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Objective: To investigate the impact of QScript implementation on pregabalin‐related poisoning presentations to the ED. Methods: This is a retrospective review of pregabalin‐related poisoning presentations to a tertiary Australian ED in the 4 years prior to, and 1 year following the introduction of QScript real‐time prescription monitoring system. Results: Pregabalin‐related poisoning presentations fell by 28% from an average of 98 presentations annually over the 4 years prior to QScript implementation to 71 in 2022. The severity of poisonings was similar over the periods. Conclusions: The introduction of QScript was associated with a reduction in pregabalin‐related poisoning presentations. [ABSTRACT FROM AUTHOR]

Background: Sharing anonymised ED data with community agencies to reduce alcohol‐related injury and assaults has been found effective in the UK. This protocol document outlines the design of an Australian multi‐site trial using shared, anonymised ED data to reduce alcohol‐related harm. Design and Method: Nine hospitals will participate in a 36 month stepped‐wedge cluster randomised trial. After a 9 month baseline period, EDs will be randomised in five groups, clustered on geographic proximity, to commence the intervention at 3 monthly intervals. 'Last‐drinks' data regarding alcohol use in the preceding 12 h, typical alcohol consumption amount, and location of alcohol purchase and consumption, are to be prospectively collected by ED triage nurses and clinicians at all nine EDs as a part of standard clinical process. Brief information flyers will be delivered to all ED patients who self‐report risky alcohol consumption. Public Health Interventions to be conducted are: (i) information sharing with venues (via letter), and (ii) with police and other community agencies, and (iii) the option for public release of 'Top 5' venue lists. Outcomes Primary outcomes will be: (i) the number and proportion of ED attendances among patients reporting recent alcohol use; and (ii) the number and proportion of ED attendances during high‐alcohol hours (Friday and Saturday nights, 20.00–06.00 hours) assigned an injury diagnosis. Process measures will assess logistical and feasibility concerns, and clinical impacts of implementing this systems‐change model in an Australian context. An economic cost–benefit analysis will evaluate the economic impact, or return on investment. [ABSTRACT FROM AUTHOR]

Objective: Orbital compartment syndrome (OCS) is a time critical condition, with ischaemic complications occurring after 90–120 min. In the prehospital setting, the diagnosis and management of OCS is challenging due to complex environmental considerations, competing clinical priorities, and limited equipment. This study aims to provide learning points on performing lateral canthotomy and cantholysis (LCC) in the prehospital setting. Methods: We performed a retrospective audit of LCC in our service from January 2016 to December 2020 by retrieving demographic and clinical details from LifeFlight Retrieval Medicine electronic database using 'OCS' and 'LCC' as keywords. Results: Three cases out of 7413 trauma missions were identified over the 5‐year period. LCC was performed at the primary scene in two cases, while one patient underwent LCC at a rural hospital near the scene of injury. Clinical findings, aeromedical considerations, and radiological findings at the receiving facility, along with visual outcomes at time of discharge are discussed. Conclusion: Prehospital LCC is rare. The Australian aeromedical context often involves lengthy transfers of trauma patients. Clinical diagnosis and management of OCS are highly challenging in the prehospital setting. It is important that prehospital physicians have access to appropriate equipment to perform LCC. They should be provided with suitable training and supported by a standard operating procedure. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was to assess transfusion practices with the implementation of a targeted viscoelastic haemostatic assay (VHA) (ROTEM®) guided coagulation management programme into a major haemorrhage protocol for trauma patients requiring ICU admission, starting from time of arrival in the ED. Methods: This retrospective observational study was conducted in a major trauma centre in Australia. One hundred and sixty‐two trauma patients admitted to the ICU between January 2013 and December 2015 with an Injury Severity Score ≥12 and who received blood products were included: 37 in the pre‐group, 48 during implementation and 77 in post‐group. The primary outcome was blood and blood product administration amounts. Results: Packed red blood cell transfusion amounts did not significantly change post introduction of the ROTEM®. There was a significant increase in fibrinogen replacement between the pre‐ and post‐groups (P < 0.001), accompanied by a reduction in the use of fresh frozen plasma (P < 0.001) and prothrombinex (P < 0.001). Platelet usage in the post‐group was higher but not reaching statistical significance (P = 0.051). Post‐implementation point‐of‐care ROTEM® testing was able to be performed in the ED in 94.8% of cases. Conclusion: Although there was no overall reduction of packed red blood cell usage, a change in the pattern of administration of other blood products was observed with the implementation of a targeted VHA (ROTEM®) guided coagulation management programme. Larger studies are needed to further define the role of early VHA testing to guide correction of trauma‐induced coagulopathy and the effect on clinical outcomes. [ABSTRACT FROM AUTHOR]

Objective: To investigate differences in presenting patient characteristics, investigation, management and related outcomes between culturally and linguistically diverse (CALD) and non‐CALD chest pain (CP) patients presenting to the ED. Methods: A cohort study of 258 patients was enrolled on presentation to Liverpool Hospital ED with a complaint of CP over a 2‐week period. Main outcomes included frequency and timeliness of diagnostic and radiological investigations, medication administered and ED length of stay. Administrative and clinical data were extracted and linked from Cerner EMR FirstNet®, PowerChart® and paper records. Results: There were 155 (60%) CALD and 103 (40%) non‐CALD patients. CALD patients were older by 10 years (95% CI 4, 15; P < 0.0001). There were no significant differences in the number of pathology and imaging investigations carried out in each group, and similarly there were no significant differences in the number of patients administered analgesia or cardiac‐specific medications. Neither group differed in their ED length of stay (median 280 vs 259.5 min; P = 0.79) or hospital admission rate (median 56% vs 55%, P = 0.8). Conclusion: Both CALD and non‐CALD ED CP patients had similar test ordering, medication administration and clinical outcomes, but this was in the context of CALD patients being 10 years older together with a small study sample size. A larger cohort, matched for age, would provide further insights into potentially important differences. [ABSTRACT FROM AUTHOR]

Objective: To estimate the proportion of ED patients in urban Queensland who are potentially suitable for general practitioner (GP) care. Methods: A retrospective analysis was conducted using ED Information System data from Metro North Hospital and Health Service in Brisbane, Australia for three consecutive financial years (2014–2015 to 2016–2017). The hospitals included two Principal Referral and two Public Acute hospitals. GP‐type patients were calculated using the Australian Institute of Health and Welfare (AIHW), Australasian College for Emergency Medicine (ACEM) and the validated Sprivulis methods. Results: Of the 822 841 ED presentations, 219 567 (27%) were potentially GP‐type patients by AIHW, 49 307 (6%) by ACEM and 61 836 (8%) by Sprivulis methods. The higher proportion of GP‐type presentations were during 08.00 to 17.00 hours by AIHW and ACEM methods. Of the lower‐acuity triage categories of 4 (286 154 presentations) and 5 (5658 presentations), AIHW estimated that 62% and 80% of the patients were GP‐type patients, as compared to 9% and 22% by ACEM, and 9% and 0.3% by Sprivulis method. The mean costs of adult GP‐type patients is $345 by the AIHW and $406 by the ACEM method, lower than non‐GP type patients ($706 and $622, respectively). Conclusions: There is considerable variation in what is considered GP‐type ED presentations based on the three methods employed and this variation may have fuelled the debate surrounding what is 'avoidable' ED utilisation. Regardless, the study findings provide an interesting addition to defining and addressing appropriate utilisation of ED services. [ABSTRACT FROM AUTHOR]

Objectives: While cervical spine injuries (CSIs) are rare in the paediatric population, presentations to EDs with possible neck injuries are common. Based on a lack of Australian data we set out to determine how many possible injuries are clinically cleared, what imaging is used on the remainder and the incidence and characteristics of confirmed paediatric CSIs. Methods: We undertook a retrospective electronic medical record review of children <18 years with potential CSIs at a large tertiary paediatric trauma centre in Victoria, Australia over a 12 month period (annual census 87 000). For possible injuries we extracted key epidemiologic, imaging and short‐term outcome data. Results: During the study period, a total of 617 patients with potential neck injuries were seen in the ED (617/87 000, 0.7%). The median age was 11 years. The most common mechanisms of injury were falls (41%), motor vehicle injuries (28%) and sports‐related injuries (24%). Four hundred and fourteen of 617 (67%) underwent neck imaging (345/414, 83% plain radiograph; 100/414, 24% computed tomography; 7/414, 1.6% magnetic resonance imaging). Twenty‐three of 617 (4.1%) had radiologically documented CSIs. Two required operative interventions for their neck injuries. Conclusion: While two‐thirds of children with potential CSIs undergo radiological evaluation, actual injuries are rare (<4%). These data suggest that there is a potential for improved targeting of cervical spine imaging for trauma. The development of a clinical decision tool may help reduce neck radiography. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study is to describe the epidemiology of major bleeding fatalities. Methods: A case series analysis of Australia's National Coronial Information System was conducted. Keywords were used to search for closed cases of major haemorrhage in the state of Victoria for the period 1 January 2009 to 31 December 2011. Coroners' findings, autopsy reports and police reports of cases were reviewed. Demographic data were extracted, and cases were assigned to a clinical bleeding context. Results: A total of 427 cases of major bleeding causing death were identified. The cohort was predominately men (69%), with a median age of 63 years (interquartile range 45-77 years). Trauma accounted for 38%, gastrointestinal haemorrhage 28%, surgical/procedural bleeding 14%, ruptured/leaking aneurysms 12% and other 8%. Most events began in homes (46%), hospitals (22%) and at the roadside (17%). Of those whose haemorrhage began in the community, 69% did not survive to hospital. Conclusions: Major bleeding fatalities occurred across a diverse range of contexts, with trauma and gastrointestinal bleeding accounting for most deaths. The majority of patients did not survive to reach hospital. Major haemorrhage occurring entirely outside hospital may be underrecognised from analyses of datasets based primarily on traumatic or in-hospital bleeding. These findings have implications for management of pre-hospital resuscitation and development of clinical practice guidelines for identification and management of major bleeding in the community. [ABSTRACT FROM AUTHOR]

Objective Anticoagulant and antiplatelet ( ACAP) drugs are associated with increased mortality in trauma patients, therefore medication history on admission is important. Whether these medications are recorded on trauma admission has not been investigated, nor if absence of a medication history is associated with worse patient outcomes. Methods We conducted a retrospective database review combining demographic and outcome data from the St George Hospital (Sydney) trauma registry with admission medication history in the electronic record. To contrast medications with a known increased risk ( ACAP) to patients with unknown risk, patients were divided into three groups: those on ACAPs, no- ACAP if medication history was present and no- ACAP documented, or no-Hx if no medication history recorded. Inclusion criteria were aged >16 and Injury Severity Score ( ISS) >12. Admission demographic data and outcome data were compared between all three groups. Results Of 533 consecutive patients, 21% comprised the no-Hx group, while 22% were on an ACAP and 57% not on an ACAP. No-Hx patients had more severe head injuries and a younger median age compared to ACAP patients (42 vs 82 years old, P < 0.001). Mortality was higher for ACAP (24%; 95% CI 17-33%) compared to no- ACAP (11%; 95% CI 8-16%) or no-Hx patients (12%; 95% CI 7-20%) ( P = 0.04). Conclusions While a large number of severe trauma patients were admitted without a medication history, no-Hx patients did not appear at increased risk of adverse outcomes. ACAP patients had a higher mortality compared to no- ACAP highlighting the vulnerability of this group. [ABSTRACT FROM AUTHOR]

Objective: To further develop and refine an Emergency Department (ED) in‐patient admission prediction model using machine learning techniques. Methods: This was a retrospective analysis of state‐wide ED data from New South Wales, Australia. Six classification algorithms (Bayesian networks, decision trees, logistic regression, naïve Bayes, neural networks and nearest neighbour) and five feature selection techniques (none, manual, correlation‐based, information gain and wrapper) were examined. Presenting problem was categorised using broad (n = 20) and specific (n = 100) representations. Models were evaluated based on Area Under the Curve (AUC) and accuracy. The results were compared with the Sydney Triage to Admission Risk Tool (START), which uses logistic regression and six manually selected features. Results: Sixty admission prediction models were trained and validated using data from 1 721 294 patients. Under the broad representation of presenting problem, the nearest neighbour algorithm with manual feature selection had the best AUC of 0.8206 (95% CI ±0.0006), while the decision tree with no feature selection had the best accuracy of 74.83% (95% CI ±0.065). Under the specific representation, almost all models improved; the nearest neighbour with information gain feature selection had the best AUC of 0.8267 (95% CI ±0.0006), while the decision tree with wrapper or no feature selection had the best accuracy of 75.24% (95% CI ±0.064). Eleven of the machine learning models had slightly better AUC than the START model. Conclusion: Machine learning methods demonstrate similar performance to logistic regression for ED disposition prediction models using basic triage information. This should be investigated further, especially for larger data sets with more complex clinical information. [ABSTRACT FROM AUTHOR]

Governments in Australasia are introducing emergency department length of stay (EDLOS) time targets similar to the UK 'four hour rule'. There is debate about whether this rule had beneficial effects on health-care outcomes. We sought to determine what effects the four hour time target for EDLOS had on clinically relevant outcomes in the UK by conducting a systematic search for evidence. Articles were screened by both authors independently and assessed for quality using standard tools. Differences in outcomes measured and how they were measured precluded meta-analysis. There were inconsistencies between target achievement reported by Trusts and that reported in the studies, and empirical evidence that the target might be unattainable. National Health Service spending on ED increased £820 000 000.00 (1998-2007) and emergency admissions rose overall by 35% (2002-2006), but not in all hospitals. Time to see a treating clinician and hospital mortality was unchanged. One hospital demonstrated a small reduction in return rate. The impact of the introduction of an ED time target and the associated massive financial investment has not resulted in a consistent improvement in care with markedly varying effects being reported between hospitals. Countries seeking to emulate the UK experience should proceed with caution. [ABSTRACT FROM AUTHOR]

Signs of Irukandji syndrome (IS) suggest an underlying catecholamine storm with research demonstrating that Carukia barnesi venom causes a significant rise in adrenaline/noradrenaline serum levels. A systematic review was undertaken to ascertain the current evidence in treating IS with magnesium salts. A literature search was conducted using Scopus, Medline and ScienceDirect. Further articles were discarded via title description and/or abstract details. The remaining were read in full, and those identified as not having sufficient information regarding magnesium and patient outcomes were removed. Nine articles were identified. One article was a randomised controlled trial, which concluded that there appears to be no beneficial difference between those patients who received the magnesium sulphate (MgSO4) and those who received the placebo and recommended against the use of MgSO4 in IS. Of the remaining eight, one reported the failure of MgSO4 and the remaining seven were case series reporting varying success in its use. This systematic review found insufficient evidence to support any clear recommendation regarding the use of magnesium, but nor was there clear evidence to recommend against its use in IS. Two case series describe significant reduction in key symptoms and hypertension but are a non-randomised albeit prospective series with the limitations accompanying this. The reporting of recrudescence of symptoms with reduction of dose does suggest a dose-response relationship. The evidence for the use of MgSO4 is at best anecdotal, and further research is required to either confirm its benefit or confirm the randomised controlled trial. [ABSTRACT FROM AUTHOR]

Objective Incident reporting systems are critical to understanding adverse events, in order to create preventative and corrective strategies. There are very few systems dedicated to Emergency Medicine with published results. All EDs in Australia and New Zealand were contacted to encourage the use of an Emergency Medicine - specific online reporting system called the Emergency Medicine Events Register (EMER). Methods We conducted an analysis of the first 150 incidents entered into EMER. EMER captures Emergency-medicine-specific details including triage score, clinical presentation, outcome, contributing factors, mitigating factors, other specialities involved and patient journey stage. These details were analysed by an expert panel. Results Over the first 26 months, 150 incidents were reported into EMER. The most common categories reported, in order, were diagnostic error, procedural complication and investigation errors. Most incidents contained more than one category of error. The most common stage of the patient's journey in which an incident was detected was after discharge from the ED. Conclusion A focus on correct diagnosis, procedure performance and investigation interpretation may reduce errors in the ED. The ability to learn from incidents and make system changes to enhance patient safety in healthcare organisations is an inherent part of providing a proactive, quality culture. [ABSTRACT FROM AUTHOR]

Objective Age-related policies allow adolescents to access paediatric and adult EDs. Anecdotally, paediatric and adult EDs report challenges when caring for older and younger adolescents, respectively. Our aim was to describe the characteristics of an adolescent population attending an adult ED, co-located with a tertiary paediatric ED. Methods The Westmead Hospital ED database was accessed for 14.5-17.9 years old presentations between January 2010 and December 2012. Patient diagnosis coding ( SNOMED) was converted to ICD-10. De-identified data were transferred into Microsoft Excel with analysis performed using spss V22. Results There were 5718 presentations made to the Westmead Hospital, Sydney, Australia ED by 4450 patients, representing 3.3% (95% CI 3.2-3.4) of total visits from all patients 14.5 years and above. The mean age of the sample was 16.6 years (male 51.8%). Presentations triaged as level 4 or 5 represented 61.0% (95% CI 58.7-61.3) of visits. The proportion of patients who did not wait to receive care was 13.8% (95% CI 12.9-14.7), which was significantly higher than adult rates ( P < 0.01). There were 279 unscheduled return visits (visits made <72 h of discharge) representing 4.9% (95% CI 4.4-5.8) of all presentations. Injury was the most common diagnosis (30.2%, 95% CI 28.8-31.6). Chronic physical illness and alcohol-related visits comprised 2.1% (95% CI 1.7-2.5) and 0.8% (95% CI 0.6-1.0) of adolescent presentations, respectively. Conclusion Contrary to reported staff perceptions, adolescent chronic physical illness presentations were not a major burden. Alcohol was likely under-recorded as a contributing factor to presentations. [ABSTRACT FROM AUTHOR]

The article discusses the challenges faced by medical practices by the rise of disruptive technologies, including the point-of-care ultrasound (POCUS) tool used in paediatric emergency. Topics of the article includes an introduction to the POCUS technology, the learning curve involved in POCUS, and the barrier facing the adoption of POCUS.

Research is an important part of emergency medicine and provides the scientific underpinning for optimal patient care. Although increasing numbers of emergency physicians participate in research activities, formal research training is currently neither part of emergency physician training in Australia nor easily available for clinicians interested in clinical research. In a two-part series, which is targeted at part-time clinical researchers in the ED, we set out and explain the key elements for conducting high-quality and ethical research. Part I addressed ethical and regulatory aspects. In Part II, we describe important elements of research science, and practical elements of research conduct and administration, which form the basis for high-quality research. [ABSTRACT FROM AUTHOR]

The article focuses on role of data sharing as part of national innovation and science agendas in research. It mentions opportunities of open data to drive economic, social and environmental prosperity. It also highlights promoting benefits of digital innovation and need for the government to improve the quality and availability of its services.

Objective To interrogate the National Coroners Information System ( NCIS) to determine the recurrent themes among coroners' recommendations that aimed to increase the safety of ED care. Methods This was a retrospective analysis of NCIS closed cases, from Queensland, New South Wales, Tasmania, Victoria, Australian Capital Territory, South Australia and North Territory, entered since its inception in 2000. The keyword 'emergency department' returned 1645 cases, of which 180 were found to be relevant. The primary outcomes were the number and nature of cases where recommendations for improvements in ED care had been made and the recurrent themes of these recommendations that could inform education initiatives. Results Of the 180 cases, 108 (60.0%) were of deceased men and subject age ranged from 2 days to 91 years. The commonest causes of death were trauma (26.7%), infection (24.4%), cardiac events (15.0%) and poisoning (8.9%). No coronial recommendations were required in 19 cases. For the remainder, recommendation themes related to issues of risk management/medico-legal, diagnostic/therapeutic error, education, documentation/communication and re-presentation. The themes associated with the different doctor designations (consultant, registrar, resident/intern) were similar, although registrars and residents/interns tended towards more diagnostic/therapeutic errors. The themes associated with hospital type (referral, urban, regional/rural) were also similar. Although theme analysis is important, some individual cases were particularly instructive. Conclusion The NCIS data theme analysis indentifies important high-risk patients and presenting complaints. These should be incorporated into emergency physician training. EDs should review the coronial recommendations to ensure that, where possible, they have been adopted. [ABSTRACT FROM AUTHOR]

Cyanide poisoning is uncommon, but generates interest because of the presumed utility of an antidote immediately available in those areas with a high risk of cyanide exposure. As part of its regular review of guidelines, the Australian Resuscitation Council conducted a systematic review of the human evidence for the use of various proposed cyanide antidotes, and a narrative review of the relevant pharmacological and animal studies. There have been no relevant comparative or placebo-controlled human trials. Nine case series were identified. Treatment with hydroxocobalamin was reported in a total of 361 cases. No serious adverse effects of hydroxocobalamin were reported, and many patients with otherwise presumably fatal poisoning survived. Sodium thiosulphate use was reported in two case series, similarly with no adverse effects. Treatment with a combination of sodium nitrite, amyl nitrite and sodium thiosulphate was reported in 74 patients, with results indistinguishable from those of hydroxocobalamin and sodium thiosulphate. No case series using dicobalt edetate or 4-dimethylaminophenol were identified, but successful use in single cases has been reported. Hydroxocobalamin and sodium thiosulphate differ from alternatives in having negligible adverse effects, and on the basis of current evidence are the antidotes of choice. The indications for the use of an antidote, the requirements for supportive care and a recommended approach for workplaces where there is a risk of cyanide poisoning are presented. [ABSTRACT FROM AUTHOR]

A stab wound to neck is an infrequent but highly important presentation to the ED in Australasia. Injuries to the two large neurovascular bundles that are vital to life might occur with associated injuries to midline aerodigestive structures. A literature review was undertaken to discuss the assessment and management of this injury in the emergency medicine setting. [ABSTRACT FROM AUTHOR]

Objectives: In June 2020, modified‐release paracetamol (paracetamol‐MR) preparations were up‐scheduled from schedule‐2 (available in pharmacy) to schedule‐3 (available by request to a pharmacist only). The present study aims to ascertain whether up‐scheduling affected the frequency of paracetamol‐MR overdoses. Methods: This is a retrospective cohort study of two data sets from 1 June 2017 to 31 May 2022. Monash Health data were extracted using the diagnosis of paracetamol overdose coding and electronic medical records data. Calls regarding paracetamol‐MR overdoses to Victorian Poisons Information Centre (VPIC) were extracted from the Poisons centre call database. We used a quasi‐experimental research design with interrupted time series analysis to evaluate the immediate impact and change in trend of poisoning‐related calls and ED presentations before and after June 2020. The change in proportion of paracetamol‐MR cases in both databases was analysed using the Χ2 test. Results: The proportion of paracetamol‐MR cases in both data sets did not change. From Monash Health, there was no level change in monthly paracetamol‐MR overdose‐related presentations following re‐scheduling (rate ratio [RR] = 1.08, 95% confidence interval [CI] = 0.57–2.01). There was no change in monthly paracetamol‐MR overdose‐related calls to VPIC following re‐scheduling (RR = 1.05, 95% CI = 0.96–1.14). Conclusion: The proportion of paracetamol‐MR overdoses did not decrease after the up‐scheduling to S3. Similarly, the frequency of overdoses by month remained similar. Further limitations on access to paracetamol products may need to be considered. [ABSTRACT FROM AUTHOR]

Objectives: In overdose, gamma‐hydroxybutyrate (GHB) and its precursors can cause decreased levels of consciousness, coma and death. Here, we aim to describe reported exposure to GHB at four EDs in Sydney, New South Wales (NSW), Australia. Methods: We searched the ED databases of four Sydney metropolitan hospitals for presentations relating to GHB exposure between 2012 and 2021. We calculated annual number of presentations stratified by hospital, age, sex, mode of arrival and triage category. Results: A total of 3510 GHB‐related presentations to ED were recorded across the four hospitals. Data for all hospitals were only available from 2015 onwards and between 2015 and 2021; there was a 114% increase in annual presentations (from 228 to 487). Males represented 68.7% of all presentations and the median age was 31 years (range 16–74 years). There was an increase in the proportion of female presentations between 2012 and 2021 (from 27.9% to 37.9%) along with the severity of presentation over the same period, with the proportion of presentations with a triage category 1 increasing from 19.7% to 34.5%. Conclusions: Increases in recorded absolute number and severity of GHB‐related presentations to Sydney EDs are a major public health concern. There may also be shifts in the demographics of those with GHB‐related presentations. Renewed efforts are required to understand the drivers of these increases to optimally target harm reduction approaches. [ABSTRACT FROM AUTHOR]

The aim of the study was to determine the training needs of doctors managing emergencies in rural and remote Australia. A systematic review of Australian articles was performed using MEDLINE (OVID) and INFORMIT online databases from 1990 to 2016. The search terms included 'Rural Health', 'Emergency Medicine', 'Emergency Medical Services', 'Education, Medical, Continuing' and 'Family Practice'. Only peer‐reviewed articles, available in full‐text that focussed on the training needs of rural doctors were reviewed. Data was extracted using pre‐defined fields such as date of data collection, number of participants, characteristics of participants, location and study findings. A total of eight studies published from 1998 to 2006 were found to be suitable for inclusion in the analysis. Six studies cited the results of self‐reported questionnaires and surveys, one used a telephone questionnaire on a hypothetical patient and one utilised a theoretical examination. The studies found a significant proportion of participants wanted more emergency training. Junior rural doctors were found to have deficiencies in knowledge about stroke. Emergency skills doctors wanted more training including: emergency ultrasound, paediatric/neonatal procedures and cricothyroidotomy. However, many of the studies were performed by training providers that may benefit from deficient results. Given that the data was over 10 years old and that advances have been made in knowledge, training opportunities and technology, the implications for current training needs of rural doctors in Australia could not be accurately assessed. Thus there is a need for further research to identify current training needs. [ABSTRACT FROM AUTHOR]

Abstract: Acute hand and wrist injuries are a common presentation to the ED and are associated with large individual and societal costs. Appropriate management of these injuries in the ED is crucial given that optimal hand function is essential for daily activities and quality of life. This rapid review investigated best practice for the assessment and management of common closed hand and wrist injuries in the ED. Databases were searched in 2017, including PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites. Primary studies, systematic reviews and guidelines published in English language in the past 12 years that addressed the acute assessment, management, follow‐up plan or prognosis were considered for inclusion. Data extraction of included articles was conducted, followed by quality appraisal to rate the level of evidence. The search revealed 2454 articles, of which 55 were included in the review (n = 23 primary articles, n = 26 systematic reviews and n = 6 guidelines). This rapid review provides clinicians who manage common closed fractures and soft tissue injuries of the hand and wrist in the ED, a summary of the best available evidence to enhance the quality of care for optimal patient outcomes. There is evidence to support taking a thorough history and physical examination with consideration of occupational and functional factors, restoring alignment and immobilising when necessary and referring onwards. Key points regarding the diagnosis and management of these injuries are provided. [ABSTRACT FROM AUTHOR]

Background: There are no medications known that improve the outcome of infants with bronchiolitis. Studies have shown the management of bronchiolitis to be varied. Objectives: To describe medication use at the seven study hospitals from a recent multi-centre randomised controlled trial on hydration in bronchiolitis (comparative rehydration in bronchiolitis [CRIB]). Methods: A retrospective analysis of extant data of infants between 2 months (corrected for prematurity) and 12 months of age admitted with bronchiolitis identified through the CRIB trial. CRIB study records, medical records, pathology and radiology databases were used to collect data using a standardised form and entered in a single site database. Medications investigated included salbutamol, adrenaline, steroids, ipratropium bromide, normal saline, hypertonic saline, steroids and antibiotics. Results: There were 3456 infants available for analysis, of which 42.0% received at least one medication during hospitalisation. Medication use varied by site between 27.0 and 48.7%. The most frequently used medication was salbutamol (25.5%). Medication use in general, and salbutamol use in particular, increased by 8.2 and 9.3%, respectively, per month after 4 months of age; from 22.9 and 3.6% at 4 months to 81.4 and 68.8% at 11 months. In infants admitted to the intensive care unit (ICU) compared with those not admitted to ICU 81.6 and 39.5%, respectively, received medication at one point during the hospital stay. Conclusions: Medication was used for infants with bronchiolitis frequently and variably in Australia and New Zealand. Medication use increased with age. Better strategies for translating evidence into practice are needed. [ABSTRACT FROM AUTHOR]

Paramedic education has been undergoing major development in Australia in the past 20 years, with many different educational programmes being developed across all Australian jurisdictions. This paper aims to review the current paramedic education programmes in Australia to identify the similarities and differences between the programmes, and the strengths and challenges in these programmes. A literature search was performed using six scientific databases to identify any systematic reviews, literature reviews or relevant articles on the topic. Additional searches included journal articles and text references from 1995 to 2011. The search was conducted during December 2010 and November 2011. Included in this review are a total of 28 articles, which are focused around five major issues in paramedic education: (i) principle on paramedic programmes and the involvement of industry partners; (ii) clinical placements; (iii) contemporary methods of education; (iv) needs for specific programmes within paramedic education; and (v) articles related to the accreditation process for paramedic programmes. Paramedic programmes across Australian universities vary with many different practices, especially relating to clinical placements in the field. The further advances of the paramedic education programmes should aim to respond to population change and industry development, which would enhance the paramedic profession across Australia. [ABSTRACT FROM AUTHOR]

Objective: To review published Australian literature about ED care of Aboriginal and Torres Strait Islander peoples. Method: Six databases were searched electronically for articles about ED use by Indigenous people in Australia. This strategy was complemented by manual searches of two websites, Emergency Medicine (1994–2004) and three bibliographies. Results: Aboriginal and Torres Strait Islander peoples attend EDs about twice as often as other Australians. The waiting times of Indigenous patients are similar to, or slightly shorter than, those of non-Indigenous patients. However, more Indigenous than other patients choose to walk out before being seen, indicating possibly greater Indigenous dissatisfaction with ED care. Conclusions: Further conclusions of the present literature review were limited by contradictory results in the few studies of reasonable quality and by general concerns about data quality, especially the poor (but slowly improving) identification of Indigenous people in routine ED data sets. Closer collaboration between ED staff and Indigenous hospital liaison staff, combined with regular monitoring of routinely-collected ED data, have the potential to improve Indigenous ED care and so contribute to improvements in Indigenous health. [ABSTRACT FROM AUTHOR]

Objective: To synthesise evidence‐based research concerning the assessment and management of acute dizziness via construction of a comprehensive clinical algorithm. Assess its clinical impact with an aim to improve the acute management of benign paroxysmal positional vertigo (BPPV) within Wyong Public Hospital ED in four key recommendations. Method: Current best practice models of care were synthesised into a single clinical, district‐based peer‐reviewed algorithm by a specialist focus group. An observational pre‐ and post‐implementation study was completed to assess the impact of the algorithm on the management of BPPV. A total of 162 notes (pre [control] n = 87 and post [intervention] n = 75) met the inclusion criteria. Adherence to the BPPV clinical practice guidelines statements 1a, 3a, 4a and 6 were analysed for statistical difference in practice between the two groups. Results: Following implementation of the Emergency VESTibular Algorithm (EVESTA), compliance showed a significant improvement in Hallpike–Dix performed by 27% (95% confidence interval [CI] 14–40%; defects pre‐intervention 40%: post‐intervention 13%) (P < 0.001), utilisation of neuroimaging reduced by 16% (95% CI 2–30%; 40%: 24%) (P < 0.05), repositioning techniques performed increased by 33% (95% CI 18–48%; 68%: 36%) (P < 0.001). Administration of vestibular suppressant medication reduced by 30% (95% CI 15–45%; 59%: 29%) (P < 0.001). An interrupted time series analysis confirmed significant change in BPPV admissions post‐project −4.23% (95% CI −7.20, −1.27%) (P = 0.041). Conclusion: Diagnosis and management of acute dizziness is challenging within the ED. Synthesis of best practice into a clinical algorithm has improved the diagnosis and evidence‐based treatment of BPPV. There is continued opportunity to improve the efficiency and effectiveness in the management of both central and peripheral acute dizziness within the ED. [ABSTRACT FROM AUTHOR]

Objective: Sex differences in patients presenting with out‐of‐hospital cardiac arrest (OHCA) and shockable rhythm might be associated with disparities in clinical outcomes. Methods: We conducted a retrospective cohort study and compared characteristics and short‐term outcomes between male and female adult patients who presented with OHCA and shockable rhythm at two large metropolitan health services in Melbourne, Australia between the period of 2014–2018. Logistic regression was used to assess the effect of sex on clinical outcomes. Results: Of 212 patients, 166 (78%) were males and 46 (22%) were females. Both males and females presented with similar rates of ST‐elevation myocardial infarction (44% vs 36%, P = 0.29), although males were more likely to have a history of coronary artery disease (32% vs 13%) and a final diagnosis of a cardiac cause for their OHCA (89% vs 72%), both P = 0.01. Rates of coronary angiography (81% vs 71%, P = 0.23) and percutaneous coronary intervention (51% vs 42%, P = 0.37) were comparable among males and females. No differences in rates of in‐hospital mortality (38% vs 37%, P = 0.90) and 30‐day major adverse cardiac and cerebrovascular events (composite of all‐cause mortality, myocardial infarction, coronary revascularization and nonfatal stroke) (39% vs 41%, P = 0.79) were observed between males and females, respectively. Female sex was not associated with worse in‐hospital mortality when adjusted for other variables (odds ratio 0.66, 95% confidence interval 0.28–1.60, P = 0.36). Conclusion: Among patients presenting with OHCA and a shockable rhythm, baseline sex and sex differences were not associated with disparities in short‐term outcomes in contemporary systems of care. [ABSTRACT FROM AUTHOR]

Objective Paediatric head injury is a common presentation to the ED. North American studies demonstrate increasing use of computed tomography (CT) brain scan (CTB) to investigate head injury. No such data exists for Australian EDs. The aim of this study was to describe CTB use in head injury over time in eight Australian EDs. Methods Retrospective ED electronic database and medical imaging database audit was undertaken for the years 2001-2010 by International Classification of Diseases (ICD) 9 or 10 code for head injury in children <16 years. EDs and medical imaging departments of eight hospitals in Australia (five tertiary referral and three mixed departments). Data for ED presentations with head injury, and all CTB performed by medical imaging were merged to obtain a data set of CTB performed within 24 h for head injury-related attendances to the ED. Descriptive and comparative analysis of CTB rates was performed. Results The rate of CTB over the decade was 10.2% (95% confidence interval (CI) 9.9-10.5). The annual rate varied from 9.5% (95% CI 8.2-10.9) to 12.5% (95% CI 11.2-13.9). CTB use did not increase over time. Median year of age at time of CT scan was 4 years, with an interquartile range of 1.5-9.4 years. Overall there was a 9.2% increase in the CTB scan rate for every additional year of age at presentation (95% CI 6.6-12.1; P < 0.001). Conclusion CTB use in head injuries did not increase during the study period, and rates of CTB were less than reported for North America. [ABSTRACT FROM AUTHOR]

Objective: There is growing evidence to suggest that culturally and linguistically diverse (CALD) patients cost the health system more than non-CALD patients because of a higher burden of disease and increased resource consumption. The present study aimed to compare the ED resource utilisation of CALD and non-CALD patients at a tertiary hospital in Sydney, Australia. Methods: The total ED resource utilisation was calculated by separating each visit into diagnostic test cost and time spent in ED components. The time component was calculated using the product of the total length of stay and a resource cost per unit time measure. Diagnostic tests were costed using the Australian Medicare Benefit Schedule. A generalised additive model was developed to estimate the isolated effect of CALD status on the resource utilisation during an ED visit. Results: CALD patients had a higher median resource utilisation than non-CALD patients ($736.93 vs $701.36, P < 0.0001); however, the generalised additive model demonstrated that CALD status was not independently associated with increased resource utilisation. Conclusion: CALD status is not an independent influence on ED resource utilisation but other explanatory variables such as increased age and altered case-mix appear to have a much greater influence. There may, however, be other reasons to consider CALD loading such as equity in healthcare and to address poorer overall health outcomes for CALD patients. [ABSTRACT FROM AUTHOR]

Objective: Paediatric status epilepticus (SE) has potential for long‐term sequelae. Existing data demonstrate delays to aspects of care. The objective of the present study was to examine the feasibility of collecting data on children with paediatric SE and describe current management strategies in pre‐hospital and in‐hospital settings. Methods: A pilot, prospective, observational cohort study of children 4 weeks to 16 years of age with SE, in four EDs in Australia. Clinical details including medications administered, duration of seizure and short‐term outcomes were collected. Follow up occurred by telephone at 1 month. Results: We enrolled 167 children with SE. Mean age was 5.4 years (standard deviation [SD] 4.1), and 81 (49%) male. Median seizure duration was 10 min (interquartile range 7–30). Midazolam was the first medication administered in 87/100 (87%) instances, mean dose of 0.21 mg/kg (SD 0.13). The dose of midazolam was adequate in 30 (35%), high (>0.2 mg/kg) in 44 (51%) and low (<0.1 mg/kg) in 13 (15%). For second‐line agents, levetiracetam was administered on 33/55 (60%) occasions, whereas phenytoin and phenobarbitone were administered on 11/55 (20%) occasions each. Mean dose of levetiracetam was 26.4 mg/kg (SD 13.5). One hundred and four (62%) patients were admitted to hospital, with 13 (8%) admitted to ICU and seven (4%) intubated. Conclusion: In children presenting with SE in Australia medical management differed from previous reports, with midazolam as the preferred benzodiazepine, and levetiracetam replacing phenytoin as the preferred second‐line agent. This pilot study indicates the feasibility of a paediatric SE registry and its utility to understand and optimise practice. [ABSTRACT FROM AUTHOR]

Objective: To describe the demographics and outcomes of sports‐related ocular injuries in an Australian tertiary eye hospital setting. Methods: Retrospective descriptive study from the Royal Victorian Eye and Ear Hospital from 2015 to 2020. Patient demographics, diagnosis and injury causation were recorded from baseline and follow‐up. Outcomes included visual acuity (VA), intraocular pressure (IOP), ocular injury diagnosis, investigations and management performed. Results: A total of 1793 individuals (mean age 28.67 ± 15.65 years; 80.42% males and 19.58% females) presented with sports‐related ocular trauma. The top three injury‐causing sports were soccer (n = 327, 18.24%), Australian rules football (AFL) (n = 306, 17.07%) and basketball (n = 215, 11.99%). The top injury mechanisms were projectile (n = 976, 54.43%) and incidental body contact (n = 506, 28.22%). The most frequent diagnosis was traumatic hyphaema (n = 725). Best documented VA was ≥6/12 at baseline in 84.8% and at follow‐up in 95.0% of cases. The greatest risk of globe rupture/penetration was associated with martial arts (odds ratio [OR] 16.22); orbital blow‐out fracture with skiing (OR 14.42); and hyphaema with squash (OR 4.18): P < 0.05 for all. Topical steroids were the most common treatment (n = 693, 38.7%). Computed tomography orbits/facial bones were the most common investigation (n = 184, 10.3%). The mean IOP was 16.1 mmHg; 103 (5.7%) cases required topical anti‐ocular hypertensives. Twenty‐six individuals (1.45%) required surgery with AFL contributing the most surgical cases (n = 5, 19.23%). Conclusion: The top three ocular injury causing sports were soccer, AFL and basketball. The most frequent injury was traumatic hyphaema. Projectiles posed the greatest risk. [ABSTRACT FROM AUTHOR]

The article offers Emergency Medicine Australasia briefs. Topics include Corticosteroids can be used to treat idiopathic facial paralysis (Bell's palsy) in children; and Studies demonstrate the advantages of nonmydriatic fundus photography (NMFP) screening over direct ophthalmoscopy in the Emergency Department (ED), but behaviour change for NMFP implementation is difficult to institute.

Objective: Non‐fatal strangulation assessment is challenging for clinicians as clear guidelines for evaluation are limited. The prevalence of non‐fatal strangulation events, clinical findings, frequency of injury on computed tomography angiogram (CTA) and outcomes across two trauma centres will be used to improve this assessment process. Methods: This is a retrospective observational study of adult presentations during 2‐year period to two major‐trauma referral hospitals and subsequent 12 months to identify delayed vascular injury. Patients included using standardised search terms. Demographic data, clinical findings, radiological reports and outcomes were included for review. Results: A total of 425 patients were included for analysis. Self‐inflicted injury comprised 62.1%, with domestic violence (28.5%) and assault (9.4%) the remainder. Manual strangulation events 36.7% of overall presentations and 63.3% following ligature strangulation (ligature strangulation, incomplete and complete hanging). On examination soft signs present in 133 (31.2%) cases, commonly neck tenderness in isolation. No hard signs suggesting vascular damage. Vascular injury was demonstrated in three cases (0.7% of the total cohort and 1.5% of CTA scans completed), and all occurred in ligature strangulation events as a result of hanging. No patients had delayed vascular injury in the 12‐month period post‐initial presentation. Conclusions: In non‐fatal strangulation presentations, the majority have subtle signs of neck injury on examination with inconsistent documentation of findings. Low rate of vascular injury overall (0.7%), and entirely in hanging events. No longer‐term vascular sequalae identified. Improving documentation focusing on hypoxic insult and evidence of airway trauma is warranted, rather than a reliance on computed tomography imaging to delineate a traumatic event in non‐fatal strangulation. [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]

Objective: Upper gastrointestinal bleeding (UGIB) is a common presentation to EDs. Limited Australian data are available. Study aims were to assess mortality and re‐bleeding rates in patients presenting with UGIB as risk‐stratified by the Glasgow Blatchford Score (GBS). Methods: We conducted a retrospective medical chart review of all patients presenting with UGIB to a Brisbane tertiary hospital ED over a 12‐month period. This descriptive study summarised the medical characteristics related to UGIB as risk‐stratified by the GBS. Non‐variceal bleeding was categorised as low‐risk (GBS 0–2) or high‐risk (GBS 3+). Variceal bleeding was not risk stratified. Results: A total of 211 patients presented with UGIB to the ED. The median age was 57 years, 67% were male. Mortality rates at 30 days were: 0% for GBS 0–2, 3% (95% confidence interval [CI] 0–6) for GBS 3+ and 10% (95% CI 0–21) for variceal groups. The overall 30‐day re‐bleeding rate was 4.3% (95% CI 2–7). High‐risk patients accessed endoscopy according to international best practice of less than 24 h (GBS 3+, 23.7 h; variceal bleeding, 7.3 h). Conclusions: Mortality and re‐bleeding outcomes are similar to other international UGIB cohorts. Patients with a low‐risk bleed were appropriately identified and discharged home. Those at higher risk were correctly identified and accessed timely endoscopy. The GBS demonstrated clinical utility in an Australian ED cohort of UGIB bleeding patients. [ABSTRACT FROM AUTHOR]

Objective: To validate the accuracy and safety of the Canadian Syncope Risk Score (CSRS) for patients presenting with syncope. Methods: Single centre prospective observational study in Brisbane, Australia. Adults presenting to the ED with syncope within the last 24 h were recruited after applying exclusion criteria. Study was conducted over 1 year, from March 2018 to March 2019. Thirty‐day serious adverse events (SAE) were reported based on the original derivation study and standardised outcome reporting for syncope. Individual patient CSRS was calculated and correlated with 30‐day SAE and disposition status from ED. Results: Two hundred and eighty‐three patients were recruited to the study. Average age was 55.6 years (SD 22.7 years), 37.1% being male with a 39.9% admission rate. Thirty‐day SAE occurred in seven patients (2.5%) and no recorded deaths. The CSRS performed with a sensitivity of 71.4% (95% confidence interval [CI] 30.3–94.9%), specificity 72.8% (95% CI 67.1–77.9%) for a threshold score of 1 or higher. Conclusion: Syncope patients in our study were predominantly very low to low risk (72%). The prevalence of 30‐day SAE was low, majority occurring following hospital discharge. Sensitivity estimates for CSRS was lower than the derivation study but lacked robustness with wide CIs because of a small sample size and number of events observed. However, the CSRS did not miss any clinically relevant outcomes in low risk patients making it potentially useful in aiding their disposition. Larger validation studies in Australia are encouraged to further test the diagnostic accuracy of the CSRS. [ABSTRACT FROM AUTHOR]

The Paediatric Research in Emergency Departments International Collaborative (PREDICT) released the Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children in 2021. We describe innovative and practical methods used to develop this guideline. Informed by GRADE‐ADOLOPMENT and ADAPTE frameworks, we adopted or adapted recommendations from multiple high‐quality guidelines or developed de novo recommendations. A Guideline Steering Committee and a multidisciplinary Guideline Working Group of 25 key stakeholder representatives formulated the guideline scope and developed 33 clinical questions. We identified four relevant high‐quality source guidelines; their recommendations were mapped to clinical questions. The choice of guideline recommendation, if more than one guideline addressed a question, was based on its appropriateness, currency of the literature, access to evidence, and relevance. Updated literature searches identified 440 new studies and key new evidence identified. The decision to develop adopted, adapted or de novo recommendations was based on the supporting evidence‐base and its transferability to the local setting. The guideline underwent a 12‐week consultation period. The final guideline consisted of 35 evidence‐informed and 17 consensus‐based recommendations and 19 practice points. An algorithm to inform imaging and observation decision‐making was also developed. The resulting process was an efficient and rigorous way to develop a guideline based on existing high‐quality guidelines from different settings. [ABSTRACT FROM AUTHOR]

Objective: Confidence treating critically ill infants presenting to general ED may be limited by inexperience, with procedures deferred until specialised transport teams arrive. Methods: This retrospective cohort study analysed critical procedures performed by referring ED physicians, compared with a neonatal emergency transport service, on infants transferred over a 12‐month period. Results: All 150 eligible infants were included, with median (interquartile range) age 28 (16–43) days. Forty critical procedures were performed in this cohort. Of 26 intubations, 17 (65%) were performed by local ED physicians. Conclusion: Referring ED physicians perform the majority of critical procedures where infants require inter‐hospital transfer by neonatal emergency transport service. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was to perform a cost–benefit analysis of retrospectively identifying missed compensable billings in a public Australian ED. Methods: A retrospective review of patients who were eligible for billing from the period of 1 April 2018 to 31 January 2019 was undertaken. Individual patient files were examined and reconciliated with the historical billing record and any discrepancies identified. Financial modelling with Vose ModelRisk and R Studio v1.2.5033 was employed to estimate future benefits of such a strategy. Uncertainty analyses included variation in wage cost (AU$0–200/h), discount rate (3–10%), presentation growth rate, percentage compensable, benefit recovered/patient, percentage recoverable and cost per patient. Results: A total of 76 523 patients presented during this time. Of these, 2737 patients were deemed compensable. A total of 740 undocumented billing items were identified with an estimated Medicare Benefits Schedule value of $59 870 and an Australian Medical Association value of $152 400. The net present value (NPV) of this identified cash flow stream in perpetuity was $1 436 892 (Medicare Benefits Schedule) and $3 657 600 (Australian Medical Association) (i.e. the total value of recovering this amount of money each year indefinitely, corrected for the time value of money). The positive NPV was maintained with sensitivity analysis. Conclusion: All scenarios examined led to a positive NPV favouring retrospectively identifying missed compensable billings. [ABSTRACT FROM AUTHOR]

Objectives: To describe the epidemiology, clinical practice and outcomes of paediatric ED intubation in Australia and New Zealand. Method: Prospectively collected airway management audit data from 43 EDs in Australia and New Zealand that was submitted to the Australia and New Zealand Emergency Department Airway Registry between 2010 and 2015. Results: Paediatric cases accounted for 4.94% (270/5463) of cases (median age = 3, interquartile range [IQR] = 2–9). A median of 5 (IQR = 2–9) intubations were reported per department per year. Most intubations were performed for medical indications (72.2%), including seizure (25.2%) and respiratory failure (15.2%). Patients were physiologically compromised prior to intubation with 69.5% comatose, 50.9% outside of the normal age‐adjusted range for respiratory rate, 15.9% hypoxic and 12.6% hypotensive. Complication rate was 33.3% and desaturation was the most common (18.5%). The ED mortality rate was 3.8%. First pass success (FPS) was 80% (95% CI 75.2–84.8). Infants less than 1 year of age had lower FPS, higher rates of difficult laryngoscopy and higher rates of desaturation than other age groups. Conclusion: Paediatric intubation in Australasian EDs is rare from a departmental and individual provider viewpoint. Success rates are similar to contemporary international registries. Complications are common and ongoing collaborative multicentre audit with resultant quality improvement is desirable to facilitate improved success and reduced complications. [ABSTRACT FROM AUTHOR]

Objective: To determine the relationships between: (i) total ED length of stay (EDLOS) and in‐hospital mortality, ward clinical deterioration; and (ii) between time of bed request, ward transfer and in‐hospital mortality, with a particular focus on patients transferred just prior to a 4 h EDLOS. Methods: Retrospective cohort study using data from three acute care hospitals in Melbourne, Australia. Adult patients admitted from the ED to a non‐monitored ward within 8 h. Patients were sub‐grouped by EDLOS; EDLOS 3.5–4 h compared to 0–3.5 h and 4–8 h. In‐hospital mortality, number of medical emergency team (MET)/cardiac arrest team (CAT) events. Results: A total of 24 746 patients were included: 4396 patients with EDLOS <210 min; 4090 patients with EDLOS of 210–240 min; and 16 260 patients with EDLOS >240 min. Mortality overall was 2.2% (n = 545), highest mortality was seen with EDLOS >4 h (2.4%, n = 399) and lowest in patients with EDLOS 3.5–4 h (1.5%, n = 63, OR 0.67 [95% CI: 0.47–0.93, P = 0.02]). Time from bed request to transfer of >240 min was associated with increased odds of death at hospital discharge (adjusted OR 1.39 [95% CI: 1.08–1.78]). There was no difference in rate of MET calls within 24 h between groups (3.5–4 h = 64 [1.5%], <3.5 h = 60 [1.5%], 4–8 h = 235 [1.4%]). Conclusions: Both shorter time in ED and shorter time between bed request and ward transfer were independently associated with improved outcomes. Whole of hospital measures to reduce length of stay in the ED should focus on shorter ward transfer times after bed request. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Low‐acuity ‘fast track’ patients represent a large portion of Australian EDs’ workload and must be managed efficiently to meet the National Emergency Access Target. The current study determined the relative importance and estimated marginal effects of patient and system‐related variables in predicting ED fast track patients who stayed longer than 4 h in the ED. Methods: Data for ED presentations between 1 July 2014 and 30 June 2015 were collected from a large regional Australian public hospital. Only ‘fast track’ patients were included in the analysis. A gradient boosting machine was used to predict which patients would have an ED length of stay greater or less than 4 h. The performance of the final model was tested using a validation data set that was withheld from the initial analysis. A total of 27 variables were analysed. Results: The model’s performance was very good (area under receiver operating characteristic curve 0.89, where 1.0 is perfect prediction). The five most important variables for predicting length of stay were time‐dependent and system‐related (not patient‐related); these were the amount of time taken from when the patient arrived at the ED to: (i) order imaging; (ii) order pathology; (iii) request admission to hospital; (iv) allocate a clinician to care for the patient; and (v) handover a patient between ED clinicians. Conclusions: We identified the most important variables for predicting length of stay greater than 4 h for fast track patients in our ED. Identifying factors that influence length of stay is a necessary step towards understanding ED patient flow and identifying improvement opportunities. [ABSTRACT FROM AUTHOR]

Objective The Sepsis-3 task force recommends the use of the quick Sequential Organ Failure Assessment (qSOFA) score to identify risk for adverse outcomes in patients presenting with suspected infection. Lactate has been shown to predict adverse outcomes in patients with suspected infection. The aim of the study is to investigate the utility of a post hoc lactate threshold (≥2 mmol/L) added qSOFA score (LqSOFA(2) score) to predict primary composite adverse outcomes (mortality and/or ICU stay ≥72 h) in patients presenting to ED with suspected sepsis. Methods Retrospective cohort study was conducted on a merged dataset of suspected or proven sepsis patients presenting to ED across multiple sites in Australia and The Netherlands. Patients are identified as candidates for quality improvement initiatives or research studies at respective sites based on local screening procedures. Data-sharing was performed across sites of demographics, qSOFA, SOFA, lactate thresholds and outcome data for included patients. LqSOFA(2) scores were calculated by adding an extra point to qSOFA score in patients who met lactate thresholds of ≥2 mmol/L. Results In a merged dataset of 12 555 patients where a full qSOFA score and outcome data were available, LqSOFA(2) ≥2 identified more patients with an adverse outcome (sensitivity 65.5%, 95% confidence interval 62.6-68.4) than qSOFA ≥2 (sensitivity 47.6%, 95% confidence interval 44.6- 50.6). The post hoc addition of lactate threshold identified higher proportion of patients at risk of adverse outcomes. Conclusions The lactate ≥2 mmol/L threshold-based LqSOFA(2) score performs better than qSOFA alone in identifying risk of adverse outcomes in ED patients with suspected sepsis. [ABSTRACT FROM AUTHOR]

Objectives To describe the rate of intensive care unit (ICU) admission, type of ventilation support provided and risk factors for ICU admission in infants with bronchiolitis. Design Retrospective review of hospital records and Australia and New Zealand Paediatric Intensive Care (ANZPIC) registry data for infants 2-12 months old admitted with bronchiolitis. Setting Seven Australian and New Zealand hospitals. These infants were prospectively identified through the comparative rehydration in bronchiolitis (CRIB) study between 2009 and 2011. Results Of 3884 infants identified, 3589 charts were available for analysis. Of 204 (5.7%) infants with bronchiolitis admitted to ICU, 162 (79.4%) received ventilation support. Of those 133 (82.1%) received non-invasive ventilation (high flow nasal cannula [HFNC] or continuous positive airway pressure [CPAP]) 7 (4.3%) received invasive ventilation alone and 21 (13.6%) received a combination of ventilation modes. Infants with comorbidities such as chronic lung disease (OR 1.6 [95% CI 1.0-2.6]), congenital heart disease (OR 2.3 [1.5-3.5]), neurological disease (OR 2.2 [1.2-4.1]) or prematurity (OR 1.5 [1.0-2.1]), and infants 2-6 months of age (OR 1.5 [1.1-2.0]) were more likely to be admitted to ICU. Respiratory syncitial virus positivity did not increase the likelihood of being admitted to ICU (OR 1.1 [95% CI 0.8-1.4]). HFNC use changed from 13/53 (24.5% [95% CI 13.7-38.3]) patient episodes in 2009 to 39/91 (42.9% [95% CI 32.5-53.7]) patient episodes in 2011. Conclusion Admission to ICU is an uncommon occurrence in infants admitted with bronchiolitis, but more common in infants with comorbidities and prematurity. The majority are managed with non-invasive ventilation, with increasing use of HFNC. [ABSTRACT FROM AUTHOR]

Objective ED chest pain assessments can be challenging, lengthy and contribute to overcrowding. Rapid accurate risk stratification strategies should improve ED length of stay (EDLOS). Emergency, Biochemistry and Cardiology implemented new guidelines using paired (<3 h) multiple cardiac markers to stratify patients. The intervention would reduce chest pain EDLOS. We observed for safety and disposition effects. Methods This is a single-site, prospective observational, before and after intervention study. In December 2009, paired multiple cardiac markers, the second at least 4 h from pain, replaced late troponins. The 4 h rule (ED flow improvement) started in April 2009 (unplanned confounder). Demographics, clinical features, risk assessment and disposition; preferably prospective. Administrative datasets provided disposition outcomes, 4 months pre-/post-intervention. Follow up with partially blinded adjudications assessed for 45 day major adverse cardiac events (MACE). Before intervention, consecutive patients were enrolled with mixed prospective/retrospective data. After, sampling occurred whenever prospective data were collected. Results Adjudicated patients were n = 1029 (14.2% MI, 14.9% MACE), 426 before, 603 after. EDLOS reduced 87 min (416-329; P < 0.001), similar to triage 2 patients without chest pain. Possibly, avoidable MACE occurred in five of 598 discharges (0.8%, CI 0.3-1.8%) with non-significant decreases (0.5%, CI 0.1-1.8%) post-intervention. Disposition changes included greater observation ward use (3.8-12.3%; P < 0.001), more discharges (47.4-52.9%, P = 0.002), less transfers (9.3-6.9%, P = 0.014) and less late inpatient discharge decisions (15.2-8.7%, P = 0.001). Conclusion Paired cardiac markers performed adequately for avoidable MACE, and disposition improved significantly. A confounding system change meant the reduced EDLOS (primary outcome) was unable to be associated with the intervention. [ABSTRACT FROM AUTHOR]