiative. Until cross-trained and disaster-experienced healthcare authorities reprioritise, this article shows the reader an excellent way to play a very weak hand.

David A Bradt

To the Editor: Tan and Fitzgerald's template for emergency department response to chemical–biological–radiological hazards appears to be based on a dubious assumption of a low level of risk.1 A recent report details exposure of emergency department staff to potentially fatal secondary contamination during a hazardous materials incident, highlighting the need for staff to have the appropriate training and equipment to deal with these events.2 I believe the level of Personal Protective Equipment (PPE) proposed by Tan and Fitzgerald is inadequate. The "facemask with filter" they describe is classified as Level C respiratory protection, and this level only conforms to the Australian Standard (for PPE) when the identity of the chemical and its vapour concentration are known, and when these do not exceed the filtering capacity of the particular filter mask being used.3,4 In the initial confusion of a hazardous materials incident, the identity of the chemical agent and its vapour will not be known. There may even be misinformation: during the 1995 Tokyo sarin attack, for example, initial advice to hospitals by the Tokyo fire service was that the incident was "a gas explosion in the Tokyo subway".5 Emergency department staff must be able to respond before the nature and severity of the chemical hazard can be determined. The only respiratory protection which conforms with the Australian Standard for PPE when the nature and severity of the chemical hazard has not been determined is the supplied gas respirator with full face shield of Level A (an encapsulating suit and self-contained breathing apparatus) or Level B (a non-encapsulating suit with self-contained breathing apparatus or a full face respirator on a gas line).3,4 Confronted with a hazardous materials emergency, potentially involving very toxic chemicals, emergency department staff need to have complete confidence in their own protection. This is only possible with the use of supplied gas respirators (Level A or B PPE), which provide complete respiratory protection. An additional problem with Level C air-purifying respirators is that their performance may be adversely affected by water ingress into the filter, which could occur during the decontamination procedures described in the template. Tan and Fitzgerald also propose having a clerk don PPE and enter the contaminated zone. Any stationery taken into a contaminated area would have to be decontaminated before being taken out to a "clean" area, and it is not clear what a clerk would add to the initial response within a contaminated zone.

Antony Nocera

In reply: We thank Bradt for his interest in our article and acknowledge his expertise in this field, which he has gathered in the United States and other countries. We also thank Nocera for his interest in our article. Our aim was to stimulate interest among the medical community in chemical–biological–radiological (CBR) response. The interdisciplinary issues mentioned by Bradt were mentioned in our article, but not in detail because of space limitations. Our personal protective equipment (PPE) conforms to Australian standards1-3 and the three decontamination lines are in keeping with other institutions. We are not aware of any simple decontamination system which, evidence-based, is superior. The choice of PPE in the ideal situation would be one that would provide adequate protection in all situations with a minimal amount of training, maintenance and expense. Nocera is correct in stating that the respiratory protection in an unidentified chemical hazard is Level A or B. These PPEs are expensive, bulky (which results in poor manual dexterity), and their use requires specialised training. The amount of chemical present on a victim surviving long enough to self-present to an emergency department is significantly less than that involved at the site of the incident. Therefore, the level of protection required for hospital staff would be less than that required by emergency rescue workers. Our PPEs were supplied by the Victorian health authorities. It is more important for staff to be familiar with their PPEs and for hospitals to have a CBR response that is regularly practised than having excessive protection that is limited to personnel who have undergone specialised training. The role of the clerk is to take patient details. These are radioed to staff in the hospital to help identify and correctly label patients, which is very important in mass casualty situations. Recent experience has demonstrated that terrorist acts are a worldwide phenomenon, and Australians are potential targets. This underlines the need for comprehensive training and maintenance of hospitals' CBR response. Since publication of the article, Victorian health authorities have reprioritised, and we therefore feel we have achieved the aims of our article.

Gim A Tan · Mark C B Fitzgerald

To the Editor: White emphasised problems that can arise if medical decisions are overly reliant on the results of laboratory tests.1 He relates the case of a patient who, because of a peculiarity of her immunology, consistently produced a false-positive test result. In probabilistic language, the issue is are there risks of both random errors and patient-specific errors? It is important to distinguish between them. Suppose a test has a false-positive rate of 10%. If this is truly random error, the probability of two false-positive results in the same person is 1%, and the probability of three false-positive results is tiny. But if it is due to there being 10% of healthy people for whom the test is invalid and who consistently give a positive result, the probability of two false-positive results in the same person is 10%, and the probability of three false-positive results is 10%! Major textbooks of medicine have excellent chapters on decision-making. These warn about limitations of sensitivity and specificity (eg, that data from the general population may not apply to people who have tested positive in screening). But, other than this, little is said about reasons for errors in testing, and the consequences for how sensitivity and specificity should be used. In most cases, the impression given is that errors occur completely randomly. However, it appears that White's example, in which repeated testing led to repeated errors, is not unique. Lee2 writes as follows: "Suppose a low-risk patient has an abnormal lung ventilation–perfusion scan. Obtaining that same test result over and over will not truly raise that patient's probability of coronary disease further and further." Perhaps Goldman3 had something similar in mind when writing, "It may be quite difficult to distinguish random laboratory errors from test results that might be falsely positive or negative because of coexistence of a process that can affect the test". Lists of possible reasons4,5 for errors include both short-acting (eg, distracting external noise, and biochemical effects of foods recently eaten) and long-term (eg, physical handicaps, and demographic factors) influences. I wonder if information about tests should routinely include separate random and patient-specific components of sensitivity and specificity. For example, it might be stated that a false-positive rate of 15% arises from 10% random errors and 5% patient-specific factors, or that a false-negative rate of 10% arises from 3% random errors and 7% patient-specific factors. This is the conclusion I have been led to by White's article.

T Paul Hutchinson

In reply: Many factors potentially contribute to error in generating a diagnostic test result, and include random pre-analytical errors arising from patient preparation and specimen collection, random errors associated with the act of measurement, and systematic errors caused by, for example, drug interference. Tested individuals may also harbour an interfering substance, such as a drug or immunoglobulin. The theoretical and practical description of these components of test error is generally well understood and documented by laboratories, and the basics of test error and diagnostic sensitivity and specificity are taught in medical schools. However, I think trying to apply probability data to a test result for a specific patient is of limited value to the treating doctor. The commoditisation and automation of much of pathology testing contributes to a perception that tests are 100% reliable, and there is also a perhaps related decline in communication between requester and provider. Most tests have limitations, many inconsequential, some important and patient-specific. Although Hutchinson draws a valid conclusion, I hope readers also concluded that communication with diagnostic laboratories remains important for safe patient care, and that test results still need to be interpreted in the context of other clinical information about a patient, and not accepted without question.

Graham H White

To the Editor: In reviewing the CD-ROM containing an integrated set of Therapeutic guidelines (eTG complete),1 Mann noted that, although utility was improved, the cost was high ($220 for a first user, and $110 for each subsequent user, compared with $264 for a set of the printed volumes which could be shared within a practice).2 Unfortunately, the cost of distilling evidence-based knowledge is also high, especially for publications that require regular review and update. In addition, there are extra costs involved in electronic conversion (text to HTML), reformatting material to fit computer screens, creating expandable and collapsible tables of contents (JavaScript) and searchable indexes. There is also a need to ensure that the electronic version works with a range of common operating systems (Windows, Macintosh and Linux) and with varied and ever-changing web browsers (eg, Netscape and Internet Explorer). In short, producing electronic versions of print publications requires additional resources, stringent quality control and considerable pre-release testing. In the near future, guideline producers face an additional technological challenge: the need to move from "static" HTML-tagged documents to "active" XML-tagged documents, in which the data elements and underlying logic are machine-readable and thus capable of interacting with the health worker and the emerging electronic medical record (computerised decision support). These developments (and Mann's concerns) raise the question as to who should pay for best-practice guidelines, including the evolving electronic conversion. Currently, the Australian government appears to lack a coherent approach to the provision of health information, at least with respect to best-practice clinical guidelines. For example, the Federal Government currently funds revision, production and distribution of The Australian immunisation handbook3 and the Manual of use and interpretation of pathology tests.4 More recently, the government has commendably funded a national subscription to the Cochrane Library. However, the government does not fund other equally valuable resources, such as the Australian medicines handbook5 or Therapeutic guidelines.1 The latter survive solely on a user-pays market model. It can be argued that it is time that the government adopted a more even-handed approach to stimulate the uptake of national best-practice guidelines and related services, perhaps by reimbursing health workers who subscribed to such services with practice incentive payments. This would lower the cost of practitioners acquiring national information resources, preserve the market model and assist guideline producers to meet the ongoing challenges of electronic conversion by improving their income stream.

Ken J Harvey

To the Editor: I was pleased to read the article on Ross River virus (RRV) disease by Mylonas and colleagues,1 because it included information on the cost of the disease. This makes it much easier to do something practical from a government and health economics perspective about the problem of RRV. The cost of $1018 per patient, including costs of negative tests looking for cases, sums to a total estimated cost to the nation of $5 million per annum (based on the reported average of 5000 cases per year in the study by Harley and colleagues2). Of note, $567 was spent per patient on diagnostic tests (56% of the total cost per patient), while the authors noted that in many cases the condition was self-limiting. I begin to wonder what is the use of spending $567 per patient diagnosed to prove a largely self-limiting condition that is treated symptomatically? Banning RRV testing could save $2.8 million per annum, which would be immediately available for mosquito control measures, and perhaps vaccine research, to reduce the burden of RRV disease. We could model the impact of a vaccination program — vaccine development cost, vaccine unit production cost, vaccine delivery, population target, and savings in disease prevented — to determine whether funding of vaccine research is worthwhile. The point is that without economic data we cannot make sensible "evidence-based" clinical management decisions. We are trapped in a scientific paradigm, and the health system implements unpopular cost–control interventions because it needs to control spiralling costs. We clinicians need to do better. If other researchers would follow the lead of Mylonas and colleagues and explore the economics of their subject, we would be able to make more rational choices about healthcare. It is up to clinicians to understand the economic agenda and suggest interventions that make both economic and clinical sense. We can then begin to make more efficient and rational use of our health dollars, relieving stress on a stressed system.

Ian R Cheong

To the Editor: Dugdale proposed recently in the Journal that people who have a skin reaction to mosquito bites are less likely to be infected by Ross River virus than those who do not.1 As he quotes Kumar, who made a similar comment about malaria infection,2 one could presumably extend his idea to other conditions transmitted by mosquitoes. This accords with my own personal experience of dengue fever acquired in Fiji. While serving there, I had two separate proven infections with dengue virus. As I react very little to mosquito bites, I could not identify the time of infection. Indeed, on the first occasion, I had just returned from a three-month stay in Adelaide and could not recall being bitten by a mosquito at all. In contrast, my wife, who developed large weals whenever bitten, went through at least three epidemics of dengue without being infected. My advice to travellers who consult me is that there is an advantage to reacting badly to mosquitoes, as one is then more likely to take anti-mosquito precautions, whereas the non-reactor is more likely to disregard them. However, Dugdale's suggestion that a local inflammatory reaction may be a factor in defence against infection is intriguing and worth following up. It should be simple to enquire retrospectively about reactions to mosquito bites in those who have had a mosquito-borne disease, as Dugdale has done for Ross River virus infection. This would provide evidence on which to base pathological and immunological studies.

Michael Sorokin

To the Editor: Dugdale recently suggested that people who develop skin reactions to mosquito bites may be protected against Ross River virus (RRV) disease.1 He noted that seven patients with a history of RRV disease all reported no skin reaction to mosquito bites, and 18 patients with no past history of RRV disease reported reacting to such bites. We argue that this correlation is entirely to be expected, as the lack of reaction to mosquito bites illustrates that the individuals have been previously exposed to many bites. At least two studies have shown a clear inverse correlation between mosquito exposure and bite reactions.2,3 Clearly, exposure to a large number of mosquito bites increases the risk of infection.4 Thus, a reaction to mosquito bites probably does not protect against RRV disease, but is simply a marker for low exposure to mosquito bites and therefore low risk of RRV infection. The rationale behind the association of itching bites and protection against RRV infection is also tenuous. Virus is likely to reach the circulation within seconds of introduction by the mosquito, whereas allergic reactions take minutes to develop. It is unlikely that a local reaction will affect viral replication at distant sites. In Dugdale's study, only people with a history of symptomatic RRV disease had undergone RRV serological testing. As about 30% of Queenslanders are seropositive,5 and 60%–75% of RRV infections are thought to be asymptomatic,6 some of the 18 people with no past history of RRV disease might be expected to have had asymptomatic RRV infection. This raises the question, does reaction to mosquito bites correlate with asymptomatic RRV infection?

Peter A Ryan · Jillann F Farmer · Brian H Kay · Andreas Suhrbier

To the Editor: I support Tattersall and colleagues1 in their attempt to use a wee bit of science and a dose of common sense to improve doctors' letters. While I would love to receive letters based on their proposed "prompt sheet", and should really try much harder myself to follow it, I'd be only too pleased — in the interim, while we await enlightenment — to receive any letter from some of my colleagues with whom I share what is supposed to be "multidisciplinary care" of patients. There is a research project in this for the brave to find out why, too often, communication is not merely inadequate but non-existent.

Alan Rodger

Re the article "Water and the environment: a natural resource or a limited luxury?", by Karin Leder, Martha I Sinclair and John J McNeil in the 2/16 December issue of the Journal (Med J Aust 2002; 177: 609-613). Due to a software error, the affiliation of the authors was incorrectly given as the National Centre for Epidemiology and Population Health, Australian National University, Acton, ACT. The correct affiliation and contact details are: Department of Epidemiology and Preventive Medicine, Monash University – Central and Eastern Clinical School, Alfred Hospital, Melbourne, VIC. Karin Leder, FRACP, MPH, DTHM, Head of Infectious Disease Epidemiology; Martha I Sinclair, PhD, Senior Research Fellow; John J McNeil, FRACP, PHD, FAFPHM, Head of Department. Correspondence: Dr Karin Leder, Department of Epidemiology and Preventive Medicine, Monash University – Central and Eastern Clinical School, Alfred Hospital, Commercial Road, Melbourne, VIC 3004. karin.lederATmed.monash.edu.au The html and pdf versions of the article available on this website have been corrected.

Karin Leder FRACP, MPH, DTHM · Martha I Sinclair PhD · John J McNeil FRACP, PHD, FAFPHM

Treatment of skin disease. Comprehensive therapeutic strategies. Mark Lebwohl, Warren R Heyman, John Berth-Jones, Ian Coulson (editors). London: Mosby, 2002 (xxiv + 693 pp). ISBN 0 7234 3198. The treatment of skin disease has often been viewed as simply deciding whether a rash is “dry” or “wet” and then choosing between a range of creams, ointments and lotions. This book should help to change this misperception by demonstrating that progress has been made; current therapeutic options have been analysed in relation to levels of evidence, thus elevating the status of dermatological therapy. The editors have invited over 200 dermatologists from around the world to summarise and assign current skin therapy for 213 separate conditions. Levels of evidence have had to be modified, as, at present, there are insufficient double-blind controlled trials for most treatments to follow the Cochrane Collaboration’s levels of evidence. By using this modification, the review of available treatments can be stratified. The format adopted for each topic is outstanding. It consists of a representative colour photograph of the condition, a brief clinical description, management strategy, specific investigations and three separate levels of treatments — first, second and third choices. Pertinent references are included within the text and there is a succinct one- to two-line summary. The inclusion of some references to what may appear to be anecdotal reports of successful treatments may serve to stimulate larger controlled studies. Most of the authors have been chosen for their recognised expert knowledge in their fields and each section is a distillation of their individual experience and assessment of current treatments. This book is a useful reference for both general practitioners and specialists, as it deals with most common skin conditions, such as dermatitis, skin infections, skin cancers, as well as rarer conditions such as Fox–Fordyce disease. The book is ideal for the busy practitioner, as each section is short, structured and packed with useful information. Almost all the treatments included are currently available in Australia. The book is a handy guide for all who treat skin diseases. Steven KossardAssociate Professor of Dermatology Skin and Cancer Foundation Australiaand St Vincent’s Hospital, NSW

Steven Kossard

Hepatitis C. An Australian perspective. Nick Crofts, Greg Dore and Stephen Locarnini (editors). Melbourne: IP Communications, 2001 (xviii + 380 pp). ISBN 0 9578617 2 9. This book is an excellent resource for healthcare professionals who work with hepatitis C, and for people suffering from this condition who wish to have access to detailed, up-to-date, technical information. The book is multi-authored and its main strength is its well-chosen authors — they are all Australian experts. Scott Bowden (Senior Scientist at the Victorian Infectious Diseases Reference Laboratory) has written a comprehensive chapter on laboratory diagnosis. He explains clearly the difficulties in comparing the two assays used for quantifying viral load, and the differences between the various serological assays. William Sievert, of Monash Medical Centre, has contributed an excellent chapter on antiviral treatment, with up-to-date information on newer treatments, and predictors of response. Margaret MacDonald, Nick Crofts, Alex Wodak and John Kaldor have written the chapter on hepatitis C transmission. Nick Crofts has expanded on transmission in a subsequent chapter entitled “Descriptive epidemiology of the hepatitis C virus”. This chapter provides an interesting and detailed review of global trends in hepatitis C. As well as technical sections on virology, pathogenesis, treatment and epidemiology, there are excellent sections on quality of life, discrimination, policy and prevention. There are always areas where an individual reviewer will see omissions. Liver transplantation is not described in any detail — many readers would like to know whether transplantation has a role, and what its success, limitations and implications are. Similarly, there is not much information on “the next ten years” in antiviral treatment. The chapters on policy and prevention are excellent, but do not address some of the gaps in current policy and practice. For example, the apparent ineffectiveness of harm reduction programs in significantly reducing the prevalence of hepatitis C is not considered, nor are the lack of culturally appropriate education or treatment facilities for ethnic groups and the lack of resources in rural areas. I hope that the positive foreword written by the former Federal Minister for Health, Dr Michael Wooldridge, indicates an ongoing commitment by government to address some of these issues. It will be interesting to see whether these gaps have been closed by the time a second edition is published in a few years’ time (as I hope it will be). A manageable size at 350 pages, the book is well referenced, well indexed and, at $85, well worth the price. Katrina J R WatsonGastroenterologist St Vincent’s Hospital, Fitzroy, VIC

Katrina J R Watson

AAA screening vindicated All men should have a single ultrasound at age 65 to screen for abdominal aortic aneurysm, says an editorial1 commenting on the recent MASS study.2, 3 The Multicentre Aneurysm Screening Study randomised nearly 70 000 British men, inviting half to have a screening ultrasound. Eighty per cent (27 147) accepted; 1333 aneurysms were detected and then monitored or repaired. Follow-up was for a mean of four years, in which time there were 65 aneurysm-related deaths in the invited group (including 22 men who had been invited but had not accepted) compared with 113 among controls, giving a risk reduction of 42%. 710 men needed to be screened to prevent one death. The cost-effectiveness ratio at 10 years was estimated to be £8000 per quality-adjusted life-year gained, well under the threshold for acceptability in Britain's National Health Service. 1. BMJ 2002; 325:1123-1124 2. BMJ 2002; 325:1135-1138 3. Lancet 2002; 360: 1531-1539 Sun, serotonin and SAD Melbourne researchers have shown that sunlight increases brain serotonergic activity, which thus may contribute to mood seasonality and seasonal affective disorder. They measured neurotransmitter levels in 101 volunteers, in blood obtained from a high internal jugular vein catheter (to directly sample venous blood from the brain) and from a central arterial catheter, and related the levels to detailed meteorological data. Brain serotonin turnover was lowest in winter. Serotonin production was directly related to the duration of bright sunlight and varied acutely with luminosity: median 395 pmol/min on bright days, compared with 49 pmol/min on dull days. There was no seasonal variation in extracerebral serotonin turnover, nor in cerebral turnover of norepinephrine or dopamine. Lancet 2002; 360: 1840-1842 Steroids for meningitis European investigators advise that adults with bacterial meningitis should be given adjunctive dexamethasone (10 mg qid for 4 days) to improve their outcome. The rationale is based on animal studies which have shown that the subarachnoid space inflammatory response is a major factor contributing to morbidity and mortality. Dexamethasone attenuates this response. In a randomised placebo-controlled trial of 301 patients, those given dexamethasone (in addition to antibiotics) were less likely to have a poor outcome (15% v 25%) or to die (7% v 15%) than controls. The effect was most apparent in patients with pneumococcal meningitis. No effect was seen on neurological sequelae such as hearing loss. N Engl J Med 2002; 347: 1549-1546 Window to the lungs? Topical β-blockers given for glaucoma are known to exacerbate bronchospasm in patients with chronic obstructive pulmonary disease or asthma, but a recent study suggests that it's not just those with known respiratory problems who are at risk. British researchers used the Mediplus database to identify 2645 people without a history of respiratory disease who were first exposed to topical β-blockers between 1993 and 1997, and compared their subsequent diagnoses of respiratory problems with those of 9094 matched controls. In the year after commencing therapy the exposed patients were 2.29 times more likely than the unexposed patients to be given, for the first time, a drug used in the treatment of reversible airways obstruction. This was equivalent to a number needed to harm of only 55 patients. BMJ 2002; 325: 1396-1397 A caution on preventers Amid growing concern about adrenal suppression in people taking high doses of inhaled corticosteroids for asthma, researchers have attempted a survey of adrenal crises associated with these medications in the United Kingdom. Surveys were sent to all paediatricians and endocrinologists in the UK, and those who identified a potential case completed a detailed questionnaire. Thirty-seven episodes in 33 patients (28 children and five adults) were identified. Most children presented with altered consciousness or coma associated with acute hypoglycaemia, whereas adults generally experienced a more insidious onset. Thirty patients had been treated with fluticasone (mean daily doses of 980 µg in children and 1380 µg in adults). Of interest was the finding that fluticasone was the drug used in 91% of cases, yet it accounted for less than 20% of all prescriptions for inhaled steroids in the UK in 1998. The authors postulated that this might relate to its high lipophilicity, allowing entry into the blood via the lungs, without first-pass hepatic metabolism. They suggested great caution in using doses of more than 400 µg/day of fluticasone in children and 1000 µg/day in adults. Arch Dis Child 2002: 87: 457-461