When is hospital the right place to be?

The received wisdom is that patients with cardiac chest pain should cut out the intermediary and call an ambulance, rather than bothering with general practitioners or helplines such as NHS Direct. This is easier said than done, when numerous attempts to educate patients about the signs and symptoms of cardiac pain have failed. Targeting women and older people may be one answer, along with making even more defibrillators available in busy public places.

A trip to hospital is not too bad if there is a chance of being sent home again after a few hours' thorough assessment. In the United States nearly a third of emergency departments have a dedicated chest pain unit where patients can be assessed rapidly and sent home if they don't need to go into hospital.

But, according to Goodacre and colleagues, whose cluster randomised trial in 14 UK hospitals these may not work. They evaluated a protocol used in chest pain units, in the ESCAPE trial. Patients with no definite evidence of acute coronary syndrome were offered observation for up to six hours, rapid testing for creatine kinase and troponin, and immediate exercise testing on a treadmill. Unlike an earlier trial in a single unit, this much larger trial did not reduce attendance at emergency departments or admissions to hospital for chest pain, and rates of immediate discharge varied widely among units.

This balance is also at the heart of the debate over the shift to midwife led childbirth in the UK. Some people argue that there is enough evidence to judge that birth outside hospital is safe, and that the earlier move into hospitals was unjustified and never evaluated. But James Drife, professor of obstetrics and gynaecology, is concerned: he insists that midwife led units are being promoted for political expediency in the absence of reliable evidence on safety

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Occupational therapy after stroke

Stroke is the second leading cause of death in the world and the leading cause of serious, long term disability in adults; about half of those who survive are dependent on others for assistance with personal activities of daily living six months after the stroke

A study was set up to determine whether occupational therapy focused specifically on personal activities of daily living improves recovery for patients after stroke.

This was a systematic review and meta-analysis. Trials were included if they evaluated the effect of occupational therapy focused on practice of personal activities of daily living or where performance in such activities was the target of the occupational therapy intervention in a stroke population.

Original data were sought from trialists. Two reviewers independently reviewed each trial for methodological quality. Disagreements were resolved by consensus.

Nine randomised controlled trials including 1258 participants met the inclusion criteria. Occupational therapy delivered to patients after stroke and targeted towards personal activities of daily living increased performance scores (standardised mean difference 0.18, P=0.01) and reduced the risk of poor outcome (death, deterioration or dependency in personal activities of daily living) (odds ratio 0.67, P=0.003). For every 100 people who received occupational therapy focused on personal activities of daily living, 11 would be spared a poor outcome.

The authors conclude that occupational therapy focused on improving personal activities of daily living after stroke can improve performance and reduce the risk of deterioration in these abilities. Focused occupational therapy should be available to everyone who has had a stroke.

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NICE guidance on childbirth in healthy women

The following gives the first part of the NICE guidelines.

General principles

•Provide information with clear explanation so that women are fully involved in decision making and supported through labour. Good communication with the healthcare team is valued by women and may improve their psychological wellbeing after birth.

•Provide supportive one to one care to women in established labour and ensure they are not left alone except for short periods—women receiving one to one care throughout their labour are significantly less likely to have a caesarean section or instrumental vaginal birth, will be more satisfied, and will have a positive experience of childbirth.

•Ensure that labour and birth progress without intervention, provided that labour is progressing normally and the woman and baby are well.*

Place of birth

•Inform women that birth is generally very safe but that the available evidence on advantages and disadvantages or cost effectiveness of different places of birth is of poor quality. Availability of midwife led units may vary locally and most births take place in hospital nowadays.

•Inform women who plan to give birth at home or in a midwife led unit that these are associated with a higher likelihood of a normal birth, with less intervention, but inform them that if something goes unexpectedly seriously wrong during labour under these circumstances, the outcome for the woman and baby could be worse .

Pain relief

A woman's desire for and choice of pain relief during labour are influenced by many factors, including her expectations, the complexity of her labour, and the severity of her pain. Flexible expectations and being prepared for labour may influence her psychological wellbeing after birth, as may good communication with the healthcare team.

•Offer the option of labouring in water, as this has been shown to reduce pain and the need for regional analgesia, with no differences in adverse outcomes.

•Inform women considering epidural analgesia that it provides the most effective pain relief in labour but also carries risks (such as longer second stage and increased likelihood of instrumental birth) and implications for their labour (such as increased monitoring of both mother and baby).

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