BMJ  2007;335 (29 September), doi:10.1136/bmj.39350.580278.47

Editor's Choice

When is hospital the right place to be?

The old man had had classic cardiac chest pain for two nights (doi: 10.1136/bmj.39129.623368.BE). Against his general practitioner's advice, he decided he would rather go to that evening's Bowls Club dinner than to hospital for tests. Should his doctor have tried harder to persuade him to go to hospital?

Will Roberts and Adam Timmis would probably say yes. But they also say, on this week's Change Page (doi: 10.1136/bmj.39342.693252.47), 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. 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, they say, along with making even more defibrillators available in busy public places.

The old man might not have minded a trip to hospital if he had known there was 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. Surely this is worth implementing in other countries? Not necessarily, according to Goodacre and colleagues, whose cluster randomised trial in 14 UK hospitals evaluated a protocol used in chest pain units (doi: 10.1136/bmj.39325.624109.AE). It's called the ESCAPE trial, perhaps describing what patients would like to do when they're stuck in hospital waiting for tests. In the intervention group, 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. As Mike Clancy says in the accompanying editorial, patients expect serious disease not to be missed and clinicians want to rule it out, but the best way to balance efficiency, safety, and choice for patients remains elusive (doi: 10.1136/bmj.39339.380093.BE).

This balance is also at the heart of the debate over the shift to midwife led childbirth in the UK. Lesley Page, professor of midwifery, argues 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 (doi: 10.1136/bmj.39343.471227.AD). 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 (doi: 10.1136/bmj.39343.461146.AD).

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Effectiveness of chest pain units

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