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Objective: Successful endotracheal intubation in the ED requires optimum body positioning. In patients with obesity, the ramp position was suggested to achieve better intubating conditions. However, limited data are available on the airway management practices for patients with obesity in Australasian EDs. The aim of this study was to identify current patient positioning practices during endotracheal intubation and its association with first‐pass success (FPS) at intubation and adverse event (AE) rates in obese and non‐obese populations. Methods: Prospectively collected data from the Australia and New Zealand ED Airway Registry (ANZEDAR) between 2012 and 2019 were analysed. Patients were categorised into two groups according to their weight: <100 kg (non‐obese) or ≥100 kg (obese). Four position categories were investigated; supine, pillow or occipital pad, bed tilt and ramp or head‐up with relation to FPS and complication rate using logistic regression modelling. Results: A total of 3708 intubations from 43 EDs were included. Overall, the non‐obese cohort had a greater FPS rate (85.9%) compared to the obese group (77.0%). The bed tilt position had the highest FPS rate (87.2%), whereas the supine position had the lowest (83.0%). AE rates were highest in the ramp position (31.2%) compared to all other positions (23.8%). Regression analysis showed ramp, or bed tilt positions and a consultant‐level intubator were associated with higher FPS. Obesity, in addition to other factors, was independently associated with lower FPS. Conclusion: Obesity was associated with lower FPS, which could be improved through performing a bed tilt or ramp positioning. [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]

Objectives: The present study aimed to describe the characteristics, performance, accuracy and significance of point‐of‐care ultrasound (POCUS) use in the ED, by utilising an expanded version of the ACEM‐mandated special skills placement (SSP) logbook, to develop a novel clinical quality registry. Methods: A prospective, observational study was performed across EDs in Australia and New Zealand over a 12‐month period. Trainees undertaking ACEM‐approved ultrasound (US) SSPs recorded all US scan interpretations and follow‐up imaging reports in an online database. Results: In total, 2647 USs were recorded by 26 special skills trainees across 10 EDs in Australia or New Zealand; of these 2356 scans (89%) were clinically indicated. Overall, 2493 scans (94%) were used for diagnostic assessment, of which 1147 (43%) had abnormal findings. Basic echocardiography, extended Focused Assessment with Sonography in Trauma and right upper quadrant scans were the most commonly used modalities. There were 134 US‐guided procedures logged in the registry. Approximately 36% of scans were reported to alter the original provisional diagnosis, whereas in another 37% of cases, POCUS was thought to confirm the original clinical suspicion. The majority of scans (76.5%) entered into the registry were physically reviewed by the SSP supervisor. Conclusions: This multicentred registry provides a detailed description of the current utilisation of POCUS within special skills US placements across EDs in Australia and New Zealand. This data should inform clinical leaders in emergency US to improve both POCUS education and governance around this important tool. [ABSTRACT FROM AUTHOR]

The use of cricoid pressure (CP) to prevent aspiration during rapid sequence induction (RSI) has become controversial, although CP is considered central to the practice of RSI. There is insufficient research to support its efficacy in reducing aspiration, and emerging concerns it reduces the first‐pass success (FPS) of intubation. This systematic review aims to assess the safety and efficacy of CP during RSI in EDs by investigating its effect on FPS and the incidence of complications, including gastric regurgitation and aspiration. A systematic review of four databases was performed for all primary research investigating CP during RSI in EDs. The primary outcome was FPS; secondary outcomes included complications such as gastric regurgitation, aspiration, hypoxia, hypotension and oesophageal intubation. After screening 4208 citations, three studies were included: one randomised controlled trial (n = 54) investigating the incidence of aspiration during the application of CP and two registry studies (n = 3710) comparing the rate of FPS of RSI with and without CP. The results of these individual studies are not sufficient to draw concrete conclusions but do suggest that aspiration occurs regardless of the application of CP, and that FPS is not reduced by the application of CP. There is insufficient evidence to conclude whether applying CP during RSI in EDs affects the rate of FPS or the incidence of complications such as aspiration. Further research in the ED, including introducing CP usage into other existing airway registries, is needed. [ABSTRACT FROM AUTHOR]

Objective: Patients intubated in the ED are at an increased risk of post‐intubation hypotension. However, evidence regarding the most appropriate induction agent is lacking. The present study aims to describe and compare the haemodynamic effect of propofol, ketamine and thiopentone during rapid sequence induction. Methods: This is an observational study using data prospectively collected from the Australian and New Zealand Emergency Department Airway Registry between June 2012 and March 2019. The distribution of induction agents across medical and trauma patients were obtained with descriptive statistics. The relationship between induction agent, dose and change in pre‐ and post‐intubation systolic blood pressure (SBP) was described using multivariable logistic regression. The SBP pre‐ and post‐intubation was the primary measure of haemodynamic stability. Results: From the 5063 intubation episodes, 2229 met the inclusion criteria. Of those, 785 (35.2%) patients were induced with thiopentone, 773 (34.7%) with propofol and 671 (30.1%) with ketamine. Of the included population, 396 (17.8%) patients experienced a reduction in pre‐intubation SBP exceeding 20%. Both propofol (P = 0.01) and ketamine (P = 0.01) had an independent and dose‐dependent association with hypotension, noting that a higher proportion of patients induced with ketamine had a shock index exceeding 0.9. Conclusion: Propofol was associated with post‐intubation hypotension and it is recommended clinicians consider using the lowest effective dose to reduce this risk. Reflecting its perceived haemodynamic stability, patients who received ketamine were more likely to have a higher shock index; however, there was also an association with post‐intubation hypotension. [ABSTRACT FROM AUTHOR]

Objective: The aims of the present study were to describe current airway management practices after a failed intubation attempt in Australian and New Zealand EDs and to explore factors associated with second attempt success. Methods: Data were collected from a multicentre airway registry (The Australian and New Zealand Emergency Department Airway Registry). All intubation episodes that required a second attempt between March 2010 and November 2015 were analysed. Analysis for association with success at the second attempt was undertaken for patient factors including predicted difficulty of laryngoscopy, as well as for changes in laryngoscope type, adjunct devices, intubator and intubating manoeuvres. Results: Of the 762 patients with a failed first intubation attempt, 603 (79.1%) were intubated successfully at the second attempt. The majority of second attempts were undertaken by emergency consultants (36.8%) and emergency registrars (34.2%). A change in intubator occurred in 56.5% of intubation episodes and was associated with higher second attempt success (unadjusted odds ratio [OR] 1.85; 95% confidence interval [CI] 1.29–2.65). In 69.7% of second attempts at intubation, there was no change in laryngoscope type. Changes in laryngoscope type, adjunct devices and intubation manoeuvres were not significantly associated with success at the second attempt. In adjusted analyses, second attempt success was higher for a change from a non‐consultant intubator to a consultant intubator from any specialty (adjusted OR 2.31; 95% CI 1.35–3.95) and where laryngoscopy was not predicted to be difficult (adjusted OR 2.58; 95% CI 1.58–4.21). Conclusions: The majority of second intubation attempts were undertaken by emergency consultants and registrars. A change from a non‐consultant intubator to a consultant intubator of any specialty for the second attempt and intubation episodes where laryngoscopy was predicted to be non‐difficult were associated with a higher success rate at intubation. Participation in routine collection and monitoring of airway management practices via a Registry may enable the introduction of appropriate improvements in airway procedures and reduce complication rates. [ABSTRACT FROM AUTHOR]

Background: An emergency front‐of‐neck access (eFONA), also called can't intubate, can't oxygenate (CICO) rescue, is a rare event. Little is known about the performance of surgical or percutaneous airways in EDs across Australia and New Zealand. Objective: To describe the management of cases resulting in an eFONA, and recorded in The Australian and New Zealand Emergency Department Airway Registry (ANZEDAR). Methods: A retrospective case series and review of ED patients undergoing surgical or percutaneous airways. Data were collected prospectively over 60 months between 2010 and 2015 from 44 participating EDs. Results: An eFONA/CICO rescue airway was performed on 15 adult patients: 14 cricothyroidotomies (0.3% of registry intubations) and one tracheostomy. The indication for intubation was 60% trauma and 40% medical aetiologies. The intubator specialty was emergency medicine in eight (53.3%) episodes. Thirteen (86.7%) cricothyroidotomies and the sole tracheostomy (6.7%) were performed at major referral hospitals with 12 (80%) surgical airways out of hours. In four (26.7%) cases, cricothyroidotomy was performed as the primary intubation method. Pre‐oxygenation techniques were used in 14 (93.3%) episodes; apnoeic oxygenation in four (26.7%). Conclusions: Most cases demonstrated deviations from standard difficult airway practice, which may have increased the likelihood of performance of a surgical airway, and its increased likelihood out of hours. Our findings may inform training strategies to improve care for ED patients requiring this critical intervention. We recommend further discussion of proposed standard terminology for emergency surgical or percutaneous airways, to facilitate clear crisis communication. [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]

Objectives: To determine the impact of the emergency physiotherapy service provided through different models of care on service quality indicators, patient flow, staff and patient satisfaction. Method: A mixed method prospective observation study was conducted between September 2014 and April 2015 in 19 EDs where a physiotherapy service is provided. Results: Patients seen by the primary contact physiotherapist (PCP) were associated with a significant reduction in ED length of stay by 108 min, wait time to treatment by 10 min (n = 4 EDs) and time‐to‐first analgesia by 18 min (n = 19 EDs) compared to those seen through usual care processes. Patients who received care by a doctor first and then physiotherapist (secondary contact model) had a prolonged length of stay compared to other care pathways. High levels of satisfaction with the PCP role were expressed by ED staff (n = 17 EDs) and patients (n = 19 EDs). More than 95% of patients who received care by PCP were satisfied with the management of their condition, understood the advice and discharge information provided and had enough time to ask questions. Conclusion: ED implementation of the PCP model may improve patient flow and efficiency of clinical skill utilisation in a complex, high demand workplace. [ABSTRACT FROM AUTHOR]

Objective: To study ED utilisation by people aged 100 years and over with a focus on patient demographics, reasons for presentation and patient flow factors. Methods: This is a retrospective descriptive analysis of linked ED Data Collection Registry for presentations to New South Wales (NSW) EDs over a 5 year period. Patients were included if they presented to an ED and were aged 100 years and over at the time of presentation. Demographics, triage category, presenting problem, ED length of stay, disposition and ED re‐presentation were determined for this age group. Results: A total of 4033 presentations to 115 NSW EDs during 2010–2014 were analysed. We found that 78% of the patients were females and 76% still living at home. This group were the second most common age group to present to ED, after the 90–99 year age group, with 87% arriving via ambulance. Most presentations were triaged as a category 3 or 4, with the most common presenting problem being because of injury (28.5%) followed by respiratory disease (11.4%) and cardiovascular disease (10.0%). Overall, 64% required hospital admission and the average length of stay for all patients was 5.7 h. Conclusions: Centenarians ED presentations are increasing over time with injuries as the most common reason for presentation. Most patients have prolonged ED length of stay and many require hospital admission. Early streaming of these patients through specialised geriatric assessment units may be more appropriate to reduce the demand on EDs and improve patient care. Models that facilitate rapid access to supported living arrangements and improved advanced care planning may be more realistic for many centenarians and different models of care need to be considered for this age group. [ABSTRACT FROM AUTHOR]

Background: Emergency departments (EDs) are pressured environment where patients with supportive and palliative care needs may not be identified. We aimed to test the predictive ability of the CriSTAL (Criteria for Screening and Triaging to Appropriate aLternative care) checklist to flag patients at risk of death within 3 months who may benefit from timely end‐of‐life discussions. Methods: Prospective cohorts of >65‐year‐old patients admitted for at least one night via EDs in five Australian hospitals and one Irish hospital. Purpose‐trained nurses and medical students screened for frailty using two instruments concurrently and completed the other risk factors on the CriSTAL tool at admission. Postdischarge telephone follow‐up was used to determine survival status. Logistic regression and bootstrapping techniques were used to test the predictive accuracy of CriSTAL for death within 90 days of admission as primary outcome. Predictability of in‐hospital death was the secondary outcome. Results: A total of 1,182 patients, with median age 76 to 80 years (IRE‐AUS), were included. The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% confidence interval [CI] = 7.7–8.6) versus 5.7 (95% CI = 5.1–6.2) and Irish mean of 7.7 (95% CI = 6.9–8.5) versus 5.7 (95% CI = 5.1–6.2). The model with Fried frailty score was optimal for the derivation (Australian) cohort but prediction with the Clinical Frailty Scale (CFS) was also good (areas under the receiver‐operating characteristic [AUROC] = 0.825 and 0.81, respectively). Values for the validation (Irish) cohort were AUROC = 0.70 with Fried and 0.77 using CFS. A minimum of five of 29 variables were sufficient for accurate prediction, and a cut point of 7+ or 6+ depending on the cohort was strongly indicative of risk of death. The most significant independent predictor of short‐term death in both cohorts was frailty, carrying a twofold risk of death. CriSTAL's accuracy for in‐hospital death prediction was also good (AUROC = 0.795 and 0.81 in Australia and Ireland, respectively), with high specificity and negative predictive values. Conclusions: The modified CriSTAL tool (with CFS instead of Fried's frailty instrument) had good discriminant power to improve certainty of short‐term mortality prediction in both health systems. The predictive ability of models is anticipated to help clinicians gain confidence in initiating earlier end‐of‐life discussions. The practicalities of embedding screening for risk of death in routine practice warrant further investigation. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to quantify the proportion of patients undergoing rapid sequence intubation using ketamine in Australian and New Zealand EDs between 2010 and 2015. Methods: The Australian and New Zealand Emergency Department Airway Registry is a multicentre airway registry prospectively capturing data from 43 sites. Data on demographics and physiology, the attending staff and indication for intubation were recorded. The primary outcome was the annual percentage of patients intubated with ketamine. A logistic regression analysis was conducted to evaluate the factors associated with ketamine use. Results: A total of 4658 patients met inclusion criteria. The annual incidence of ketamine use increased from 5% to 28% over the study period (P < 0.0001). In the logistic regression analysis, the presence of an emergency physician as a team leader was the strongest predictor of ketamine use (odds ratio [OR] 1.83, 95% confidence interval [CI] 1.44–2.34). The OR for an increase in one point on the Glasgow Coma Scale was 1.10 (95% CI 1.07–1.12), whereas an increase of 1 mmHg of systolic blood pressure had an OR of 0.98 (95% CI 0.98–0.99). Intubation occurring in a major referral hospital had an OR of 0.68 (95% CI 0.56–0.82), while trauma conferred an OR of 1.38 (95% CI 1.25–1.53). Conclusions: Ketamine use increased between 2010 and 2015. Lower systolic blood pressure, the presence of an emergency medicine team leader, trauma and a higher Glasgow Coma Scale were associated with increased odds of ketamine use. Intubation occurring in a major referral centre was associated with lower odds of ketamine use. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To describe the practice and procedure of emergency intubation in Whanganui Emergency Department, New Zealand and determine whether intubation can be carried out effectively in the rural setting. Method: A prospective observational study using the Australia and New Zealand Airway Registry proforma to collect data on the indication, lead intubator, first‐pass success rate and peri‐procedural complications. Data were also collected on whether a formal airway assessment was carried out and whether a checklist was used. Results: Twenty‐three patients were intubated in the emergency department over a 12‐month period. Sixty‐two percent (14/23 cases) were medical encounters and the remaining 38% of indications due to a trauma. Head injury was the most common indication (23%). Ninety‐two percent of primary intubators were emergency department‐based Fellowship of the Australasian College for Emergency Medicine or resident medical officers, while anaesthetic‐trained operators accounted for just 8%. Our first‐pass intubation success rate was 87% and 16% of cases had procedural complications. Sixty‐five percent (15/23) carried out a formal airway assessment and a checklist was only used in 23% of cases. Conclusion: This sequential case series is the first study looking at airway management in rural New Zealand emergency department airway practice. Overall intubation success rates were comparable to larger tertiary centres across Australasia. We have demonstrated that with adequate resources and adherence to interventions, a rural emergency department can provide effective airway management. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to describe the practice of endotracheal intubation across a range of Australasian EDs. Methods We established a multicentre airway registry (The Australian and New Zealand Emergency Department Airway Registry [ ANZEDAR]) prospectively capturing intubations from 43 Australian and New Zealand EDs over 24 months using the ANZEDAR form. Information recorded included patient demographics, intubation indications, predicted difficulty, rapid sequence induction and endotracheal intubation preparation technique, induction drugs, airway adjuncts and complications. Factors associated with first attempt success were explored. Results Of the 3710 intubations captured, 3533 were in adults (95.2%), 2835 (76.4%) for medical and 810 (21.8%) for trauma indications. Overall, 3127 (84.3%) patients were successfully intubated at the first attempt; the majority by ED doctors (2654 [72.1%]). A total of 10 surgical airways were performed, all of which were successful cricothyroidotomies. Propofol, thiopentone or ketamine were used with similar frequency for induction, and suxamethonium was the most often used muscle relaxant. Adverse events were reported in 964 (26%), the majority involving desaturation or hypotension. Conclusion Australasian ED doctors, predominantly specialist emergency physicians or trainees, perform the majority of ED intubations using rapid sequence induction as their preferred technique mainly for medical indications. First attempt success rate was not different between different types of EDs, and is comparable published international data. Complications are not infrequent, and are comparable to other published series. Monitoring and reporting of ED intubation practice will enable continued improvements in the safety of this high-risk procedure. [ABSTRACT FROM AUTHOR]

Objective We aim to investigate whether a bundle of changes made to the practice of endotracheal intubation in our ED was associated with an improvement in first pass success rate and a reduction in the incidence of complications. Methods We used a prospective observational study. Results The data on 360 patients who were intubated during an 18-month period following the introduction of these changes were compared with our previously published observational data. Success on first attempt at intubation improved 83.4% to 93.9% ( P < 0.0001). The proportion of patients with one or more complication fell from 29.0% to 19.4% ( P < 0.042). Oesophageal intubation fell from 4.0% to 0.3% ( P < 0.001), and there was a non-significant reduction in the rate of desaturation, from 15.6% to 10.9% ( P < 0.07). Conclusion We have shown that, through the introduction of a bundle of changes that spans the domains of staff training, equipment and practice standardisation, we have made significant improvements in the safety of patients undergoing endotracheal intubation in our ED. [ABSTRACT FROM AUTHOR]