Search

Objective: Clinical decision aids (CDAs) can help clinicians with patient risk assessment. However, there is little data on CDA calculation, interpretation and documentation in real‐world ED settings. The ABCD2 score (range 0–7) is a CDA used for patients with transient ischaemic attack (TIA) and assesses risk of stroke, with a score of 0–3 being low risk. The aim of this study was to describe ABCD2 score documentation in patients with an ED diagnosis of TIA. Methods: Retrospective observational study of patients with a working diagnosis of a TIA in two Australian EDs. Data were gathered using routinely collected data from health informatics sources and medical records reviewed by a trained data abstractor. ABCD2 scores were calculated and compared with what was documented by the treating clinician. Data were presented using descriptive analysis and scatter plots. Results: Among the 367 patients with an ED diagnosis of TIA, clinicians documented an ABCD2 score in 45% (95% CI 40–50%, n = 165). Overall, there was very good agreement between calculated and documented scores (Cohen's kappa 0.90). The mean documented and calculated ABCD2 score were similar (3.8, SD = 1.5, n = 165 vs 3.7, SD = 1.8, n = 367). Documented scores on the threshold of low and high risk were more likely to be discordant with calculated scores. Conclusions: The ABCD2 score was documented in less than half of eligible patients. When documented, clinicians were generally accurate with their calculation and application of the ABCD2. No independent predictors of ABCD2 documentation were identified. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the association between time from ED presentation to intensive care unit (ICU) transfer on mortality in patients presenting with septic shock. Methods: Adult patients with suspected septic shock enrolled in the Australasian Resuscitation in Sepsis Evaluation trial were included. The primary outcome of this post‐hoc analysis was 90‐day mortality. ED‐to‐ICU time was analysed as both a continuous variable and a binary variable (≤ vs >4 h). Analysis incorporated mixed effects regression, with ICU site as a random effect, time‐to‐event analysis and competing risks regression; all with and without inverse probability of treatment weighting to account for confounding baseline covariates. Results: Data from 1301 patients were included. Median (interquartile range [IQR]) ED‐to‐ICU time was 4.3 (3.1, 6.3) hours, with 588 patients (45%) transferred within 4 h. The ≤4‐h group were younger, 64 (51, 74) versus 67 (52, 76) years (P = 0.04), with higher APACHE III scores, 50 (37, 65) versus 47 (35, 62) (P = 0.002), and higher unadjusted 90‐day mortality, odds ratio (OR) 1.53 (95% confidence interval 1.15, 2.03), P = 0.01. After adjustment for pre‐specified confounders, the 90‐day mortality OR was 1.09 (0.83, 1.44), P = 0.52. Adjusted for death as a competing event and illness severity, hospital length of stay was similar between groups, whereas ICU duration remained longer for the ≤4‐h group. Conclusion: In patients presenting to the ED with septic shock, ED‐to‐ICU time less than 4 h was not associated with altered 90‐day mortality, although this should be interpreted with caution due to study limitations. [ABSTRACT FROM AUTHOR]

Objective: Describe the characteristics and predictors of mortality for patients who spend more than 24 h in the ED waiting for an in‐patient bed and compare baseline clinical and demographic characteristics between tertiary and non‐tertiary hospitals. Methods: This was a state‐wide analysis data linkage analysis of adult (age >16 years) ED presentations across New South Wales from 2019 to 2020. Cases were included if their mode of separation from ED indicated admission to an in‐patient unit including critical care ward and their ED length of stay was greater than or equal to 24 h. Cases were categorised by service‐related groups based on principle diagnosis. Results: A total of 26 854 eligible cases were identified. The most common diagnosis groups were psychiatry, cardiology and respiratory. The odds ratio (OR) for 30‐day all‐cause mortality in admitted patients with an ED length of stay greater than 24 h were highest in those aged >75 years (OR 15.18, 95% confidence interval [CI] 9.99–23.07, P < 0.001), oncology (OR 10.45, 95% CI 7.93–13.77, P < 0.001) and haematology patients (OR 2.95, 95% CI 2.01–4.33, P < 0.001). Conclusion: Interventions and models of care to address ED access block need to focus on mental health patients, older patients particularly those with cardiorespiratory illness and oncology and haematology patients for whom risk of mortality is disproportionately higher. [ABSTRACT FROM AUTHOR]

Objective: To assess whether the introduction of point‐of‐care rotational thromboelastometry (ROTEM) analysis influences blood product transfusion and coagulation management in a modern Australian level 1 trauma centre. Methods: Retrospective blood transfusion data collection from all level 1 trauma patients with an Injury Severity Score (ISS) >12 presenting to the Royal Adelaide Hospital in 2016 and 2018. Evaluation of changes in blood product administration with the addition of point‐of‐care viscoelastic testing in the ED in 2018. Results: A total of 774 patients were analysed with 380 in 2016 and 394 in 2018. Almost a quarter of all 2018 trauma patients (93/394) had ROTEM performed within 24 h of ED arrival, 42% of these having an ISS >25. There was a significant increase in the number of patients receiving cryoprecipitate following the introduction of ROTEM (P = 0.01). In those receiving cryoprecipitate, there was a significant reduction in subsequent platelet and fresh frozen plasma use (P < 0.001). Overall, there was a reduction in expenditure on red cells, platelets and fresh frozen plasma from 2016 to 2018. Conclusion: Point‐of‐care ROTEM was performed in a small proportion of patients, mainly those with a higher ISS. ROTEM introduction in the ED altered blood product transfusion practices for major trauma patients with an ISS >12, leading to a potentially safer transfusion strategy and cost savings for key blood products. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence of fundus pathology in metropolitan Australian EDs utilising a non‐mydriatic fundus photography screening programme. Secondary objectives include diagnostic accuracy among emergency physicians compared to telehealth ophthalmologist review. Methods: Prospective cross‐sectional study investigating non‐mydriatic fundus photography as a new diagnostic test in two tertiary Australian EDs. Consecutive adult patients were enrolled if they presented with headache, focal neurological deficit, visual disturbance or diastolic BP >120 mmHg. Diagnostic agreement was determined using kappa statistics and sensitivity and specificity using a reference standard consensus ophthalmology review. Results: A total of 345 consecutive patients were enrolled among whom 56 (16%, 95% confidence interval [CI] 13–21) had urgent fundus pathology. Agreement between emergency physician and ophthalmic assessment of fundus photographs was 74% (kappa = 0.196, P = 0.001). Emergency physicians had 40% sensitivity (95% CI 27–54) and 82% specificity (95% CI 76–86) for detecting urgent pathology on photographs. Conclusions: Fundus photography detects a clinically significant proportion of fundus pathology and urgent diagnoses. Telehealth specialist image review is important to detect some important, time‐critical illnesses that can be missed in routine care. This offers an accurate alternative to direct ophthalmoscopy that warrants further research in Australian EDs. [ABSTRACT FROM AUTHOR]

Objective: In trauma patients with potential cervical spine injury, immobilisation with a rigid cervical collar is widely recommended to prevent a secondary spinal cord injury. There is a lack of evidence for the effectiveness of this practice, but increasing evidence for complications from rigid collars. Soft foam collars may mitigate some of these issues and are used in our health service in place of rigid collars in selected patients at risk for traumatic cervical spine injury. The objective of the present study was to describe the neurological outcome of patients according to the cervical stabilisation technique used. Methods: A multi‐centre, retrospective, consecutive, case series of all patients assessed for a traumatic cervical spine injury from October 2017 to July 2018 was conducted. Data were obtained by a medical chart review. The primary outcome was the development of a new neurological deficit because of spinal cord injury while in hospital. Results: Inter‐rater reliability of data abstraction demonstrated very strong agreement (kappa 0.85, 95% confidence interval 0.80–0.90). Of 2036 patients, 1133 were managed in a soft collar. A new neurological deficit because of spinal cord injury developed in two patients managed in a rigid collar. One case managed in a soft collar was uncertain because of an incomplete baseline neurological examination. Conclusion: The use of soft foam cervical collars in patients at risk for a cervical spine injury does not appear to increase the risk for secondary spinal cord injury but larger prospective studies are required before a robust conclusion on safety can be claimed. In trauma patients with potential cervical spine injury, immobilisation with a rigid cervical collar is widely recommended to prevent a secondary spinal cord injury, despite a lack of evidence for this practice, but increasing evidence for complications. Soft foam collars may mitigate some of these issues and do not appear to increase the risk for secondary spinal cord injury. Larger prospective studies are required before a robust conclusion on safety can be claimed. [ABSTRACT FROM AUTHOR]

Objective: This research aimed to (i) assess the effects of time‐varying predictors (day of the week, month, year, holiday, temperature) on daily ED presentations and (ii) compare the accuracy of five methods for forecasting ED presentations, including four statistical methods and a machine learning approach. Methods: Predictors of ED presentations were assessed using generalised additive models (GAMs), generalised linear models, multiple linear regression models, seasonal autoregressive integrated moving average models and random forest. The accuracy of short‐term (14 days), mid‐term (30 days) and long‐term (365 days) forecasts were compared using two measures of forecasting error. Results: The data are the numbers of presentations to public hospital EDs in South‐East Queensland, Australia, from 2009 to 2015. ED presentations are largely affected by year of presentation, and to a lesser extent by month, day of the week and holidays. Maximum daily temperature is also a significant predictor of ED presentations. Of the four statistical models considered, the GAM had the greatest forecasting accuracy, and produced consistent and coherent forecasts, likely due to its flexibility in modelling complex time‐varying effects. The random forest machine learning approach had the lowest forecasting accuracy, likely due to overfitting the data. Conclusions: Calendar and temperature variables, not previously considered in the Australian literature, were found to significantly impact ED presentations. This study also demonstrates the potential of GAMs as a dual explanatory and forecasting method for the modelling, and more accurate prediction, of ED presentations. [ABSTRACT FROM AUTHOR]

Objective: To assess whether the initiation of vasopressor infusions via peripheral venous catheters (PVC) compared to central venous catheters (CVC) in ED patients with early septic shock was associated with differences in processes of care and outcomes. Methods: We conducted a post‐hoc analysis of the ARISE trial. We compared participants who had a vasopressor infusion first commenced via a PVC versus a CVC. The primary outcome was 90 day mortality. Results: We studied 937 participants. Of these, 389 (42%) had early vasopressor infusion commenced via a PVC and 548 (58%) via a CVC. Trial participants who received a vasopressor infusion via a PVC were more severely ill, with higher median (interquartile range [IQR]) Acute Physiology And Chronic Health Evaluation (APACHE II) scores (17 [13–23] versus 16 [12–21], P = 0.003), and higher median (IQR) lactate (mmol/L) (3.6 [1.9–5.8] versus 2.5 [1.5–4.5], P < 0.001). After adjusting for baseline covariates, the estimated odds ratio for mortality for PVC‐treated patients was 1.26 (95% confidence interval 0.95–1.67, P = 0.11). Trial participants who had vasopressors commenced via PVC had a shorter median (IQR) time to commencement of antimicrobials (55 [32–96] versus 71.5 [39–119] min, P < 0.001) and a shorter median (IQR) time to commencement of vasopressors (2.4 [1.3–3.9] versus 4.9 [3.5–6.6] h, P < 0.001). Conclusion: The practice of commencing a vasopressor infusion via a PVC was common in the ARISE trial and more frequent in trial participants with higher severity of illness. Commencement of a vasopressor infusion via a PVC was associated with some improvements in processes of care and, after adjustment, was not associated with an increased risk of death. [ABSTRACT FROM AUTHOR]

Objective: To describe and compare characteristics and outcomes of patient presentations brought in by police (BIBP) with those not BIBP (NBIBP) to one Australian ED. Methods: A retrospective observational study. All patient presentations to a tertiary hospital ED made during the period 8 October 2012 to 7 April 2013 were included. Routinely collected ED information data and medical record review data were used. ED care delivery for people BIBP from the watch house (WH) or other location was compared. Univariate comparison and multivariate logistic regression analyses were performed to identify the different characteristics and ED outcomes between BIBP and NBIBP groups. Results: A total of 35 127 ED presentations occurred within the 6 month period; 392 (1.1%) were BIBP. Compared with those NBIBP, those BIBP were diagnosed with 'psychiatric' and 'toxicology‐related' illnesses in higher proportions. Overlap in health conditions (primarily for physical health reasons) between those BIBP and NBIBP existed. Presentations BIBP from the WH reflected 'physical health emergencies' whereas presentations BIBP from other locations reflected 'behavioural emergencies'. Compared to those NBIBP, those BIBP had a longer wait to be seen (by about 5 min), longer ED length of stay (LOS) if not admitted (by about 20 min) but shorter ED LOS if admitted (by about 59 min). When adjusted for sex, age group and diagnosis, ED LOS (if admitted) and admission rate were statistically significant. For those BIBP, mental health related orders and alcohol breath tests were common. Conclusions: Patients BIBP were different to those NBIBP. Despite comprising a small proportion of overall ED attendances, they are a group where mental health and drug and alcohol issues are over‐represented. Differences in ED care delivery for those BIBP highlights potential opportunities for pre‐hospital healthcare interventions. [ABSTRACT FROM AUTHOR]

Objective To identify risk factors for thunderstorm asthma (TA) in subjects ≥15 years of age from information available in routine clinical records. Methods: Retrospective and hospital‐based case–control study of various clinical factors in all TA cases (n = 53) who presented to a single‐site ED in November 2016 (TA16) and in a control group of patients (n = 156) who presented to the same ED with asthma during the pollen season over eight non‐TA years. Bivariate analysis and multivariable logistic regression modelling was performed to calculate the odds of TA asthma in the presence of potential risk factors. Results: A logistic regression model revealed that the odds of TA were lower for age (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.95–0.99), higher for Asian country of birth (OR 4.09, 95% CI 1.40–11.95) and higher for oral beta‐blocker use (OR 6.43, 95% CI 1.58–26.33) compared to controls. No difference was found between TA16 cases and controls for allergies (to medication, grass pollen, animal), hayfever, smoking, oral non‐steroidal anti‐inflammatory drugs, or aspirin. Newly diagnosed asthma was higher in TA16 cases versus controls (32.1% vs 12.2%, P = 0.001). Conclusions: Oral beta‐blocker medications, younger age and Asian‐born heritage are risk factors for TA. Further study is required to explore the potential association between beta‐blockers and TA. [ABSTRACT FROM AUTHOR]

Objectives: To assess the association between ED occupancy and relevant outcomes including ED waiting times, rates of admission and representation and length of stay when hospitalised. Methods: Retrospective study of all ED presentations by New South Wales (NSW), Australia, residents to 15 NSW public, principal referral or paediatric specialist hospitals between 1 January to 31 December 2015 (N = 935 282). ED data were linked longitudinally (to ED data) and cross‐sectionally to hospital admissions data. An ED‐system measure of occupancy was assigned to each ED record. The study outcomes were ED waiting time, admission to hospital, 28 day representation, and length of stay (LOS) when admitted. Outcomes were analysed using univariate analyses and multivariable general linear and binary logistic regression models. Results: Increased ED occupancy was associated with increased ED waiting times, particularly at low‐baseline occupancy (e.g. rate ratio = 2.22, 95% confidence interval [CI] [2.10–2.35], for non‐urgent triaged patients). However, results were conditional on triage category, such that estimated effects were smaller or not significant in emergency and resuscitation triaged patients (e.g. rate ratio = 1.59, 95% CI [1.52–1.65], for emergency patients). ED occupancy only showed small or no associations with admission to hospital, 28 day representation and LOS when admitted. Conclusions: Higher ED occupancy was associated with increased waiting times conditional on triage category and baseline occupancy. Collectively, the results show that NSW principal referral EDs are robust, and are currently capable of handling variation in occupancy by prioritising treatment for the most urgent patients. [ABSTRACT FROM AUTHOR]

Objective The majority of ureteric calculi pass spontaneously and are uncomplicated, yet use of computed tomography urography (CTU) has increased in recent years. This study describes a cohort of ED patients undergoing CTU for renal colic and assesses the predictors of urologic intervention. Methods A retrospective cohort study enrolled patients who underwent CTU at three Melbourne EDs. Demographic data, clinical assessments, laboratory and radiological findings and interventions were abstracted. Univariate analysis was performed and significant predictors were entered into a multivariate logistic regression model to calculate adjusted odds ratios for associations with urologic intervention. Results Six hundred and seventeen patients underwent 626 CTUs; mean age was 48 and 67.7% were male. 58.2% of scans found calculi, of which median size was 4 mm. 9.2% of scans revealed an alternate diagnosis, of which 2.7% were acutely important. 14.6% of patients with calculi received an intervention. Multivariate analysis found the factors associated with intervention were female sex (OR 3.9, 95% CI 1.8-8.7), proximal calculus site (OR 4.1, 95% CI 1.5-11.7), single kidney (OR 9.0, 95% CI 1.7-49.0) and calculus size > 5 mm (OR 7.0, 95% CI 3.3-14.7). Conclusion Factors associated with urologic intervention included female sex, single kidney, calculus size >5 mm and proximal calculus. Information on acute alternate diagnoses was uncommon. A prospective study is needed to further clarify clinical parameters that could predict intervention to allow targeting of CTU to those most likely to benefit. [ABSTRACT FROM AUTHOR]

Background A regional epidemiological analysis of Australasian disasters in the 20th century to present was undertaken to examine trends in disaster epidemiology; to characterise the impacts on civil society through disaster policy, practice and legislation; and to consider future potential limitations in national disaster resilience. Methods A surveillance definition of disaster was developed conforming to the Centre for Research on the Epidemiology of Disasters (CRED) criteria (≥10 deaths, ≥100 affected, or declaration of state emergency or appeal for international assistance). The authors then applied economic and legislative inclusion criteria to identify additional disasters of national significance. Results The surveillance definition yielded 165 disasters in the period, from which 65 emerged as disasters of national significance. There were 38 natural disasters, 22 technological disasters, three offshore terrorist attacks and two domestic mass shootings. Geographic analysis revealed that states with major population centres experienced the vast majority of disasters of national significance. Timeline analysis revealed an increasing incidence of disasters since the 1980s, which peaked in the period 2005-2009. Recent seasonal bushfires and floods have incurred the highest death toll and economic losses in Australasian history. Reactive hazard-specific legislation emerged after all terrorist acts and after most disasters of national significance. Conclusion Timeline analysis reveals an increasing incidence in natural disasters over the past 15 years, with the most lethal and costly disasters occurring in the past 3 years. Vulnerability to disaster in Australasia appears to be increasing. Reactive legislation is a recurrent feature of Australasian disaster response that suggests legislative shortsightedness and a need for comprehensive all-hazards model legislation in the future. [ABSTRACT FROM AUTHOR]

Objective The study aims to determine if trained scribes in an Australian ED can assist emergency physicians ( EPs) to work with increased productivity. Methods This was a pilot, prospective, observational study conducted at a private ED in Melbourne. A scribe is a trained assistant who works with an EP and performs non-clinical tasks that reduce the time spent providing clinical care for patients. Shifts with and without a scribe were compared. The primary outcomes were patients per hour per doctor and billings per patient. Additional analyses included total patient time in ED; individual doctor productivity; time to see a doctor; time on ambulance bypass; and complaints/issues identified with scribes. Results There was an overall increase in doctor consultations per hour of 0.32 patients (95% confidence interval ( CI) 0.17, 0.47). This varied between doctors from an increase in patients per hour of 0.16 (95% CI −0.09, 0.40) to 0.65 (95% CI 0.41, 0.89). Billings per patient were increased (AUD15.24; 95% CI −AUD18.51, AUD48.99), but the increase was not statistically significant; time to see a doctor reduced by 22 min (95% CI 11, 33); bypass episodes reduced by 66 min per shift (95% CI 11, 122), total patient ED stay remained constant. Conclusions In this pilot study, scribe usage was feasible, and overall improvements in consultations per hour were seen. Overall income improved by AUD104.86 (95% CI AUD38.52, AUD171.21) per scribed hour. Further study is recommended to determine if results are sustained or improved over a longer period. [ABSTRACT FROM AUTHOR]

Objective Children admitted to hospital commonly require peripheral intravenous catheters ( PIVCs) for treatment. This study sought to address a gap in the literature about current practice in the securement and dressing of PIVCs in paediatric acute care, and to ascertain the duration and failure of these devices. Methods A prospective cohort study conducted at the Royal Children's Hospital in Queensland, Australia. All patients aged 0-15 years, who presented to the ED between 16 July and 16 October 2012, and had a PIVC inserted prior to emergent admission to the hospital were included. Results Of 458 participants, median device duration was 29 h ( IQR 13-58 h), and ranged from less than 1 h to 16 days. One quarter (113/456, 24.8%) of PIVCs were removed due to device failure, presenting as: infiltration (65/456, 14.3%); accidental dislodgement (23/456, 5.0%); blockage (12/456, 2.6%); phlebitis (7/456, 1.5%); or 'other' (6/456, 1.3%). PIVC securement and dressings were predominantly bordered polyurethane dressings and splints ( n = 457/458, 99.8%). PIVC placement in the antecubital fossa, in comparison to the hand, was significantly associated with an increased risk for failure ( P = 0.03). No other patient and device characteristics had a significant association with device failure ( P > 0.05). The median dwell time of PIVCs that failed was significantly longer than the PIVCs that did not fail (44.0 vs 25.5 h; P = 0.002). Less than half (53/113, 46.9%) of failed catheters were replaced with a new PIVC. Conclusions Observed failure rates were high for a clinically essential device; however, there is no established rate of acceptability against which the results can be benchmarked against to facilitate effectiveness of practice. Many PIVCs appeared to remain in place longer than needed. Dressing and securement practice was homogenous. PIVC placement in the antecubital fossa should be minimised to reduce the risk of paediatric PIVC failure. [ABSTRACT FROM AUTHOR]

Objective To determine trainee perspectives of the utility of a trainee research project ( TRP) or the coursework pathway ( CP) in completing the Trainee Research Requirement of the ACEM. Methods A survey based on the ACEM learning objectives for research was sent to all trainees and Fellows who had completed or intending to complete the Trainee Research Requirement between 2010 and 2012. Participants were asked to rate the value of the TRP or CP on a scale of 1 to 10 (1 = 'not useful' and 10 = 'invaluable'). In addition, open-ended questions were asked for qualitative assessment. Results Survey response was 142/621 (23%). Most participants had undertaken the CP (113/142, 79%). Median scores were better for the CP compared with the TRP, and when results were dichotomised to scores of 1-5 as being not useful and 6-10 as being useful, a significantly higher proportion of participants rated the CP as being useful across all learning objectives ( P ≤ 0.01). There was a bimodal distribution of scores for TRPs, with a minority of trainees reporting a very poor TRP experience. Cost was the most commonly cited negative aspect of the CP, whereas the TRP was perceived as time consuming and being difficult to attain. Conclusions More ACEM trainees are undertaking the CP compared with a TRP. The CP was associated with better self-reported fulfilment of the ACEM learning objectives for research. There is scope for the ACEM to improve the experience of trainees wishing to undertake their own research projects. [ABSTRACT FROM AUTHOR]

Objective The present study aims to study whether using a videolaryngoscope ( A.P. Advance™) facilitates or hinders intubation by non-anaesthetists inexperienced in its use. Methods Thirty doctors from Emergency and Intensive Care Medicine backgrounds performed laryngoscopy and tracheal intubation using the Macintosh laryngoscope ( MAC), A.P. Advance™ Normal Blade ( AP N) and A.P. Advance™ Difficult Airway Blade ( AP DAB) in simulated normal and difficult airway manikins. The primary outcomes measured were time to successful tracheal intubation and failure to intubate within 3 min or three attempts. Secondary outcomes were number of intubation attempts, adjuncts used, glottic view and ease of intubation. Results There was a higher rate of failed intubation in the simulated difficult airway in participants using the AP N blade than either the MAC or AP DAB (23% vs 3% and 7%, P = 0.031). This was associated with a longer median time to intubate with the AP N and the AP DAB versus MAC (56.6, 50.2 vs 39.9 s, P = 0.007 and P = 0.041). In the normal airway median time to intubate was longest with the AP N (27.8 s), and this was significantly slower than the MAC (18.1 s, P = 0.003) and the AP DAB (17.3 s, P < 0.001). No one failed to intubate the normal manikin. Conclusions The use of the A.P. Advance™ videolaryngoscope should not be considered, without adequate prior training and experience, in the management of a difficult airway. The level of adequate training has yet to be established. [ABSTRACT FROM AUTHOR]

Objective: The present study aims to quantify the sensitivity and specificity of three-point compression ultrasonography for diagnosing proximal lower extremity deep venous thrombosis when performed by Australian consultant emergency physicians with limited specific training. Secondary aims included quantifying rapidity, technical adequacy, predictability of equivocal results and relationships between emergency physician experience and proficiency. Methods: This prospective diagnostic study enrolled a convenience sample of adult patients presenting to a major ED with suspected lower extremity deep venous thrombosis. The index test was abbreviated compression ultrasonography examining three points: common femoral, proximal great saphenous and popliteal veins. Emergency physicians received specific training. The reference test was full-leg duplex ultrasonography in the Radiology Department. Results: A total of 15 emergency physicians participated, enrolling 178 subjects. Sensitivity of the index test was 77.8% (95% confidence interval: 54.8-91.0%), specificity was 91.4% (95% confidence interval: 84.9%-95.3%) and accuracy was 89.6% (95% confidence interval: 83.1-94.2%). Median duration of the index test was 10 min 34 s (interquartile range: 6 min 31 s) and ED diagnosis occurred significantly before Radiology Department diagnosis. The only statistically significant relationship between emergency physician experience and proficiency related to rapidity, which increased from the 36th scan. Equivocal index tests occurred in 9.2% of examinations and emergency physicians predicted equivocal assessments with specificity of 86.1% (95% confidence interval: 78.8-91.1%). Conclusions: Abbreviated ultrasonography performed by emergency physicians for proximal lower extremity deep venous thrombosis could be valuable. However, more precise estimates for sensitivity and greater understanding of relationships between emergency physician experience and proficiency are required. [ABSTRACT FROM AUTHOR]

Objective The study aimed to determine factors related to ICU mortality in critically ill patients transferred by Adult Retrieval Victoria ( ARV) medical staff. Patients who died in ICU after interhospital transfer were compared against those who survived. Methods This was a retrospective cohort study of ARV cases between 1 January 2009 and 30 June 2010. Retrieval data were linked with data from the ANZICS CORE APD ( Australia and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database). Victoria Data Linkage ( VDL) performed linkage of data. Data included demographic and clinical data obtained during transfer and clinical data recorded in ICU. Results Of the 601 cases transferred by ARV during the study period, 549 cases were eligible for linkage to 25 543 ANZICS APD case records for the same period. VDL matched 460 of these cases (83.8%). Mortality rate in the matched sample was 13.9%. Variables associated with mortality were: advanced age (odds ratios [ OR] 1.02, 95% confidence interval [ CI] 1.00-1.04, P = 0.02), principal referral problem cardiac ( OR 1.84, 95% CI 1.02-3.32, P = 0.04), lower mean arterial blood pressure ( OR 0.97, 95% CI 0.95-0.99, P = 0.005) and tachycardia ( OR 1.02, 95% CI 1.00-1.03, P = 0.008) on arrival at destination hospital. Conclusions Advanced age, lower mean arterial blood pressure and tachycardia towards the completion of transfer were associated with increased ICU mortality in this population. Clinicians should be aware of the additional risk for cardiac patients. [ABSTRACT FROM AUTHOR]

Objective The present study aims to describe early ED representation rates and identify the causes for this commonly seen problem. Methods This was a retrospective chart review of all patients that represented within 72 h of discharge from a tertiary level ED in Sydney, Australia, over a 2 month period between 1 May 2010 and 30 June 2010. Presentations were categorised according to their diagnosis and cause for representation. Each representation was then classified as being avoidable or unavoidable. Results There were 10 141 presentations to the ED during the study period, with 497 patients (4.9%, 95% confidence interval [ CI] 4.5-5.3) representing within 72 h of discharge. Disease-related causes of representation were seen in 55.1% (95% CI 50.7-59.5), with 39% (95% CI 34.8-43.4) of these caused by disease progression and 12.3% (95% CI 9.6-15.5) for scheduled review. Patient-related causes were seen in 32.2% (95% CI 28.2-36.4) of representations with 20.9% (95% CI 17.6-24.7) of these for patients who did not wait or left against medical advice. Physician-related causes were seen in 3.2% (95% CI 2.0-5.2) of representations. Furthermore, 23.7% (95% CI 20.2-27.7) of patients who represented to the ED required hospital admission. A total of 37.0% (95% CI 32.9-41.4) of representations were assessed as being preventable. Conclusion Early ED representations are a common problem. The majority of preventable representations are patient related, and interventions to target these areas might be of benefit in reducing this problem. [ABSTRACT FROM AUTHOR]

Objective To estimate the ability of commonly measured laboratory variables to predict imminent (within the same or next calendar day) medical emergency team ( MET) calls, ICU admission or death. Methods We performed a retrospective observational study of ED patients. We estimated the ability of each laboratory variable or combination of variables together with patient age to predict imminent MET calls, ICU admission or death. We externally validated our findings in patients from a different hospital. Results We studied 160 341 batches in 71 453 ED patients (average age: 59.9 ± 22.1 years) for a total of 1 million individual measurements. There were 341 MET calls, 160 ICU admissions from the wards and 858 deaths. Multivariable modelling achieved a receiver operating characteristic area under the curve (ROC-AUC) of 0.69 (95% CI 0.63-0.74) for imminent MET call with prediction occurring a mean of 11.9 h before the call. Additionally, it achieved a ROC-AUC of 0.82 (95% CI 0.73-0.87) for imminent ICU admission. Finally, it achieved a ROC-AUC of 0.90 (95% CI 0.87-0.91) for imminent death. When tested using an additional 37 367 batches from a cohort of 21 430 ED patients from a second teaching hospital, the multivariate model achieved a ROC-AUC of 0.70 (95% CI 0.66-0.73) for imminent MET call, a ROC-AUC of 0.84 (95% CI 0.78-0.90) for imminent ICU admission. Finally, it achieved a ROC-AUC of 0.89 (95% CI 0.86-0.91) for imminent death. Conclusions Commonly performed laboratory tests can help predict imminent MET calls, ICU admission or death in ED patients. Prospective investigations of the clinical utility of such predictions appear desirable. [ABSTRACT FROM AUTHOR]

Objectives The National Pain Management Initiative was established by the National Institute of Clinical Studies to improve analgesic practice across Australian EDs. Methods A barrier analysis provided information to better implement changes in analgesic practice. A working party was established and developed a multifaceted intervention strategy and clinical indicators. An online data collection system was developed and sites collected data at three monthly intervals for 18 months. A stepped-wedge design was chosen to manage the number of hospitals involved. Clinical indicators included documentation of pain score, time to analgesia, appropriate use of parenteral narcotics and effectiveness of analgesia for severe pain. Results A total of 16 627 patient datasets were entered from 45 metropolitan and regional hospitals. There was an increase from 41% to 64% in documented pain score (difference in proportions 23%, 95% confidence interval: 20-26) and median time to analgesia fell from 61 min (interquartile range: 23-122) to 41 min (interquartile range: 15-95). Appropriate parenteral narcotic use was over 90% for all time points combined. For all patients with severe pain there was no significant change in the proportion with a documented reduction of pain within 1 h of presentation. Conclusion Significant improvements in documentation of pain score and time to analgesia were demonstrated through a national project of targeted improvement. Parenteral narcotic use has a high level of adherence to recommended practice. An improvement in the effectiveness of analgesia in severe pain has not been clearly demonstrated in this study. [ABSTRACT FROM AUTHOR]

Objectives To describe perceptions of medical students and emergency doctors towards careers in emergency medicine ( EM), and to identify influences on career choice. Methods A prospective, cross-sectional questionnaire study was performed in three EDs. The instrument used Likert-type items addressing: factors important in the choice of a career, factors offered by a career in EM, and opinions of EM. EM consultants and registrars and a cohort of final-year medical students participated. Results Overall, 22 consultants, 30 registrars and 164 students completed the questionnaire (77.1% overall response). Student interest in an EM career increased from 10/161 (6.2% [95% CI 3.0-11.1%]) before, to 26/137 (19.0% [95% CI 12.8-26.6%]) after an EM attachment ( P = 0.0014). The highest proportion of students chose work-life balance as being an important factor for career choice (143/163 students, 87.7% [95% CI 81.2-92.6%]). Compared with consultants and registrars, students had negative perceptions about lifestyle factors that EM offered, as well as about the future of the specialty, job security and workplace stress. Some students also preferred careers with opportunities for research, subspecialty practice, and better pay and conditions, yet perceived EM as not offering these factors. Students considered EM as an acute, procedural, public hospital specialty, with diverse patient problems and minimal continuity of care. Smaller proportions of students considered these factors important for career choice. Conclusion Increasing the attractiveness of a career in EM requires changing student perceptions of lifestyle and satisfaction benefits, access to EM subspecialties, increasing ED research, information about job security, and improved work conditions. [ABSTRACT FROM AUTHOR]

Objective: The ED is emerging as a priority for efforts to improve rates of organ and tissue donation (OTD) in Australia, but little is known of ED clinicians' attitudes, education or practices in the area. We aimed to determine the attitudes and OTD-related educational background and practices of Australian ED clinicians. Methods: This was a national cross-sectional survey of members of the Australasian College for Emergency Medicine (ACEM) and the College of Emergency Nursing Australasia (CENA); online questionnaire of 133 items, graded responses using Likert and ordinal multi-category scales, plus open-ended qualitative questions. Results: Of 2969 ACEM members, 599 (20.2%) responded; of 1026 CENA members, 212 (20.7%) responded. Respondents were broadly representative of the membership, with male trainee specialists underrepresented. Most ED staff supported OTD, although many were not certain that facilitating OTD was their role, or that the ED was the right place to identify donors. Around a quarter of medical and nursing staff had received no education regarding OTD. Having received education was related to professional status, cultural background, place of work and years of experience, and was significantly associated with attitude towards OTD and whether staff participated in OTD-related tasks. Conclusions: More education on OTD is needed and requested by ED clinicians in Australia, particularly on OTD after cardiac death, management of a donor, brain death and obtaining consent. Postgraduate curricula should reflect this need for more OTD-related education in emergency medicine and nursing. [ABSTRACT FROM AUTHOR]

Objective: The role of neuroimaging in children presenting with new-onset seizure is poorly defined. This study evaluates the incidence of abnormal CT findings in children admitted to the paediatric intensive care unit (PICU) with new-onset seizure and examines potential clinical variables associated with abnormal head CT findings. Methods: A retrospective analysis of 89 previously asymptomatic children admitted to Sydney Children's Hospital (Sydney, Australia) PICU between November 2005 and September 2009 with new-onset seizure was undertaken. Demographic data, clinical details and head CT findings were abstracted from medical records. The clinical significance and the impact of CT findings on acute management decisions was analysed. Clinical variables associated with abnormal clinically significant CT results were examined. Results: A total of 71/89 patients underwent head CT. Of the children who underwent head CT ( n= 71), clinically significant CT results were found in 19.7% of patients and head CT findings resulted in a change in acute management in 7% of patients. Children without fever were more than twice as likely to have a positive CT scan ( P= 0.049); however, a substantial proportion (6/45) of febrile children also had abnormal scans. Focal seizures were not predictive of abnormal CT results. There was a significant relationship between abnormal CT and multiple seizures ( P < 0.02), and age less than 24 months ( P < 0.049). Conclusion: In this highly selected group head CT findings are frequently abnormal and might change acute management. Children admitted to the PICU with first presentation of seizure who have multiple seizures and/or are aged <2 years should have immediate CT or MRI scanning. [ABSTRACT FROM AUTHOR]

Objective: Prosthetic hip dislocation is common. This study compares prosthetic hip relocations attempted within the ED by emergency doctors and those under orthopaedic care in the ED or operating theatre (OT). Methods: Retrospective cohort study of patients presenting to Auckland City Hospital Adult Emergency Department with prosthetic hip dislocations between 1 January 2003 and 14 April 2008. Primary outcomes were proportion of successful relocation attempts and length of hospital stay. Secondary outcomes were: time to relocation, complications, post-procedural advice, representation rate and long-term outcomes for first-time dislocations. There were 410 eligible presentations during the study period. Results: Emergency medicine (EM) was successful in 254/323 attempts (79%, 95% confidence interval [CI] 74-83). Orthopaedics were successful in 25/35 reductions in the ED (71%, 95% CI 55-84) and 49/51 OT attempts (96%, 95% CI 86-100), P = 0.004 for location OT versus ED. Median times to discharge were 8.8 h for EM, 28.3 h for orthopaedics in the ED and 81 h for orthopaedics in the OT, P < 0.001 for EM versus orthopaedics. Mechanical complications of procedures and early redislocations were infrequent. Complication of sedation were more often seen in OT compared to ED (23/47 [49%, 95% CI 35-63] vs 37/318 [12%, 95% CI 9-16]). Conclusion: There was no difference between EM and orthopaedics in the proportion of hips successfully relocated or complications in the ED; however, EM patients were discharged much sooner, with important resource implications. Procedures carried out in the OT were more successful than in the ED but resulted in prolonged hospital stays and were associated with more complications. [ABSTRACT FROM AUTHOR]

Objective: To determine which of the disaster triage tag systems in use in Australia and New Zealand is better in terms of the time taken to complete the triage and the ease of use. Methods: A disaster scenario was created. Mock patients were provided with clinical information to allow them to be triaged in a disaster sieve. Six different triage tag systems available in Australia and New Zealand were trialled. Participants triaged 10 patients with each triage tag system. The 10 patients used were different for each of the tag systems and were standardized for acuity and triage category. The time to complete the triage of the 10 patients with each different tag system was measured. The participants then completed a questionnaire with regards to the ease of use of the different tags and were asked to nominate their most preferred tag. Results: The Victorian cruciate fold up tag was the quickest to complete, with an average of 6.6 min to triage 10 patients, compared with an average time for all systems of 7.8 min. New Zealand tags were found to be the easiest to use, easiest to fill in and were considered the most preferred tag. Conclusion: The Victorian style of tag was found to be the most efficient in terms of the time to complete a triage. The New Zealand tags were the easiest to use, easiest to fill in and the most preferred tag by the participants. We recommend that one of these tags be adapted for use as a nationwide system. [ABSTRACT FROM AUTHOR]

Objective: Hospital EDs are a significant and high-profile component of Australia's health-care system, which in recent years have experienced considerable crowding. This crowding is caused by the combination of increasing demand, throughput and output factors. The aim of the present article is to clarify trends in the use of public ED services across Australia with a view to providing an evidence basis for future policy analysis and discussion. Methods: The data for the present article have been extracted, compiled and analysed from publicly available sources for a 10 year period between 2000-2001 and 2009-2010. Results: Demand for public ED care increased by 37% over the decade, an average annual increase of 1.8% in the utilization rate per 1000 persons. There were significant differences in utilization rates and in trends in growth among states and territories that do not easily relate to general population trends alone. Conclusions: This growth in demand exceeds general population growth, and the variability between states both in utilization rates and overall trends defies immediate explanation. The growth in demand for ED services is a partial contributor to the crowding being experienced in EDs across Australia. There is a need for more detailed study, including qualitative analysis of patient motivations in order to identify the factors driving this growth in demand. [ABSTRACT FROM AUTHOR]

Objective: This retrospective, observational cohort study investigated whether the clinical features of a patient's pain, including anatomical location, organ system and likely treating speciality, impact on the delivery of analgesia within 30 min in EDs. Methods: Data were obtained from 24 centres across Australia between April 2008 and March 2009. Principal outcome was delivery of analgesia within 30 min or less. Factors that might explain any differences were analysed, including anatomical location of the pain, likely treating speciality, organ system affected, age, sex, day and time of presentation, hospital location, documented pain score and triage category. Analysis was by the χ2-test for independence of proportions and multiple logistic regression. A P-value <0.05 was considered statistically significant. Results: There were 4598 patients, of whom 2578 were male. The median age was 36 years (range 0-103). Both limb origin of pain (χ2= 46.1, P < 0.001) and documentation of a pain score (χ2= 48.6, P < 0.001) were strongly associated with delivery of analgesia within 30 min. Attending a rural ED was a significant risk factor for delayed analgesia (χ2= 12.5, P < 0.001). Burns patients (40.2%, 47 of 117, P < 0.001) and orthopaedic patients (26.1%, 259 of 992, P < 0.001) were much more likely to received analgesia within 30 min than the mean (19.5%, 896 of 4598). Conclusions: Patients presenting with burns, orthopaedic conditions or with a limb location of pain are more likely to receive analgesia within 30 min in Australian EDs. Clinicians should be aware of possible trends in the delivery of timely analgesia to patients with pain. [ABSTRACT FROM AUTHOR]

Objective: To identify any significant differences in the population of patients brought in to a hospital ED under involuntary mental health orders, based on whether the orders are initiated by police or health professionals. Methods: A retrospective analysis of consecutive presentations to a tertiary hospital ED with a co-located psychiatric emergency care centre over a 12 month period, with univariate and multivariate statistical comparisons. Results: Two hundred and eighty-two patients (making 378 ED presentations) met the case definition and were analysed. Compared with patients on medical orders, patients on police orders had significantly more presentations related to violence, longer stays in ED and lower rates of admission to an inpatient bed, but were no more likely to require restraint or security intervention within the ED. Conclusions: Patients on police and medical orders differ considerably, but the impact of these differences on ED workload is small. [ABSTRACT FROM AUTHOR]

Objective: To determine the nature, incidence and risk factors for sedation-related events during ED procedural sedation, with particular focus on the drugs administered. Methods: Eleven Australian EDs enrolled consecutive adult and paediatric patients between January 2006 and December 2008. Patients were included if a sedative drug was administered for an ED procedure. Data collection was prospective and employed a specifically designed form. Multivariate logistic regression was employed to determine risk factors for sedation-related events. Results: Two thousand, six hundred and twenty-three patients were enrolled (60.3% male, mean age 39.2 years). Reductions of fracture/dislocations of shoulders, wrists and ankles were most common. Four hundred and sixty-one (17.6%) cases experienced at least one airway event that required intervention. Airway obstruction, hypoventilation and desaturation occurred in 12.7%, 6.4% and 3.7% of all patients, respectively. Two thousand, one hundred and forty-six cases had complete datasets for further analyses. Increasing age and level of sedation, pre-medication with fentanyl, and sedation with propofol, midazolam or fentanyl were risk factors for an airway event ( P < 0.05). Ketamine was a protective factor. Hypotension (systolic pressure <80 mmHg) occurred in 34 (1.6%) cases with midazolam being a significant risk factor ( P < 0.001). Vomiting also occurred in 34 (1.6%) cases, 12 of whom required an intervention. One patient aspirated. Vomiting occurred after administration of all drugs but was not associated with fasting status. Other events were rare. Conclusions: Sedation-related events, especially airway events, are common but very rarely have an adverse outcome. Elderly patients, deeply sedated with short-acting agents, are at particular risk. The results will help tailor sedation to individual patients. [ABSTRACT FROM AUTHOR]

Objective: To determine factors associated with failure to successfully complete a procedure during sedation in the ED. Methods: Eleven Australian EDs enrolled consecutive adult and paediatric patients between January 2006 and December 2008. Patients were included if a sedative drug was administered for an ED procedure and the success or failure of the procedure was recorded. Results: Data were available for 2567 patients. Of these, 1548 (60.3%, 95% CI 58.4-62.2) were male and 456 (17.8%, 95% CI 16.3-19.3) were age <16 years. The most common procedures performed were reduction of major joints and laceration repair. A total of 149 procedures (5.8%, 95% CI 5.0-6.8) failed. There were significant differences in failure rates between the types of procedure undertaken, with reduction of hips, digits and mandibles associated with the highest failure rates ( P < 0.001). In adults, body weight >100 kg was also associated with increased risk of procedural failure (odds ratio 2.3, 95% CI 1.3-4.1). Ketamine used as a single agent had the lowest procedural failure rate (2.5%, 95% CI 1.1-5.4) whereas propofol had the highest (5.9%, 95% CI 4.6-7.6). However, these two drugs were generally used in different age groups and for different procedures. Conclusions: Procedures performed under sedation in the ED have a low failure rate. However, increased body weight and specific procedures, such as hip reduction, are associated with significantly higher failure rates. Special consideration should be given to these patient groups before undertaking sedation in the ED. [ABSTRACT FROM AUTHOR]

Intranasal fentanyl's (INF) effectiveness is established using highly concentrated INF (HINF). Standard concentration INF (SINF) is more widely available. We aimed to illustrate the equivalence of SINF to HINF. Double-blinded randomized controlled trial was used within a children's hospital ED. Children aged 3-15 years with fractures were randomized to SINF or HINF. Outcome measures included pain scores at time zero and every 10 min until 30 min. Additional analgesic agents were noted. Data in 189 children (91 HINF, 98 SINF) were obtained. Pre-analgesia median VAS was 80.0 mm (interquartile range [IQR] 60.0-95.5) in SINF, 77.5 mm (IQR 60.0-100) in HINF. At 10 min median VAS was 49.5 mm (IQR 26.5-68.5) and 43.0 mm (IQR 15.2-66.0), respectively, at 20 min 27.5 mm (IQR 18.5-56.5) and 35.0 mm (IQR 9.0-57.0) and at 30 min 20.0 mm (IQR 10.0-46.0) and 21.5 mm (IQR 4.75-51.0). Each agent demonstrated significant decrease in pain scores (median decrease 40 mm, P = 0.000). Additional analgesia was given in 67 (42 SINF, 25 HINF) ( P = 0.028). The decrease in pain scores between children < and ≥50 kg in SINF was significant both overall ( P = 0.005) and between 10 and 20 min ( P = 0.003). There was no difference in HINF at any time by weight. The two concentrations of INF were equivalent in reducing pain, with a trend to increased oral additional agents in the more dilute solution. The widespread use of this readily available analgesic in the standard concentration can be supported, particularly in patients <50 kg. [ABSTRACT FROM AUTHOR]

Objective: To determine if screening for undiagnosed type 2 diabetes mellitus (T2DM) and pre-diabetes is feasible in an Australian ED; to estimate the prevalence of T2DM and pre-diabetes in the Australian ED population. Methods: Prospective cross-sectional prevalence survey in the ED of St Vincent's Hospital, Melbourne, an adult, tertiary referral centre seeing approximately 40 000 patients annually. A convenience sample of adult patients was screened with finger-prick random blood glucose and glycosylated haemoglobin (HbA1c); those over 6.0 mmol/L and 6.0% were referred for oral glucose tolerance test (OGTT). Diagnoses of T2DM and pre-diabetes were made according to World Health Organization definitions. Those not attending for OGTT were contacted by phone, and interviewed about their reasons. Results: Seven hundred and twenty-five patients were recruited; 135 (18.6%; 95% confidence intervals [CI] 15.9-21.6%) had known T2DM, leaving 590 screened, of whom 210 screened positive. Of the 192 referred for OGTT, 147 (77%) did not attend despite several telephone reminders. Of the 45 (23%) completing OGTT, pre-diabetes was present in eight (17.8%; 95% CI 9.0-31.6%) and T2DM in six (13.3%; 95% CI 5.9-26.6%). Many people interviewed (18/86, 21%) did not attend for OGTT on the advice of their doctors. Conclusions: This inner city tertiary ED has a high prevalence of T2DM, diagnosed and undiagnosed, with as much as half our population possibly affected. Although ED screening might have a high yield, opportunistic screening is not feasible, with difficulties in staff engagement and patient follow up for diagnostic testing. Future studies might consider finger-prick fasting blood glucose through a patient's general practitioner for diagnosis. [ABSTRACT FROM AUTHOR]

Objective: To determine the current availability, uses and credentialing processes of emergency clinician performed ultrasound (EDUS) in Australian ED. Methods: Cross-sectional survey of Australian ED that are accredited for advanced training. Results: Ninety-four per cent of respondents (67/71, 95% confidence interval [CI] 86–98%) reported availability of EDUS. Availability was similar in both major referral and non-major referral ED. The most common uses for EDUS were focused abdominal sonography for trauma in 93% (62/67, 95% CI 83–97%), vascular access procedures in 90% (60/67, 95% CI 80–95%) and abdominal aortic aneurysm assessment in 88% of respondents (59/67, 95% CI 78–94%). Of the 67 departments with EDUS availability, 60% (40/67, 95% CI 48–71%) had a credentialing process. Of the major referral group 80% (20/25, 95% CI 61–91%) had a credentialing process compared with 52% (20/42, 95% CI 33–62%) in the non-major referral group. Conclusion: Emergency department ultrasound is widely available in Australia. Only 60% of surveyed ED had a credentialing process in place for EDUS. This may be of concern given the current Australasian College for Emergency Medicine policy regarding EDUS. [ABSTRACT FROM AUTHOR]

Objective: To determine which aspects of ED management are adversely affected by patient obesity, to determine the level of obesity above which management is made more difficult and to make recommendations on how these effects might be mitigated. Methods: This was a cross-sectional survey of patients and the staff caring for them in a single ED. Doctors, nurses and radiographers managing consecutive patients, during a range of enrolment periods, completed a self-administered questionnaire. Each was asked to record how the level of their patient's obesity increased the difficulty of specific management items, using a Likert scale. Staff also provided recommendations to mitigate the effects of obesity for each patient, if applicable. For each management item, body mass index (BMI) and management difficulty were correlated (Spearman's rank correlation). Results: Seven hundred and fifty patients and their ED carers were enrolled. Patient BMI was positively correlated with all aspects of ED clinical management examined (correlation coefficient range 0.28–0.57, P < 0.001). BMI most strongly correlated with difficulty in finding anatomical landmarks, venous pressure measurement, physical examination, patient positioning and procedures generally, especially cannulation and venipuncture (coefficient > 0.5, P < 0.001). Doctors reported more difficulties than nurses and radiographers. Generally, management difficulty did not increase until the BMI was in the obese or morbidly obese range. Most staff recommendations related to issues of patient mobility including equipment, staffing and bariatric devices. Conclusion: Patient obesity significantly increases the difficulty of ED patient management. Staff recommendations to mitigate these effects were few but may inform changes in ED practice. [ABSTRACT FROM AUTHOR]

Objective: To identify risk factors and associations for sexually transmitted infections (STI) in young Aboriginal women presenting to an ED for non-genitourinary reasons, in order to better target opportunistic screening in this group. To determine the prevalence of chlamydia and gonorrhoea in women presenting to the Alice Springs Hospital ED. Methods: A cross-sectional study involving STI screening and participant interview between January 2007 and September 2007 was used. The participants were a convenience sample of Aboriginal women aged 16–35 years presenting to the Alice Springs Hospital ED for non-genitourinary reasons. The main outcome measures were the prevalence of gonorrhoea and chlamydia and significant associations for STI. Results: A total of 213 women were included in the study. The prevalence rates of women screened were 8.9% for chlamydia, 9.4% for gonorrhoea and 16.0% for gonorrhoea or chlamydia. Identified objective associations for positive STI diagnosis included presenting with an injury due to an assault (odds ratio [OR], 3.56), self-reported past history of an STI (OR, 2.53) and leucocytes on urinalysis (OR, 2.19). Conclusion: The prevalence of STI is high in young Aboriginal women presenting to Alice Springs Hospital ED. Screening is acceptable to these patients using low vaginal swabs, and may be targeted at those women with the identified associations. The results of the present study may have relevance to other hospital ED in areas with a high prevalence of STI. A prospective study is needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Objective: The effect of nightshift on ED staff performance is of clinical and risk-management significance. Previous studies have demonstrated deterioration in psychomotor skills but the present study specifically assessed the impact of nightshift on clinical performance. Methods: The ED registrars in a tertiary hospital were enrolled in a prospective observational study and served as their own controls. During nightshift, subjects were presented simulated scenarios and tested with eight clinical questions developed to Fellowship examination standard. Matched scenarios and questions for the same subjects during dayshift served as controls. Two investigators, blinded to subject identity and the setting in which questions were attempted, independently collated answers. Results: Of 22 eligible subjects, all were recruited; four were excluded owing to incomplete data. A correlation of 0.99 was observed between the independent scoring investigators. Of a possible score of 17, the median result for nightshift was 9.5 (interquartile range: 8–11); corresponding value for dayshift was 12 (interquartile range: 10–13); P= 0.047. Conclusion: Nightshift effect on clinical performance is anecdotally well known. The present study quantifies such effects, specifically for the ED setting, and paves the way for focused research. The implications for clinical governance strategies are significant, as the fraternity embraces the mandate to maintain quality emergency care 24 h per day. [ABSTRACT FROM AUTHOR]

Introduction: To examine hospitalizations in a cohort of 224 patients who presented with non-fatal heroin overdose to an ED. Methods: A record linkage study, using the morbidity, mental health and mortality databases in the Data Linkage Unit of the Department of Health, Western Australia. The main outcome measures were hospital separations 5 years before and after entry into the cohort. Results: Before entry into the cohort, 199 (89%) patients had an admission to mental health services. These 199 had a combined total of 1367 separations, most commonly for a mental health condition, injury or poisoning. Women had more than twice the relative risk (RR) of men for all separations (RR 2.35, 95% confidence interval [CI] 1.96–2.82, P < 0.001) and for injury and poisoning separations (RR 2.04, 95% CI 1.56–2.66, P < 0.001). The highest concentrations of separations occurred within 1 year before and 1 year after entry into the cohort. There were 12 (5.4%, 95% CI 2.9–9.4%) deaths, most commonly from overdose. Conclusion: Non-fatal heroin overdose ED presentations are associated with a cluster of hospitalizations around that episode, likely to be related to heroin availability. Presentation to hospital by heroin users represents an opportunity to counsel less risky behaviour. [ABSTRACT FROM AUTHOR]

Objectives: Victoria's new trauma care system has been followed by reductions in preventable and potentially preventable deaths and in deficiencies contributing to death. This improvement has followed triaging more patients to expanded major trauma services where mortality was already lower rather than to improved results within the major trauma services, metropolitan or rural trauma services or ambulance services, Victoria. The objective of the present study was to identify continuing inadequacies within the individual trauma services and in association with representatives of these services to develop appropriate countermeasures. Methods: Initially, presentations were made to each trauma service of their fatalities evaluated after introduction of the new trauma system. At separate working party meetings with each service consensus recommendations were finalized and these disseminated to stakeholders. Results: Recommendations related to the need for Trauma Director/Coordinator appointments at all designated hospitals receiving major trauma, improved facilities and equipment, the trauma team, referral, communications, protocols, a prompting system, education, audit and feedback, infrastructure, staffing, documentation and inter-hospital patient transfer. Conclusion: Interaction between the Consultative Committee on Road Traffic Fatalities and Victorian trauma services identified continuing deficiencies in the new trauma care system and developed consensus recommendations to target these problems. These require implementation through the State Trauma Committee. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to determine patient satisfaction with procedural sedation as a function of nature of the procedure and depth of sedation. Method We undertook a prospective observational study of adult patients who received procedural sedation in two EDs (20 month period). The level of sedation was determined by an investigator, using the Observers Assessment of Anaesthesia/Sedation Scale (1 = awake to 6 = no response to noxious stimuli). Patient satisfaction was measured with the Iowa Satisfaction with Anaesthesia Scale after full recovery. This was self-administered, comprised 11 items (e.g. 'I felt pain') and has a score range of −3 (poor satisfaction) to +3 (very satisfied). Results A total of 163 patients were enrolled (51.2% men, mean age 50.7 years). The median (interquartile range) satisfaction score was 2.7 (0.7). Patient satisfaction was lower among patients who had orthopaedic procedures (median 2.6 vs 2.8, P < 0.01) and among patients who had a pre-sedation opioid (2.6 vs 2.8, P = 0.03). Satisfaction was positively correlated with deeper sedation (Spearman's correlation coefficient 0.49, P < 0.001). Satisfaction also differed significantly between the four most common sedation regimens ( P < 0.001). It was greatest among those who were administered propofol with or without fentanyl and least among those who were administered nitrous oxide with or without opioid. Patients sedated with propofol with or without fentanyl had the greatest depths of sedation. There was no difference in satisfaction among patients who were and were not sedated by a consultant (median 2.6 and 2.7, respectively, P = 0.84). Conclusion Generally, the level of patient satisfaction is high. Greater satisfaction is associated with deeper sedation, sedation with propofol and non-orthopaedic procedures. [ABSTRACT FROM AUTHOR]