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Objectives: To examine changes in out‐of‐hospital cardiac arrest (OHCA) characteristics and outcomes during 2003–2022, and 12‐month outcomes for people who experienced OHCA during 1 January 2010 – 30 June 2022. Study design: Retrospective observational study; analysis of Victorian Ambulance Cardiac Arrest Registry (VACAR) data. Setting, participants: OHCA events in Victoria not witnessed by emergency medical services personnel, 1 January 2003 – 31 December 2022. Main outcome measures: Crude and age‐standardised annual OHCA incidence rates; survival to hospital discharge. Results: Of 102 592 OHCA events included in our analysis, 67 756 were in men (66.3%). The age‐standardised incidence did not change significantly across the study period (2003: 89.1 cases, 2022: 91.2 cases per 100 000 population; for trend: P = 0.50). The proportion of OHCA cases with attempted resuscitation by emergency medical services in which bystanders attempted cardio‐pulmonary resuscitation increased from 40.3% in 2003/2004 to 72.2% in 2021/2022, and that of public access defibrillation from 0.9% to 16.1%. In the Utstein comparator group (witnessed OHCA events in which the initial cardiac rhythm was ventricular fibrillation or ventricular tachycardia, with attempted resuscitation by emergency medical services), the odds of survival to hospital discharge increased during 2003–2022 (adjusted odds ratio (aOR), 3.08; 95% confidence interval [CI], 2.22–4.27); however, the odds of survival was greater than in 2012 only in 2018 (aOR, 1.37; 95% CI, 1.04–1.80) and 2019 (aOR, 1.68; 95% CI, 1.28–2.21). The COVID‐19 pandemic was associated with reduced odds of survival (aOR, 0.63; 95% CI, 0.54–0.74). Of 3161 people who survived OHCA and participated in 12‐month follow‐up, 1218 (38.5%) reported full health according to the EQ‐5D. Conclusion: Utstein survival to hospital discharge increased threefold during 2003–2022, and the proportions of cases in which bystanders provided cardio‐pulmonary resuscitation or public access defibrillation increased. The COVID‐19 pandemic was associated with a substantial reduction in survival, and new strategies are needed to improve outcomes. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the impact of the Southeast Melbourne Virtual Emergency Department (SEMVED) on transfers from residential aged care facilities (RACFs) to traditional EDs. Methods: A cohort study of residents requesting transfer to the ED via ambulance within participating health networks' catchments from April to June 2022. Results: Two hundred thirty‐eight VED consultations occurred with 79% (188/238) avoiding transfer. This represented an avoidance of 12% (188/1511) of all requests for transfer during operating hours. Conclusions: SEMVED prevented unnecessary transfers and enabled in‐facility care. Integration into community outreach programmes could enhance care delivery. Patient safety outcomes were not formally assessed by our methodology. [ABSTRACT FROM AUTHOR]

Over 10 million ED visits occur each year across Australia and Aotearoa New Zealand. Outside basic administrative data focused on time‐based targets, there is minimal information about clinical performance, quality of care, patient outcomes, or equity in emergency care. The lack of a timely, accurate or clinically useful data collection represents a missed opportunity to improve the care we deliver each day. The present paper outlines a proposal for a National Acute Care Secure Health Data Environment, including design, possible applications, and the steps taken to date by the Australasian College for Emergency Medicine ED Epidemiology Network in collaboration with the College of Emergency Nursing Australasia. Optimal use of the existing information collected routinely during clinical care of emergency patients has the potential to enable data‐driven quality improvement and research, leading to better care and better outcomes for millions of patients and families each year. [ABSTRACT FROM AUTHOR]

Objectives Methods Results Conclusions The aim of the present study was to examine the profile, management and outcomes of adult patients with severe burns within the Victorian State Trauma System (VSTS).Data from the Victorian State Trauma Registry (VSTR) was analysed to characterise patient and injury characteristics and review pre‐hospital management and clinical outcomes of adult patients with severe burns.There were 421 cases over 13 years of the study. Approximately 80% of cases were flame burns, and 5% were associated with other significant trauma. Approximately 75% were male; with 83% of patients under 65 years old, 40% of lower socioeconomic status, 25% having pre‐existing drug and alcohol involvement, and 36% living with associated comorbidities. All but 11 patients (of 421) were managed definitively at the burns service. Around one‐third of patients had interhospital transfer, with median (interquartile range (IQR)) time spent in the primary hospital 3.0 (1.9–4.3) h. Only five patients had multiple interhospital transfers. Nearly 75% of patients were admitted to an ICU. The median (IQR) length of definitive hospital stay was 27.2 (11.2–44.9) days. The mortality rate was 23.8%.Severe burns are uncommon injuries with high mortality. There is a high rate of adherence to VSTS guidelines for managing patients with severe burns, and a decrease in patients requiring transfer associated with an increase in acceptable time to a trauma‐receiving hospital. The VSTS operates to deliver almost all patients with severe burns to the definitive burns service efficiently. [ABSTRACT FROM AUTHOR]

Objective: The ambulance service in Victoria, Australia implemented a revised clinical response model (CRM) in 2016 which was designed to increase the diversion of low‐acuity Triple Zero (000) calls to secondary telephone triage and reduce emergency ambulance dispatches. The present study evaluates the influence of the revised CRM on emergency ambulance response times and ED presentations. Methods: A retrospective study of emergency calls for ambulance between 1 January 2015 and 31 December 2018. Ambulance data were linked with ED presentations occurring up to 48 h after contact. Interrupted time series analyses were used to evaluate the impact of the revised CRM. Results: A total of 2 365 529 calls were included. The proportion allocated a Code 1 (time‐critical, lights/sirens) dispatch decreased from 56.6 to 41.0% after implementation of the revised CRM. The proportion of calls not receiving an emergency ambulance increased from 10.4 to 19.6%. Interrupted time series analyses demonstrated an improvement in Code 1 cases attended within 15 min (Key Performance Indicator). However, for patients with out‐of‐hospital cardiac arrest or requiring lights and sirens transport to hospital, there was no improvement in response time performance. By the end of the study period, there was also no difference in the proportion of callers presenting to ED when compared with the estimated proportion assuming the revised CRM had not been implemented. Conclusion: The revised CRM was associated with improved Code 1 response time performance. However, there was no improvement in response times for high acuity patients, and no change in the proportion of callers presenting to ED. [ABSTRACT FROM AUTHOR]

The centralisation of trauma services in western countries has led to an improvement in patient outcomes. Effective trauma systems include a pre‐hospital trauma system. Delivery of high‐level pre‐hospital trauma care must include identification of potential major trauma patients, access and correct application of lifesaving interventions (LSIs) and timely transport to definitive care. Globally, many nations endorse nationwide pre‐hospital major trauma triage guidelines, to ensure a universal approach to patient care. This paper examined clinical guidelines from all 10 EMS in Australia and Aotearoa/New Zealand. All relevant trauma guidelines were included, and key information was extracted. Authors compared major trauma triage criteria, all LSI included in guidelines, and guidelines for transport to definitive care. The identification of major trauma patients varied between all 10 EMS, with no universal criteria. The most common approach to trauma triage included a three‐step assessment process: physiological criteria, identified injuries and mechanism of injury. Disparity between physiological criteria, injuries and mechanism was found when comparing guidelines. All 10 EMS had fundamental LSI included in their trauma guidelines. Fundamental LSI included haemorrhage control (arterial tourniquets, pelvic binders), non‐invasive airway management (face mask ventilation, supraglottic airway devices) and pleural wall needle decompression. Variation in more advanced LSI was evident between EMS. Optimising trauma triage guidelines is an important aspect of a robust and evidence driven trauma system. The lack of consensus in trauma triage identified in the present study makes benchmarking and comparison of trauma systems difficult. Effective trauma systems include a pre‐hospital trauma system. Delivery of high‐level pre‐hospital trauma care must include identification of potential major trauma patients, access and correct application of lifesaving interventions (LSIs), and timely transport to definitive care. Authors compared major trauma triage criteria, all LSI included in guidelines, and guidelines for transport to definitive care, and identified variations between all systems included in the present study. [ABSTRACT FROM AUTHOR]

Introduction: Triage is widely regarded as an essential function of emergency care (EC) systems, especially in resource‐limited settings. Through a systematic search and review of the literature, we investigated the effect of triage implementation on clinical outcomes and process measures in low‐ and middle‐income country (LMIC) emergency departments (EDs). Methods: Structured searches were conducted using MEDLINE, CENTRAL, EMBASE, CINAHL, and Global Health. Eligible articles identified through screening and full‐text review underwent risk‐of‐bias assessment using the Newcastle‐Ottawa Scale. The quality of evidence for each effect measure was summarized using GRADE. Results: Among 10,394 articles identified through the search strategy, 58 underwent full‐text review and 16 were included in the final synthesis. All utilized pre‐/postintervention methods and a majority were single center. Effect measures included mortality, waiting time, length of stay, admission rate, and patient satisfaction. Of these, ED mortality and time to clinician assessment were evaluated most frequently. The majority of studies using these outcomes identified a positive effect, namely a reduction in deaths and waiting time among patients presenting for EC. The quality of the evidence was moderate for these measures but low or very low for all other outcomes and process indicators. Conclusions: There is moderate quality of evidence supporting an association between the introduction of triage and a reduction in deaths and waiting time. Although the available data support the value of triage in LMIC EDs, the risk of confounding and publication bias is significant. Future studies will benefit from more rigorous research methods. [ABSTRACT FROM AUTHOR]

Objective: To measure the prevalence of alcohol and/or other drug (AOD) detections in suspected major trauma patients with non‐transport injuries who presented to an adult major trauma centre. Methods: This registry‐based cohort study examined the prevalence of AOD detections in patients aged ≥18 years who: (i) sustained non‐transport injuries; and (ii) met predefined trauma call‐out criteria and were therefore managed by an interdisciplinary trauma team between 1 July 2021 and 31 December 2022. Prevalence was measured using routine in‐hospital blood alcohol and urine drug screens. Results: A total of 1469 cases met the inclusion criteria. Of cases with a valid blood test (n = 1248, 85.0%), alcohol was detected in 313 (25.1%) patients. Of the 733 (49.9%) cases with urine drug screen results, cannabinoids were most commonly detected (n = 103, 14.1%), followed by benzodiazepines (n = 98, 13.4%), amphetamine‐type substances (n = 80, 10.9%), opioids (n = 28, 3.8%) and cocaine (n = 17, 2.3%). Alcohol and/or at least one other drug was detected in 37.4% (n = 472) of cases with either a blood alcohol or urine drug test completed (n = 1263, 86.0%). Multiple substances were detected in 16.6% (n = 119) of cases with both blood alcohol and urine drug screens (n = 718, 48.9%). Detections were prevalent in cases of interpersonal violence (n = 123/179, 68.7%) and intentional self‐harm (n = 50/106, 47.2%), and in those occurring on Friday and Saturday nights (n = 118/191, 61.8%). Conclusion: AOD detections were common in trauma patients with non‐transport injury causes. Population‐level surveillance is needed to inform prevention strategies that address AOD use as a significant risk factor for serious injury. [ABSTRACT FROM AUTHOR]

Objective: Virtual ED (VED) can potentially alleviate ED overcrowding which has been a public health challenge. The aim of the present study was to conduct a return‐on‐investment analysis of a VED programme developed in response to changing healthcare needs in Australia. Methods: An economic model was developed based on initial patient outcome data to assess the healthcare costs, potential costs saved and return on investment (ROI) from the VED. The VED programme operating as part of Alfred Health Emergency Services. The participants were the first 188 patients accessing the Alfred Health VED. VED is the delivery of emergency assessment and management of specific patients virtually via audio‐visual teleconferencing. ROI ratios that compare cost savings with intervention costs. Results: The mean total operational cost of VED for 79 days for 188 patients was A$344 117 (95% uncertainty interval [UI] $296 800–$392 088). The VED led to a potential A$286 779 (95% UI $241 688–$330 568) healthcare cost saving from reductions in emergency visits and A$97 569 (95% UI $74 233–$123 117) cost saving in ambulance services. The ROI ratio was estimated at 1.12 (95% UI 0.96–1.32). Conclusions: The VED was cost neutral in a conservatively modelled scenario but promising if any hospital admission could be saved. Ongoing research examining a larger cohort with community follow up is required to confirm this promising result. [ABSTRACT FROM AUTHOR]

Objectives: The Victorian State Trauma System recommends that all major trauma patients receive definitive care at a major trauma service (MTS). The aim of the present study was to assess the outcomes of patients with major trauma after near‐hangings who received definitive management at an MTS compared to a non‐MTS. Methods: This was a registry‐based cohort study of all adult (age ≥16 years) patients with near‐hanging included in the Victorian State Trauma Registry from 1 July 2010 to 30 June 2019. Outcomes of interest were death at hospital discharge, time to death and extended Glasgow Outcome Scale (GOSE) score of 5–8 (favourable) at 6 months. Results: There were 243 patients included and 134 (55.1%) in‐hospital deaths. Among patients presenting to a non‐MTS, 24 (16.8%) were transferred to an MTS. There were 59 (47.6%) deaths at an MTS and 75 (63.0%) at a non‐MTS (odds ratio [OR] 0.53; 95% confidence interval [CI] 0.32–0.89). However, more patients were managed at a non‐MTS after out‐of‐hospital cardiac arrest (58.8% vs 50.8%) and less patients had serious neck injury (0.8% vs 11.3%). After adjustment for out‐of‐hospital cardiac arrests and serious neck injury, management at an MTS was not associated with mortality (adjusted OR [aOR] 0.61; 95% CI 0.23–1.65) or favourable GOSE at 6 months (aOR 1.09; 95% CI 0.40–3.03). Conclusions: After major trauma sustained from near‐hanging, definitive management at an MTS did not offer a mortality benefit or better functional outcomes. Consistent with current practice, these findings suggest that most near‐hanging related major trauma patients could be managed safely at a non‐MTS. [ABSTRACT FROM AUTHOR]

Objective: Supported by the state government, three health networks partnered to initiate a virtual ED (VED), as part of a broader roll‐out of emergency telehealth services in Victoria. The aim of the present study (Southeast Region Virtual Emergency Department‐1 [SERVED‐1]) was to report the initial 5‐month experience and included all patients assessed through the service over the first 5 months (1 February 2022 to 30 June 2022). Methods: VED consults occurred after referral from paramedics in the pre‐hospital setting. Electronic medical records were retrospectively reviewed for demographic, presenting complaint and outcome data. The primary outcome was the count of VED consultations. The secondary outcome was the proportion of patients where physical ED attendance was avoided within 72 h. The proportion of physical ED attendances avoided sub‐grouped by primary presenting complaints were reported. Results: There were 1748 patients who had a VED consultation, of which 1261 (72.1%; 95% confidence interval [CI] 70.0–74.2) patients had physical presentation to an ED avoided in the 72 h following the consult. There was a significant increase in consultations over the 5‐month period (incidence rate ratio 1.27; 95% CI 1.23–1.31, P < 0.001) that was consistent in the three health services. The most common presenting complaints were COVID‐19 and shortness of breath, and physical presentation was avoided most often among younger patients and those with COVID‐19. Conclusions: Initial experience demonstrated a significant increase in adoption of the service and an overall avoidance of physical ED attendance by a majority of patients. These results support ongoing VED consultations, complemented by follow up and health economic evaluations. [ABSTRACT FROM AUTHOR]

Objectives: To assess the mental health and wellbeing of health and aged care workers in Australia during the second and third years of the coronavirus disease 2019 (COVID‐19) pandemic, overall and by occupation group. Design, setting, participants: Longitudinal cohort study of health and aged care workers (ambulance, hospitals, primary care, residential aged care) in Victoria: May–July 2021 (survey 1), October–December 2021 (survey 2), and May–June 2022 (survey 3). Main outcome measures: Proportions of respondents (adjusted for age, gender, socio‐economic status) reporting moderate to severe symptoms of depression (Patient Health Questionnaire‐9, PHQ‐9), anxiety (Generalized Anxiety Disorder scale, GAD‐7), or post‐traumatic stress (Impact of Event Scale‐6, IES‐6), burnout (abbreviated Maslach Burnout Inventory, aMBI), or high optimism (10‐point visual analogue scale); mean scores (adjusted for age, gender, socio‐economic status) for wellbeing (Personal Wellbeing Index–Adult, PWI‐A) and resilience (Connor Davidson Resilience Scale 2, CD‐RISC‐2). Results: A total of 1667 people responded to at least one survey (survey 1, 989; survey 2, 1153; survey 3, 993; response rate, 3.3%). Overall, 1211 survey responses were from women (72.6%); most respondents were hospital workers (1289, 77.3%) or ambulance staff (315, 18.9%). The adjusted proportions of respondents who reported moderate to severe symptoms of depression (survey 1, 16.4%; survey 2, 22.6%; survey 3, 19.2%), anxiety (survey 1, 8.8%; survey 2, 16.0%; survey 3, 11.0%), or post‐traumatic stress (survey 1, 14.6%; survey 2, 35.1%; survey 3, 14.9%) were each largest for survey 2. The adjusted proportions of participants who reported moderate to severe symptoms of burnout were higher in surveys 2 and 3 than in survey 1, and the proportions who reported high optimism were smaller in surveys 2 and 3 than in survey 1. Adjusted mean scores for wellbeing and resilience were similar at surveys 2 and 3 and lower than at survey 1. The magnitude but not the patterns of change differed by occupation group. Conclusion: Burnout was more frequently reported and mean wellbeing and resilience scores were lower in mid‐2022 than in mid‐2021 for Victorian health and aged care workers who participated in our study. Evidence‐based mental health and wellbeing programs for workers in health care organisations are needed. Trial registration: Australian New Zealand Clinical Trials Registry: ACTRN12621000533897 (observational study; retrospective). [ABSTRACT FROM AUTHOR]

Objective: To explore and compare the characteristics of frequent attenders to the ED at an Australian and a Canadian tertiary hospitals by utilising a network analysis approach. Methods: We conducted a retrospective population‐based study using administrative data over the 2018 and 2019 calendar years. Participants were from a tertiary hospital in Melbourne, Australia, and Toronto, Canada. Frequent attenders were defined as patients with four or more visits in 12 months. Characteristics of younger (18–39 years), middle‐aged (40–69 years) and older (70 years and older) frequent attenders were described using descriptive statistics and network analyses. Results: Younger frequent attenders were characterised by mental illness and substance use, while older frequent attenders had high rates of physical (including chronic) diseases. Middle‐aged frequent attenders were characterised by a combination of mental and physical illnesses. These findings were observed at both hospitals. Across all age groups, the network analyses between the Melbourne and Toronto hospitals were different. Among older frequent attender visits, more diagnoses were associated with high triage acuity at the Toronto hospital than at the Melbourne hospital. Some associations were similar at both sites, for example, the negative correlation between high triage acuity and joint pain. Conclusion: Younger, middle‐aged and older frequent attenders have distinct characteristics, made readily apparent by using network analyses. Future interventions to reduce ED visits should consider the heterogeneity of frequent attenders who have needs specific to their age, presenting problems and jurisdiction. [ABSTRACT FROM AUTHOR]

Objective: To report the frequency of electric scooter‐related trauma and association with alcohol and other drug (AOD) use. Methods: A retrospective cohort study was conducted, including presentations from 1 January 2017 to 31 May 2022 to a metropolitan health service. Results: There were 272 cases included, with increasing frequency, of which 65 (24%) had AOD exposure. Most AOD‐related trauma occurred at night, among males, without helmet use, had higher injury severity, requirement for surgical intervention and longer hospital length of stay. Conclusions: Urgent preventive measures with a focus on reducing AOD exposure and promoting of helmet use is indicated. [ABSTRACT FROM AUTHOR]

Objective: To report the initial experience of a newly built Priority Primary Care Centre (PPCC) from the ED perspective. Methods: A single‐centre prospective cohort study, assessing referrals to the PPCC from 1 February to 30 June 2023. Results: There were 1240 patients referred to the PPCC from the ED, of which 87 (7.0%) were referred back to the ED. The incidence rate of PPCC referrals was 4.2% (95% confidence interval 4.0–4.5). Conclusions: The PPCC enabled re‐direction of a small proportion of ED presentations. Early results suggest that such patients can be adequately selected and managed at PPCCs. [ABSTRACT FROM AUTHOR]

The purpose of this note is to define a graph whose vertex set is a finite group G $G$, whose edge set is contained in that of the commuting graph of G $G$ and contains the enhanced power graph of G $G$. We call this graph the deep commuting graph of G $G$. Two elements of G $G$ are joined in the deep commuting graph if and only if their inverse images in every central extension of G $G$ commute. We give conditions for the graph to be equal to either of the enhanced power graph and the commuting graph, and show that automorphisms of G $G$ act as automorphisms of the deep commuting graph. [ABSTRACT FROM AUTHOR]

There has been great interest regarding tele‐emergency care (TEC) and its utility following the COVID‐19 pandemic. We have seen a roll out of multiple TEC services across Australia, operating in isolation, without coordination and under differing models of care, creating the potential for an uncoordinated, inefficient healthcare system. We outline a potential framework under which TEC services might function as part of the current system, defining potential strategies that may be used to appropriately coordinate the acute care of select patients outside of the ED as well as improve the efficiency of the physical ED itself. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was to describe the burden of patients presenting to the ED with symptoms occurring after receiving a COVID‐19 vaccination. Methods: This was a retrospective cohort study performed over a 4‐month period across two EDs. Participants were eligible for inclusion if it was documented in the ED triage record that their ED attendance was associated with the receipt of a COVID‐19 vaccination. Data regarding the type of vaccine (Comirnaty or ChAdOx1) were subsequently extracted from their electronic medical record. Primary outcome was ED length of stay (LOS) and secondary outcomes included requests for imaging and ED disposition destination. Results: During the study period of 22 February 2021 to 21 June 2021, 632 patients were identified for inclusion in the present study, of which 543 (85.9%) had received the ChAdOx1 vaccination. The highest proportion of COVID‐19 vaccine‐related attendances occurred in June 2021 and accounted for 21 (8%) of 262 total daily ED attendances. Patients who had an ED presentation related to ChAdOx1 had a longer median ED LOS (253 vs 180 min, P < 0.001) compared to Comirnaty and a higher proportion had haematology tests and imaging requested in the ED. Most patients (n = 588, 88.8%) were discharged home from the ED. Conclusion: There was a notable proportion of ED attendances related to recent COVID‐19 vaccination administration, many of which were associated with lengthy ED stays and had multiple investigations. In the majority of cases, the patients were able to be discharged home from the ED. [ABSTRACT FROM AUTHOR]

This study describes the duration and reasons for hospitalisation for three cohorts of younger adults with neurological conditions who either used residential aged care (RAC) or lived in the community. Hospitalisations as a clinical event indicate conditions for which younger people in RAC may need support as they move into community‐based housing. Data describing 3 years of hospitalisations in Victorian public hospitals and emergency departments were used. The neurological conditions occurring among the three cohorts include (1) Cerebral Vascular Accident (CVA), (2) Traumatic Brain Injury (TBI) and (3) Multiple Sclerosis (MS). Frequency of hospitalisation, length of stay and leading causes of potentially preventable hospitalisations were examined. Two hundred and fifty‐two (2.7%) of 9333 patients hospitalised for these neurological conditions subsequently used RAC. Hospitalisations were more frequent for those using RAC compared to those living in the community for cohorts with CVA and TBI (6.26 vs. 2.65 events per person‐year for CVA and 4.34 vs. 1.88 for TBI) while hospitalisations were more frequent among those in the community compared to those using RAC for the cohort living with MS (3.62 vs. 5.35 per person‐year). However, for all the cohorts, the average length of acute hospital stays was longer among RAC users than among those in the community (19.6 vs. 6.2 days for CVA, 15.5 vs. 4.5 for TBI and 12.2 vs. 7.0 for MS). Leading causes for hospitalisation were complex comorbidities and changes in health status (such as seizures, ulcers, dehydration and cellulitis). Efforts should be made to design supports and proactively manage health needs leading to these hospitalisations. [ABSTRACT FROM AUTHOR]

Objective: We sought to explore the activities, responsibilities and experience of leadership from Pacific emergency medicine (EM) doctors. Additionally, we explored knowledge, attitudes, leadership gaps and training insights for individual clinicians, and from a Pacific regional perspective. Methods: This was a qualitative study using in‐depth, semi‐structured interviews of invited Pacific EM doctors occupying a leadership role in their countries. Data were recorded, transcribed and triangulated with written field notes. Whole interviews and responses per topic were analysed using data‐platform‐based and manual methods. Inductive and deductive coding and thematic content analysis was performed in partnership with Pacific co‐researchers to determine overall meaning. Monash University granted ethics approval. Results: Twelve doctors participated (11 verbal, one written response), representing six different Pacific Island countries. Four key themes were identified which reflected both the individual agency of the Pacific EM doctors and how their experience was constituted by others; professional identity and style; nurturing relationships and building solidarity; growth through experience, education and challenge; and progress and precarity. Pacific EM leaders perform clinical, management, advocacy and education tasks, and build their capacity and resilience through leadership training. They have a strong desire for regional solidarity and networking. Conclusions: Pacific EM doctors embrace leadership in their home countries and collaborate to drive positive change, build teams and gain recognition. As pioneers and advocates for EM, they bear high responsibility and risk burnout. These findings can inform future targeted leadership training and contribute to building Pacific regional networks for career sustainability and specialty advancement. We interviewed 12 Pacific emergency medicine (EM) doctors to explore their activities, responsibilities and experience of leadership, from both an individual and regional perspective. Pacific EM doctors modelled a supportive, collaborative style of leadership that balanced approachability with authority and was nurtured through interpersonal and regional solidarity. Targeted leadership training, supportive relationships and resource sharing will enable future regional networking, specialty development and sustainable individual leadership for EM doctors across the Pacific. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to characterise the most common injury profiles and interventions in older major trauma patients, and how they change with age. Methods: This is a retrospective review of interventions, injury profiles and outcomes of major trauma patients aged 65 years and older from 2007 to 2018, using data from the Victorian State Trauma Registry. A latent class analysis (LCA) was used to identify homogenous injury groups. Results: The LCA identified five injury profiles: isolated head injury; chest/upper limb injuries; multi‐trauma; isolated spine; and head/chest/upper limb. Among 10,001 patients, 50% had an isolated head injury, and 83% of patients received definitive treatment at a major trauma centre. 50% of patients received a surgical or non‐surgical intervention, and 36% underwent surgery. These proportions declined with increasing age. Conclusions: Older patients with major trauma are a heterogeneous group, whose mechanisms and patterns of injury, and clinical management change with increasing age. [ABSTRACT FROM AUTHOR]

Objective: Trauma is one of the most common contributors to maternal and foetal morbidity and mortality. The aim of the present study was to describe the characteristics and outcomes of major trauma in pregnant patients using a population‐based registry. Methods: Registry‐based study using data from the Victorian State Trauma Registry (VSTR), a population‐based database of all hospitalised major trauma (death due to injury, Injury Severity Score [ISS] ≥12, admission to an intensive care unit [ICU] for more than 24 h and requiring mechanical ventilation for at least part of their ICU stay or urgent surgery) in Victoria, Australia, from 1 July 2007 to 30 June 2019. Pregnant patients with major trauma were identified on the VSTR. We summarised patient data using descriptive statistics. Results: Over the 12‐year study period, there were 63 pregnant major trauma patients. Fifty‐two (82.5%) patients sustained injuries resulting from road transport collisions. The maternal survival rate was 98.4% and the foetal survival rate was 88.9%. Thoracic injury was the most common injury (25/63), followed by abdominal injury (23/63). Eighty‐six percent of the third trimester patients (19/22) were transported directly to a major trauma service with capacity for definitive care of the pregnancy. Conclusion: The present study demonstrated road transport injury was the most common mechanism of injury and both maternal survival rates and foetal survival rates were high. This information is essential for trauma care system planning and public health initiatives to improve the clinical management and outcomes of pregnant women with major trauma. [ABSTRACT FROM AUTHOR]

Objective: The Interagency Integrated Triage Tool (IITT) is a novel, three‐tier triage system recommended by the World Health Organization. The present study sought to assess the validity and reliability of a pilot version of the tool in a resource‐limited ED in regional Papua New Guinea. Methods: This pragmatic prospective observational study, conducted at Mount Hagen Provincial Hospital, commenced 1 month after IITT implementation. The facility did not have a pre‐existing triage system. All ED patients presenting within a 5‐month period were included. The primary outcome was sensitivity for the detection of time‐critical illness, defined by 10 pre‐specified diagnoses. The association between triage category and ED outcomes was examined using Cramer's V correlation coefficient. Reliability was assessed by inter‐rater agreement between a local and an experienced external triage officer. Results: There were 9437 presentations during the study period and 9175 (97.2%) had a triage category recorded. Overall, 138 (1.5%) were classified as category 1 (emergency), 1438 (15.7%) as category 2 (priority) and 7599 (82.8%) as category 3 (non‐urgent). When applied by a mix of community health workers, nurses, health extension officers and doctors, the tool's sensitivity for the detection of time‐critical illness was 77.8% (95% confidence interval 64.4–88.0). The admission rate was 14.5% (20/138) among emergency patients, 12.0% (173/1438) among priority patients and 0.4% (30/7599) among non‐urgent patients (P = 0.00). Death in the ED occurred in 13 (9.4%) of 138 emergency patients, 34 (2.4%) of 1438 priority patients and four (0.1%) of 7599 non‐urgent patients (P = 0.00). The negative predictive value for these outcomes was >99.5%. Among 170 observed triage assessments, weighted κ was 0.81 (excellent agreement). On average, it took clinicians 2 min 43 s (standard deviation 1:10) to complete a triage assessment. Conclusion: There is limited published data regarding the predictive validity and inter‐rater reliability of the IITT. In this pragmatic study, the pilot version of the tool demonstrated adequate performance. Evaluation in other emergency care settings is recommended. [ABSTRACT FROM AUTHOR]

Objective: To determine the sensitivity of the Interagency Integrated Triage Tool to identify severe and critical illness among adult patients with COVID‐19. Methods: A retrospective observational study conducted at Port Moresby General Hospital ED during a three‐month Delta surge. Results: Among 387 eligible patients with COVID‐19, 63 were diagnosed with severe or critical illness. Forty‐seven were allocated a high acuity triage category, equating to a sensitivity of 74.6% (95% CI 62.1–84.7) and a negative predictive value of 92.7% (95% CI 88.4–95.8). Conclusion: In a resource‐constrained context, the tool demonstrated reasonable sensitivity to detect severe and critical COVID‐19, comparable with its reported performance for other urgent conditions. [ABSTRACT FROM AUTHOR]

Australia is rapidly moving towards 'living with COVID‐19', with relaxation of some public health measures. The number of severe cases of COVID‐19 may be mitigated by vaccination, but 'living with COVID‐19' will be associated with higher number of patients seeking emergency care. This impending impact on the emergency care system requires recognition, monitoring and co‐ordinated management. Current challenges include a lack of emergency care monitoring systems, staff shortages and patient flow processes that are quickly overwhelmed by large numbers, particularly in a system already operating at capacity. Effective monitoring systems are required for health systems to proactively detect and respond to stresses. Additional solutions include public health messaging and clinical innovation to facilitate care of the right patient in the right place at the right time. Optimising staff numbers and morale, and efficient patient flow, are integral steps to increasing capacity within the emergency care system. [ABSTRACT FROM AUTHOR]

Almost all known Aphidiinae (Hymenoptera: Braconidae) parasitoid species in New Zealand have been introduced as biological control agents (BCAs) for introduced aphids or have self‐introduced. The New Zealand endemic aphid (Hemiptera: Aphididae) fauna consists of a small number of species that are parasitised, on occasion, by Aphidiinae that remain unidentified. A persistent concern has been that introduced BCAs are among the parasitoids attacking the rare endemic aphids. After 14 years of collection, 66 cytochrome oxidase I (COI) gene sequences were obtained from emerged parasitoids, mummies or by specific PCR from parasitised New Zealand aphids. Parasitoid samples were from 13 aphid species (eight endemic, plus five introduced species feeding on native plants) at 20 locations. The Aphidiinae COI sequences comprised two new clades of native New Zealand parasitoids. One species‐rich clade appeared to represent a radiation after dispersal to New Zealand, whereas the second clade consisted only of parasitoids from a single endemic host. The patterns of aphid/parasitoid associations were strongly suggestive of host specificity towards the endemic aphids, while a subgroup of the newly discovered native Aphidiinae was found parasitising four introduced aphid species, despite the short time period these aphids are assumed to have been in New Zealand. We found no evidence for attack of endemic aphids by introduced BCAs or other introduced aphidiines. On the rare occasions that parasitism was detected in the most common endemic Aphidinae aphid, Aphis cottieri Carver, 1999, it was by a native Aphidiinae lineage, not by Aphidius ervi Haliday, 1834. [ABSTRACT FROM AUTHOR]

Background: Injury represents 260 000 hospitalisations and $27 billion in healthcare costs each year in Canada. Evidence suggests that there is significant variation in the prevalence of hospital admissions among emergency department presentations between countries and providers, but we lack data specific to injury admissions. We aimed to estimate the prevalence of potentially low‐value injury admissions following injury in a Canadian provincial trauma system, identify diagnostic groups contributing most to low‐value admissions and assess inter‐hospital variation. Methods: We conducted a retrospective multicentre cohort study based on all injury admissions in the Québec trauma system (2013‐2018). Using literature and expert consultation, we developed criteria to identify potentially low‐value injury admissions. We used a multilevel logistic regression model to evaluate inter‐hospital variation in the prevalence of low‐value injury admissions with intraclass correlation coefficients (ICC). We stratified our analyses by age (1‐15; 16‐64; 65‐74; 75+ years). Results: The prevalence of low‐value injury admissions was 16% (n = 19 163) among all patients, 26% (2136) in children, 11% (4695) in young adults and 19% (12 345) in older adults. Diagnostic groups contributing most to low‐value admissions were mild traumatic brain injury in children (48% of low‐value paediatric injury admissions; n = 922), superficial injuries (14%, n = 660) or minor spinal injuries (14%, n = 634) in adults aged 16‐64 and superficial injuries in adults aged 65+ (22%, n = 2771). We observed strong inter‐hospital variation in the prevalence of low‐value injury admissions (ICC = 37%). Conclusion: One out of six hospital admissions following injury may be of low value. Children with mild traumatic brain injury and adults with superficial injuries could be good targets for future research efforts seeking to reduce healthcare services overuse. Inter‐hospital variation indicates there may be an opportunity to reduce low‐value injury admissions with appropriate interventions targeting modifications in care processes. [ABSTRACT FROM AUTHOR]

Objective: To compare the frequency and outcomes of cardiac arrests in general practice clinics with those of paramedic‐witnessed cardiac arrests. Design, setting: Retrospective study; analysis of Victorian Ambulance Cardiac Arrest Registry data, 1 January 2000 – 30 December 2019. Participants: Patients with non‐traumatic cardiac arrests whom emergency medical services staff attempted to resuscitate. Main outcome measures: Survival to hospital discharge. Results: 6363 cases of cardiac arrest were identified: 216 in general practice clinics (3.4%) and 6147 witnessed by paramedics (96.6%). The proportion of patients presenting with initial shockable rhythms was larger in clinic (126 patients, 58.3%) than paramedic‐witnessed cases (1929, 31.4%). The proportion of general practice clinic cases in which defibrillation was provided in the clinic increased from 2 of 37 in 2000–2003 (5%) to 19 of 57 patients in 2016–2019 (33%); survival increased from 7 of 37 (19%) to 23 of 57 patients (40%). For patients with initial shockable rhythms, 57 of 126 in clinic cases (45%) and 1221 of 1929 people in paramedic‐witnessed cases (63.3%) survived to hospital discharge; of 47 general practice patients defibrillated by clinic staff, 27 survived (57%). For patients with initial shockable rhythms, the odds of survival were greater following paramedic‐witnessed events (adjusted odds ratio [aOR], 3.39; 95% CI, 2.08–5.54) or general clinic arrests with defibrillation by clinic staff (aOR, 2.23; 95% CI, 1.03–4.83) than for general practice clinic arrests in which arriving paramedics provided defibrillation. Conclusion: Emergency medical services should be alerted as soon as possible after people experience heart attack warning symptoms. Automated external defibrillators should be standard equipment in general practice clinics, enabling prompt defibrillation, which may substantially reduce the risk of death for people in cardiac arrest. [ABSTRACT FROM AUTHOR]

Objective: This retrospective observational study aimed to compare the impact of the Prevent Alcohol and Risk‐Related Trauma Youth (P.A.R.T.Y.) Program when delivered as In‐hospital or Outreach models to rural and regional students. Methods: The study population were consented participants from regional areas between 2013 and 2017 who completed pre‐programme, immediately post‐programme and 3–5 months post‐programme surveys. Responses from the metropolitan In‐hospital programme participants and regional Outreach programme participants were analysed within groups across the three time points. The primary outcome variable was a change in self‐reported perception of driving after drinking alcohol. Secondary outcome variables were designating a safe driver after drinking, perception of risk of injury if not wearing a seatbelt, risks of injury if undertaking physical risk‐taking activities and likelihood of the programme changing perceptions. Results: There were 1314 participants invited to participate and 547 (42%) sets of complete surveys were received, of whom 296 (54%) were Outreach participants. Pre‐programme, a significantly lower proportion of Outreach participants reported 'definitely not' to driving after drinking (84% vs 91%), and perceived a 'definite' likelihood of sustaining injury if not wearing a seatbelt (57% vs 66%). Outreach participants displayed improvements in likelihood to drive after drinking alcohol immediately post‐programme and on follow up (P = 0.028). Responses to all other secondary outcome measures demonstrated some improvement. Conclusions: Although demographically similar, baseline perceptions toward alcohol, risk‐taking and injury differed between groups. Improvements in perception were demonstrated across both models. These findings support P.A.R.T.Y. as an injury prevention initiative for regional youth. [ABSTRACT FROM AUTHOR]

Objective: To assess the feasibility of an ED presenting complaint (PC) tool that categorised all ED PCs into 10 categories. Methods: A retrospective analysis of 1445 consecutive patient encounters was conducted. The primary outcome was the frequency of use of the 10 PC categories. Results: Of the 1203 patient encounters meeting inclusion criteria, the PC tool was completed by clinicians in 574 (47.7%). When completed, the tool's 10 options were selected for most presentations (72.3%). Conclusion: The PC tool captured the majority of presenting complaints in 10 categories. External validation is recommended. [ABSTRACT FROM AUTHOR]

Objective: The role of paramedics in hospital triage or streaming models has not been adequately explored and is potentially a missed opportunity for enhanced patient flow. The aim of the present study was to assess the concordance between a streaming decision by paramedics with the decision by nurses after arrival to the ED. Methods: A prospective observational study was conducted. Paramedics were met at the entrance to the hospital and asked which destination they thought was appropriate (the index test). The ED nurse streaming decision was the reference standard. Cases of discordance were reviewed and assessed for clinical risk by an independent expert panel that was blinded. Results: We collected data from 500 cases that were transported by ambulance consisting of 55% males with a median age of 57 years (interquartile range 38–75). The overall concordance between paramedics' and streaming decision was 86.4% (95% confidence interval 83.1–89.1). The concordance was highest among patients streamed to resuscitation and general cubicles. Among discordant cases (n = 68), 39 were streamed to a more acute destination than the paramedic suggested. Of the 68 discordant cases, 56 were deemed to be of no clinical risk. Conclusions: Despite limited knowledge of patient load within the ED, paramedics can allocate a streaming destination with high accuracy and this appears to be associated with low clinical risks. Early pre‐hospital notification of streaming destination with proactive allocation of ED destination presents a real opportunity to minimise off‐load times and improve patient flow. [ABSTRACT FROM AUTHOR]

Objective: The objective was to evaluate the effectiveness of methoxyflurane versus standard care for the initial management of severe pain among adult emergency department (ED) patients. Methods: This randomized parallel‐group open‐label phase IV trial of methoxyflurane was conducted in a tertiary hospital ED setting in Australia. Inclusion criteria required adult patients to have an initial pain score ≥ 8 on the 11‐point Numerical Rating Scale (NRS). Patients were randomized 1:1 to receive either inhaled methoxyflurane (3 mL) or standard analgesic treatment at ED triage. The primary outcome was the proportion of patients achieving clinically substantial pain reduction, defined as a ≥50% drop in the pain score at 30 minutes. Secondary outcomes included the pain score at multiple time points (15, 30, 60, 90 minutes) and the difference in the proportion of patients achieving a >2‐point reduction on the NRS. Results: There were 120 patients randomized and analyzed between September 4, 2019, and January 16, 2020. The primary outcome was achieved in six (10%) patients in the methoxyflurane arm and three (5%) in the standard care arm (p = 0.49). A higher proportion of patients in the methoxyflurane arm reported a >2‐point drop on the NRS at all time points (17% vs. 5% at 15 minutes, 25% vs. 9% at 30 minutes, 30% vs. 10% at 60 minutes, and 33% vs. 13% at 90 minutes). Methoxyflurane use was also associated with lower median pain scores at all time points. Conclusion: Initial management with inhaled methoxyflurane in the ED did not achieve the prespecified substantial reduction in pain, but was associated with clinically significant lower pain scores compared to standard therapy. [ABSTRACT FROM AUTHOR]

SOE measures to achieve physical distancing and restrict community contact were not associated with significant changes in time to ED presentation after acute stroke and AMI. Time to initial investigation and life‐saving interventions were also unchanged in the first 28 days. Public health messaging encouraging patients with acute illness or injury to seek medical assessment should be continued. Objectives: To determine if Victorian State of Emergency (SOE) measures to combat COVID‐19 were associated with delayed presentations or management of acute stroke and acute myocardial infarction (AMI). Methods: This was a retrospective, pre‐ and post‐implementation study using data from an adult, tertiary cardiology and neurosciences centre with 24‐h capacity for endovascular procedures. All primary presentations with acute stroke or AMI during the first 28 days of stage 2 and stage 3 SOE restrictions (26 March to 23 April 2020) were compared to an equivalent period without restrictions (26 March to 23 April 2019). The primary outcome variable was time from onset of symptoms to ED presentation. Results: There were 52 (1.6% of all ED presentations) patients who met inclusion criteria during the SOE period and 57 (1.0%) patients in the comparator period. Patients were equally matched for demographics, disease severity and prior history of stroke or AMI. Median time from symptom onset to presentation was 227 (93–1183) min during the SOE period and 342 (119–1220) min during the comparator period (P = 0.24). Among eligible patients with ischaemic stroke or ST‐elevation AMI, median time to primary reperfusion intervention was 65 (37–78) min during SOE and 44 (39–60) min in the comparator period (P = 0.54). There were no differences in mortality at hospital discharge (9.6% vs 10.5%) and hospital length of stay (5.4 vs 4.3 days). Conclusions: In the first 28 days, SOE measures to combat COVID‐19 were not associated with delays in presentation or life‐saving interventions for patients with acute stroke and AMI. [ABSTRACT FROM AUTHOR]

Objective: The number of patients with suspected COVID‐19 presenting to Australian EDs continues to impose a burden on healthcare services. Isolation is an important aspect of infection prevention and control, but has been associated with undesirable consequences among hospital inpatients. The aim of the present study was to determine if isolation is associated with an increased length of stay (LOS) in the ED. Methods: The Registry for Emergency Care Project is a prospective cohort study with a series of nested sub‐studies. The present study was a retrospective analysis of adult patients allocated an Australasian Triage Scale category of 1 or 2 who presented to a tertiary ED between 18 and 31 May 2020. The primary outcome was ED LOS. Regression methods were used to determine the independent association between ED isolation and LOS. Results: There were 447 patients who met inclusion criteria, of which 123 (28%) were managed in isolation. The median (interquartile range) ED LOS was 259 (210–377) min for the isolation group and 204 (126–297) min for the non‐isolation group, a difference in median ED LOS of 55 min (P < 0.001). Isolation was independently associated with a 23% increase in ED LOS (P = 0.002) and doubled the odds of an ED stay of more than 4 h (adjusted odds ratio 2.2 [1.4–3.4], P = 0.001). Conclusion: Consistent with the anecdotal experience of Australian ED clinicians, the present study demonstrated an increased ED LOS for patients managed in isolation. Enhanced infection prevention and control precautions will be required during and beyond the current pandemic, creating significant ongoing challenges for emergency care systems. [ABSTRACT FROM AUTHOR]

Objective: To determine if COVID‐19 State of Emergency (SOE) restrictions were associated with a reduction in presentations to two urban EDs in Melbourne, Victoria. Methods: This retrospective observational study included adult patients presenting to The Alfred and Sandringham Hospital EDs during the first month of stage 2 and 3 SOE restrictions (26 March–25 April 2020). Patients transferred from other hospitals or diagnosed with COVID‐19 were excluded. The primary outcome was the average number of presentations per day. Secondary outcomes included the average daily number of presentations for pre‐specified subgroups defined by triage category and diagnosis. The independent impact of SOE restrictions, adjusted for underlying trends in attendance, was determined using negative binomial regression and reported as an incident rate ratio (IRR) with a 95% confidence interval (CI). Results: Average daily attendance during the exposure period was 174.7. In the absence of SOE restrictions, 278.8 presentations per day were predicted, a reduction of 37.3% (IRR 0.63, 95% CI 0.59–0.67). Attendance was lower than anticipated for all triage categories (especially category 5 [IRR 0.51, 95% CI 0.44–0.59]) and diagnostic groups (including circulatory problems [IRR 0.62, 95% CI 0.50–0.76] and injury [IRR 0.58, 95% CI 0.53–0.63]). There were fewer than predicted presentations for several sentinel diagnoses, including gastroenteritis (IRR 0.27, 95% CI 0.17–0.42) and renal colic (IRR 0.55, 95% CI 0.33–0.92). Conclusions: SOE restrictions were associated with a significant reduction in ED presentations across a range of triage categories and diagnoses. Public health messaging should emphasise the importance of timely ED attendance for acute illness and injury. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was to describe the epidemiological and clinical features of ED patients with suspected and confirmed COVID‐19. Methods: The COVID‐19 Emergency Department (COVED) Project is an ongoing prospective cohort study that includes all adult patients presenting to The Alfred Hospital ED who undergo testing for SARS‐CoV‐2. Current guidelines recommend testing for patients with fevers or chills, acute respiratory symptoms or a high‐risk exposure history, as well as implementation of infection prevention and control precautions for all suspected and confirmed cases. Study outcomes include a positive SARS‐CoV‐2 test result and intensive respiratory support. Results: In the period 1–30 April 2020, 702 of 3453 ED patients (20%; 95% CI 19–22) were tested, with a significant increase during the study period (incident rate ratio 1.019; 95% confidence interval 1.017–1.021, P < 0.001). The primary outcome of a positive SARS‐CoV‐2 test was recorded in 14 patients (2%; 95% confidence interval 1–3). Shortness of breath (77%), fatigue (100%), myalgia (67%) and diarrhoea (67%) were common among positive cases, while close contact (9%), fever (0%) and healthcare occupation (0%) were not. No positive cases required intensive respiratory support in the ED. Conclusions: The volume of ED patients with suspected COVID‐19 is increasing. Low numbers of positive cases precluded development of accurate predictive tools, but the COVED Project is fulfilling an important role in monitoring the burden of infection prevention and control requirements on the ED. The increasing number of patients meeting isolation criteria has the potential to impact on patient flow and may lead to ED overcrowding. [ABSTRACT FROM AUTHOR]

Objective: To assess the effect of patient and system characteristics on emergency medical service (EMS) delays prior to arrival at hospital in suspected ST‐elevation myocardial infarction (STEMI). Methods: This was a retrospective observational study of 1739 patients who presented with suspected STEMI to the EMS in Melbourne, Australia between October 2011 and January 2014. Our primary outcome measure was call‐to‐hospital time, defined as the time in minutes from emergency call to hospital arrival. We examined the association of patient and system characteristics on call‐to‐hospital time using multivariable linear regression. Results: The mean call‐to‐hospital time was 60.1 min (standard deviation 20.5) and the median travel distance was 13.0 km (interquartile range 7.2–23.1). In the multivariable model, patient characteristics associated with longer call‐to‐hospital time were age ≥75 years (2.3 min; 95% confidence interval [CI] 0.6–4.0), female sex (1.9 min; 95% CI 0.3–3.4), pre‐existing mental health disorder (4.0 min; 95% CI 1.9–6.1) or musculoskeletal disease (2.7 min; 95% CI 1.0–4.4), absence of chest pain (3.0 min; 95% CI 1.1–4.8), and presentation with clinical complications. System factors associated with call‐to‐hospital time include lower dispatch priority (12.7 min; 95% CI 9.0–16.5) and non‐12‐lead electrocardiography (ECG) capable ambulance first on scene (4.5 min; 95% CI 3.1–5.8). Patients who were not initially attended by a 12‐lead capable ambulance were less likely to receive a 12‐lead ECG within 10 min (18.5% vs 71.0%, P < 0.001). Conclusion: A range of patient and system factors may influence EMS delays in STEMI. However, optimising dispatch prioritisation and widespread availability of prehospital 12‐lead ECG could lead to substantial reduction in time to treatment. [ABSTRACT FROM AUTHOR]

Objective: In Australia, the current ED burden related to COVID‐19 is from 'suspected' rather than 'confirmed' cases. The initial aim of the Registry for Emergency Care (REC) Project is to determine the impact of isolation processes on the emergency care of all patients. Methods: The REC Project builds on the COVID‐19 Emergency Department Quality Improvement (COVED) Project. Outcomes measured include times to critical assessment and management. Results: Clinical tools will be generated to inform emergency care, both during and beyond the COVID‐19 pandemic. Conclusions: The REC Project will support ED clinicians in the emergency care of all patients. [ABSTRACT FROM AUTHOR]

Objective: To test the administration of intravenous (i.v.) propofol at a procedural sedation dose compared to standard therapy for initial management of migraine in the ED. Methods: This was an open label, randomised controlled pilot trial. Eligible patients were adults with a diagnosis of migraine and planned for treatment with i.v. medications. Patients were randomised to propofol or standard therapy groups. The primary outcome variable was time to discharge (TTD) defined as time from intervention to discharge from the ED. Secondary outcomes were safety of propofol administration and change in pain scores. A reduction of pain by ≥50% or discharge from the ED was defined as favourable. All analyses were performed on an intention‐to‐treat basis. Results: Data from 29 patients were analysed, with 15 patients in the propofol group and 14 patients in the standard therapy group. TTD was significantly lower in the propofol group with median of 290 (interquartile range 162–500) min compared to 554.5 (interquartile range 534–639) min in the standard therapy group (P = 0.021). The hazard ratio for the defined favourable outcome of reduction of pain scores or discharge from the ED was 1.54 (95% CI 0.69–3.41). Conclusions: Initial management of migraine with i.v. propofol at procedural sedation doses significantly reduced TTD compared to standard therapy. We did not detect any significant safety concerns although the study was not adequately powered to detect safety of the intervention and requires validation. [ABSTRACT FROM AUTHOR]

Objective: The COVID‐19 Emergency Department (COVED) Quality Improvement Project aims to provide regular and real‐time clinical information to ED clinicians caring for patients with suspected and confirmed COVID‐19. The present study summarises data from the first 2 weeks of the study. Methods: COVED is an ongoing prospective cohort study that commenced on 1 April 2020. It includes all adult patients presenting to a participating ED who undergo testing for SARS‐CoV‐2. Data are collected prospectively and entered into a bespoke registry. Outcomes include a positive SARS‐CoV‐2 polymerase chain reaction test result and requirement for intensive respiratory support. Results: In the period 1–14 April 2020, 240 (16%) of 1508 patients presenting to The Alfred Emergency and Trauma Centre met inclusion criteria. Of these, 11 (5%) tested positive for SARS‐CoV‐2. The mean age of patients was 60 years and the commonest symptoms were acute shortness of breath (n = 122 [67%]), cough (n = 108 [56%]) or fever (n = 98 [51%]). Overseas travel or known contact with a confirmed case was reported by 24 (14%) and 16 (10%) patients, respectively. Fever or hypoxia was recorded in 23 (10%) and 11 (5%) patients, respectively. Eleven (5%) patients received mechanical ventilation in the ED, of whom none tested positive for SARS‐CoV‐2. Conclusions: Among patients presenting to a tertiary ED with suspected COVID‐19, only a small proportion tested positive for SARS‐CoV‐2. Although the low incidence of positive cases currently precludes the development of predictive tools, the COVED Project demonstrates that the rapid establishment of an agile clinical registry for emergency care is feasible. [ABSTRACT FROM AUTHOR]

Objectives: There is an urgency to support Australian ED clinicians with real‐time tools as the COVID‐19 pandemic evolves. The COVID‐19 Emergency Department (COVED) Quality Improvement Project has commenced and will provide flexible and responsive clinical tools to determine the predictors of key ED‐relevant clinical outcomes. Methods: The COVED Project includes all adult patients presenting to a participating ED and meeting contemporary testing criteria for COVID‐19. The dataset has been embedded in the electronic medical record and the COVED Registry has been developed. Results: Outcomes measured include being COVID‐19 positive and requiring intensive respiratory support. Regression methodology will be used to generate clinical prediction tools. Conclusion: This project will support EDs during this pandemic. [ABSTRACT FROM AUTHOR]

Objective: The objective of the present study is to examine variations in paramedic care of the agitated patient, including verbal de‐escalation, physical restraint and sedation, provided by ambulance services in Australia and New Zealand. Methods: To examine the care of agitated patients, we first identified and reviewed all clinical practice guidelines for the management of agitated patients in Australian and New Zealand ambulance services between September and November 2018. We then conducted a structured questionnaire to obtain further information on the training, assessment and care of agitated patients by the ambulance services. Two authors extracted the data independently, and all interpretations and results were reviewed and confirmed by relevant ambulance services. Results: There were 10 independent clinical practice guidelines for the care of agitated patients in the 10 ambulance services. All services reported training in the management of agitated patients, and two services used a validated tool to assess the level of agitation. All services used physical restraint, although six services required police presence to restrain the patient. All ambulance services used some form of sedation, typically divided into the management of mild to moderate, and severe agitation. The most common agent for sedation was midazolam, while ketamine was the most common agent for sedating severely agitated patients. The maximum dose was varied, and contraindications for sedating agents varied between services. Conclusions: There were wide variations across the ambulance services in terms of the assessment of agitation, as well as the use of physical restraint and sedation. [ABSTRACT FROM AUTHOR]

Objectives: To examine the association between discharge destination (home or inpatient rehabilitation) for adult patients treated in hospital for isolated lower limb fractures and patient-reported outcomes.Design: Review of prospectively collected Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) data.Setting, Participants: Adults (18-64 years old) treated for isolated lower limb fractures at four Melbourne trauma hospitals that contribute data to the VOTOR, 1 March 2007 - 31 March 2016.Main Outcome Measures: Return to work and functional recovery (assessed with the extended Glasgow Outcomes Scale, GOS-E); propensity score analysis of association between discharge destination and outcome.Results: Of 7961 eligible patients, 1432 (18%) were discharged to inpatient rehabilitation, and 6775 (85%) were followed up 12 months after their injuries. After propensity score adjustment, the odds of better functional recovery were 56% lower for patients discharged to inpatient rehabilitation than for those discharged directly home (odds ratio, 0.44; 95% CI, 0.37-0.51); for the 5057 people working before their accident, the odds of return to work were reduced by 66% (odds ratio, 0.34; 95% CI, 0.26-0.46). Propensity score analysis improved matching of the discharge destination groups, but imbalances in funding source remained for both outcome analyses, and for also for site and cause of injury in the GOS-E analysis (standardised differences, 10-16%).Conclusions: Discharge to inpatient rehabilitation after treatment for isolated lower limb fractures was associated with poorer outcomes than discharge home. Factors that remained unbalanced after propensity score analysis could be assessed in controlled trials. [ABSTRACT FROM AUTHOR]

Objective: The Victorian Emergency Minimum Dataset (VEMD) collects administrative and clinical data for all presentations to Victorian public ED. The present study aimed to examine the level of agreement between the VEMD data and the medical record for a sample of patients coded as having acute cardiovascular conditions (acute coronary syndrome, stroke and transient ischaemic attack [TIA]) and unspecified chest pain in the VEMD. Methods: Six months of data provided to the VEMD from a large metropolitan hospital was obtained, and a random sample of 10% of cases (n = 310) were selected for review. Data for eight VEMD items were compared for concordance to data recorded in the ED medical record. Results: Complete concordance between the VEMD and medical records for all eight items was observed only for 101 (33%) presentations. Overall, the least concordant variables were those with a high number of coding options: usual type of accommodation (76%), referral pattern (84%) and primary diagnosis (85%). The concordance of the VEMD primary diagnosis varied when examined as individual codes (range 75%–100%) and when combined (acute coronary syndrome = 94%, stroke or TIA = 85% and chest pain unspecified = 75%). The level of agreement for some items improved when VEMD codings were combined. Conclusion: When compared to the medical record, our data suggest there is likely variation in the accuracy of some VEMD items, and suggests a larger prospective validation of the VEMD is warranted. For researchers using existing VEMD data, combining of some codes may be necessary. [ABSTRACT FROM AUTHOR]

Objectives: To determine the population of patients where patient transfer may be prevented by assessment of a senior ED registrar at the referring hospital. Methods: Patients transferred from Caulfield Hospital, specialising in community services, rehabilitation, aged care and aged mental health to The Alfred Emergency and Trauma Centre, an adult major referral centre within the same clinical network were identified from 1 July 2016 to 31 December 2016. Medical records were reviewed independently by two clinicians to determine preventability of transfer and whether attendance by a senior ED registrar could have prevented the transfer. Results: There were 221 patients included with a mean age of 73.6(15.1) years. The median time spent in the ED was 4 h (interquartile range 2–8) and 197 (89.1%) were admitted. There were 107 (48.6%) transfers deemed preventable or potentially preventable, with 104 preventable by attendance of a senior ED registrar. The most common indication for transfer was acute trauma (n = 55; 24.9%), and the odds of a case being preventable or potentially preventable if transferred for the primary indication of trauma was 3.9 (95% confidence interval 2.1–7.1; P < 0.001). Among the preventable cases, the total cost of transfer was AU$105 984 over 6 months, not accounting for the costs of duplication of care. Conclusions: This proof‐of‐concept study suggests that strategies to expand the provision of acute care to outreach within specialist networks and reduce patient transfers should be further explored. An outreach programme for improved acute assessment of patients at the referring hospital particularly after acute trauma may prevent transfers, improving care pathways. [ABSTRACT FROM AUTHOR]

Objective: A serum lactate level >2 mmol/L has been chosen as the preferred cut‐off value for screening of patients with suspected sepsis. In patients with suspected sepsis presenting to the ED, we aimed to determine the outcomes of patients with initial lactate levels ≤2 mmoL/L, but abnormal bicarbonate or anion gaps (AGs). Methods: This prospective cohort study enrolled patients from an adult tertiary referral hospital who presented with suspected sepsis. The predictive value of lactate, bicarbonate and the AG for intensive care unit (ICU) admission and death at hospital discharge were evaluated using area under the receiver operating characteristic curves (AUROC). Results: There were 441 patients with suspected sepsis enrolled from February 2016 to June 2017. There were 96 (22.0%) patients who were admitted to the ICU and at hospital discharge, 42 (9.6%) patients had died. There was no statistically significant difference between the AUROCs of lactate or bicarbonate level or AG to predict ICU admission (P = 0.17). There was no statistically significant difference between the AUROCs of lactate or bicarbonate level or AG to predict mortality at hospital discharge (P = 0.44). Among the 73 patients with normal lactate levels, but abnormal bicarbonate or AG, there were seven (9.6%) deaths. Conclusions: A normal lactate level alone should not be used to exclude life‐threatening sepsis. Patients with metabolic acidosis characterised by low bicarbonate or high AG levels, but with normal lactate levels, have high rates of ICU requirement and mortality and should also be considered for early, aggressive therapy. [ABSTRACT FROM AUTHOR]

Objective: Deficits in healthcare quality are becoming an increasing concern globally. Within the low‐ to middle‐income country (LMIC) setting insufficient quality has become a bigger barrier to reducing mortality than insufficient access, where 60% of deaths from conditions amenable to healthcare, are due to poor quality care. Measuring quality is key towards improving the effectiveness of healthcare in this setting. Methods: A mixed methods sequential‐explanatory study was conducted, to describe what Emergency Medical Service (EMS) practitioners understood about quality systems within the LMICs, using South Africa as an example. Part 1 consisted of a cross‐sectional survey (n = 169), the results of which were utilised to develop a semi‐structured interview guide for Part 2. Interviews of participants from Part 1 explored the results of the survey (n = 20) and were analysed through content analysis to develop core categories central to the understanding of quality assessment in the LMICs. Results: Despite relatively poor knowledge of organisational‐specific quality systems, understanding of the core components and importance of quality systems was demonstrated. The role of these systems in the LMICs was supported by participants, where the importance of context, system transparency, reliability and validity were essential towards achieving ongoing success and utilisation. The role of leadership and communication towards the effective facilitation of such a system was equally identified. Conclusion: Within EMS, quality systems are in their infancy. It could be argued that this is somewhat more pronounced in the LMICs, where knowledge of organisational quality systems was found to be poor. Despite this, there was a strong general understanding of the importance of quality systems, and the role they have to play in this setting. [ABSTRACT FROM AUTHOR]