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Background: Until recently, midazolam sedation was routinely used in our institution for bone marrow aspirates and lumbar punctures in children with cancer. It has been perceived by many doctors and [...]

Background: General practitioners (GPs) face the challenge of diagnosing conjunctivitis accurately and confidently. Conjunctivitis and red eye are common presentations that confer diagnostic uncertainty. GPs are pivotal in diagnosing and managing conjunctivitis-like symptoms, making them a critical first port of call for patients. Accurately identifying and treating this common eye infection can help ensure the best possible outcomes., Objective: This article presents an overview of conjunctivitis, exploring its causes and how to accurately assess and diagnose. We also discuss how to safely refer patients for investigation and provide appropriate safety netting., Discussion: Conjunctivitis can be secondary to a range of conditions, commonly viral, bacterial and allergic pathogens. It tends to be a self-limiting disease; however, symptoms might persist for up to three weeks. Accurate clinical diagnosis for conjunctivitis is difficult, and thus it can be useful to send a swab for polymerase chain reaction and culture to confirm the diagnosis.

Introduction: Communication failings may compromise the diagnostic process and pose a risk to quality of care and patient safety. With a focus on emergency care settings, this project aims to examine the critical role and impact of communication in the diagnostic process, including in diagnosis-related health and research policy, and diagnostic patient-clinician interactions in emergency departments (EDs)., Methods and Analysis: This project uses a qualitatively driven multimethod design integrating findings from two research studies to gain a comprehensive understanding of the impact of context and communication on diagnostic excellence from diverse perspectives. Study 1 will map the diagnostic policy and practice landscape in Australia, New Zealand and the USA through qualitative expert interviews and policy analysis. Study 2 will investigate the communication of uncertainty in diagnostic interactions through a qualitative ethnography of two metropolitan Australian ED sites incorporating observations, field notes, video-recorded interactions, semistructured interviews and written medical documentation, including linguistic analysis of recorded diagnostic interactions and written documentation. This study will also feature a description of clinician, patient and carer perspectives on, and involvement in, interpersonal diagnostic interactions and will provide crucial new insights into the impact of communicating diagnostic uncertainty for these groups. Project-spanning patient and stakeholder involvement strategies will build research capacity among healthcare consumers via educational workshops, engage with community stakeholders in analysis and build consensus among stakeholders., Ethics and Dissemination: The project has received ethical approvals from the Human Research Ethics Committee at ACT Health, Northern Sydney Local Health District and the Australian National University. Findings will be disseminated to academic peers, clinicians and healthcare consumers, health policy-makers and the general public, using local and international academic and consumer channels (journals, evidence briefs and conferences) and outreach activities (workshops and seminars)., Competing Interests: Competing interests: JM is a member of the Council of Education of the Australasian College for Emergency Medicine., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Emergency Department (ED) care is provided for a diverse range of patients, clinical acuity and conditions. This diversity often calls for different vital signs monitoring requirements. Requirements often change depending on the circumstances that patients experience during episodes of ED care., Aim: To describe expert consensus on vital signs monitoring during ED care in the Australasian setting to inform the content of a joint Australasian College for Emergency Medicine (ACEM) and College of Emergency Nursing Australasia (CENA) position statement on vital signs monitoring in the ED., Method: A 4-hour online nominal group technique workshop with follow up surveys., Results: Twelve expert ED nurses and doctors from adult, paediatric and mixed metropolitan and regional ED and research facilities spanning four Australian states participated in the workshop and follow up surveys. Consensus building generated 14 statements about vital signs monitoring in ED. Good consensus was reached on whether vital signs should be assessed for 15 of 19 circumstances that patients may experience., Conclusion: This study informed the creation of a joint position statement on vital signs monitoring in the Australasian ED setting, endorsed by CENA and ACEM. Empirical evidence is needed for optimal, safe and achievable policy on this fundamental practice., Competing Interests: Declaration of Competing Interest All authors are Fellows of CENA or ACEM., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To examine the nature and severity of badminton-related ocular injuries in Melbourne, Australia., Methods: This is a retrospective chart review. A search of the medical records was conducted for patients presenting to the ED at The Royal Victorian Eye and Ear Hospital, with badminton-related eye injuries from June 2018 to May 2023. Data were extracted, focusing on injury mechanism, patient demographics and treatment outcomes., Results: In total, 88 patients were included in the study, comprising 64 (73%) men and 24 (27%) women. The mean patient age was 36.13 years. The most common injury was hyphaema (73%), followed by commotio retinae (45%). One patient sustained a penetrating eye injury when a shuttlecock shattered the spectacles he was wearing during play. Medical intervention was required for 90% of patients. The most common interventions were steroid eye drops (80%) and cycloplegic eyedrops (76%). A total of six (7%) patients required surgical management. For those 69 patients followed up at The Royal Victorian Eye and Ear Hospital, 77% of patients had a final best-corrected visual acuity of 6/6 or greater., Conclusions: Hyphaema, commotio retinae and traumatic uveitis were the most commonly diagnosed injuries. The majority of patients with badminton-related eye injuries required medical treatment, and some necessitated surgical intervention. To mitigate these risks, there is a pressing need to develop an eye safety policy for Australian badminton players, and players should exercise caution when wearing spectacles during play to prevent potential penetrating eye injuries., (© 2024 Australasian College for Emergency Medicine.)

Diagnostic error affects up to 10% of clinical encounters and is a major contributing factor to 1 in 100 hospital deaths. Most errors involve cognitive failures from clinicians but organisational shortcomings also act as predisposing factors. There has been considerable focus on profiling causes for incorrect reasoning intrinsic to individual clinicians and identifying strategies that may help to prevent such errors. Much less focus has been given to what healthcare organisations can do to improve diagnostic safety. A framework modelled on the US Safer Diagnosis approach and adapted for the Australian context is proposed, which includes practical strategies actionable within individual clinical departments. Organisations adopting this framework could become centres of diagnostic excellence. This framework could act as a starting point for formulating standards of diagnostic performance that may be considered as part of accreditation programs for hospitals and other healthcare organisations.

Objective: To describe the demographics and outcomes of sports-related ocular injuries in an Australian tertiary eye hospital setting., Methods: Retrospective descriptive study from the Royal Victorian Eye and Ear Hospital from 2015 to 2020. Patient demographics, diagnosis and injury causation were recorded from baseline and follow-up. Outcomes included visual acuity (VA), intraocular pressure (IOP), ocular injury diagnosis, investigations and management performed., Results: A total of 1793 individuals (mean age 28.67 ± 15.65 years; 80.42% males and 19.58% females) presented with sports-related ocular trauma. The top three injury-causing sports were soccer (n = 327, 18.24%), Australian rules football (AFL) (n = 306, 17.07%) and basketball (n = 215, 11.99%). The top injury mechanisms were projectile (n = 976, 54.43%) and incidental body contact (n = 506, 28.22%). The most frequent diagnosis was traumatic hyphaema (n = 725). Best documented VA was ≥6/12 at baseline in 84.8% and at follow-up in 95.0% of cases. The greatest risk of globe rupture/penetration was associated with martial arts (odds ratio [OR] 16.22); orbital blow-out fracture with skiing (OR 14.42); and hyphaema with squash (OR 4.18): P < 0.05 for all. Topical steroids were the most common treatment (n = 693, 38.7%). Computed tomography orbits/facial bones were the most common investigation (n = 184, 10.3%). The mean IOP was 16.1 mmHg; 103 (5.7%) cases required topical anti-ocular hypertensives. Twenty-six individuals (1.45%) required surgery with AFL contributing the most surgical cases (n = 5, 19.23%)., Conclusion: The top three ocular injury causing sports were soccer, AFL and basketball. The most frequent injury was traumatic hyphaema. Projectiles posed the greatest risk., (© 2022 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for Emergency Medicine.)

During the diagnostic process, clinicians may make assumptions, prematurely judge or diagnose patients based on their appearance, their speech or how they are portrayed by other clinicians. Such judgements can be a major source of diagnostic error and are often linked to unconscious cognitive biases - faulty quick-fire thinking patterns that impact clinical reasoning. Patient safety is profoundly influenced by cognitive bias and language, i.e. how information is presented or gathered, and then synthesised by clinicians to form and communicate diagnostic decisions. Here, we discuss the intricate links between interpersonal communication, cognitive bias, and diagnostic error from a patient's, a linguist's and clinician's perspective. We propose that through patient engagement and applied health communication research, we can enhance our understanding of how the interplay of communication behaviours, biases and errors can impact upon the patient experience and diagnostic error. In doing so, we provide new avenues for collaborative diagnostic error research striving towards healthcare improvements and safer diagnosis., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objectives: To investigate from a linguistic perspective how clinicians deliver diagnosis to patients, and how these statements relate to diagnostic accuracy., Methods: To identify temporal and discursive features in diagnostic statements, we analysed 16 video-recorded interactions collected during a practice high-stakes exam for internationally trained clinicians (25% female, n=4) to gain accreditation to practice in Australia. We recorded time spent on history-taking, examination, diagnosis and management. We extracted and deductively analysed types of diagnostic statements informed by literature., Results: Half of the participants arrived at the correct diagnosis, while the other half misdiagnosed the patient. On average, clinicians who made a diagnostic error took 30 s less in history-taking and 30 s more in providing diagnosis than clinicians with correct diagnosis. The majority of diagnostic statements were evidentialised (describing specific observations (n=24) or alluding to diagnostic processes (n=7)), personal knowledge or judgement (n=8), generalisations (n=6) and assertions (n=4). Clinicians who misdiagnosed provided more specific observations (n=14) than those who diagnosed correctly (n=9)., Conclusions: Interactions where there is a diagnostic error, had shorter history-taking periods, longer diagnostic statements and featured more evidence. Time spent on history-taking and diagnosis, and use of evidentialised diagnostic statements may be indicators for diagnostic accuracy., (© 2021 Walter de Gruyter GmbH, Berlin/Boston.)

Objective: To create a roster that eliminated unnecessary cross-staff exposure to ensure the hospital had sufficient staff to run the ED in the event that a group of staff are affected by COVID-19. This roster was aimed at providing staff with 'manageable shift lengths, down-time between shifts, regular breaks and access to refreshments' as dictated by the Victorian Department of Health and Human Services., Methods: Creating six fixed teams in our ED. Teams work blocks of three consecutive days of 12 h shifts, each block alternates between day and night shifts., Results: We managed to completely eliminate unnecessary crossover of staff thus reducing risk of having a large part of our workforce incapacitated should any member be affected by COVID., Conclusion: A pandemic roster plan to minimise staff exposure from other colleagues during a pandemic was possible. This helps to ensure an adequate workforce in the unfortunate event a staff contracts the disease leading to other close contact staff requiring isolation or succumbing to the same illness., (© 2021 Australasian College for Emergency Medicine.)

Healthcare systems across the world are challenged with problems of misdiagnosis, non-beneficial care, unwarranted practice variation and inefficient or unsafe practice. In countering these shortcomings, clinicians must be able to think critically, interpret and assimilate new knowledge, deal with uncertainty and change behaviour in response to compelling new evidence. Three critical thinking skills underpin effective care: clinical reasoning, evidence-informed decision-making and systems thinking. It is important to define these skills explicitly, explain their rationales, describe methods of instruction and provide examples of optimal application. Educational methods for developing and refining these skills must be embedded within all levels of clinician training and continuing professional development., (© 2021 Royal Australasian College of Physicians.)

Background Diagnostic error is a major preventable cause of harm to patients. There is currently limited data in the literature on the rates of misdiagnosis of doctors working in an ophthalmic emergency department (ED). Misdiagnosis was defined as a presumed diagnosis being proven incorrect upon further investigation or review. Methods In this retrospective audit, data was collected and analysed from 1 week of presentations at the Royal Victorian Eye and Ear Hospital (RVEEH) ED. Results There were 534 ophthalmic presentations during the study period. The misdiagnosis rates of referrers were: general practitioners (30%), optometrists (25.5%), external hospital EDs (18.8%), external hospital ophthalmology departments (25%) and private ophthalmologists (0%). Misdiagnosis rates of RVEEH doctors were: emergency registrars (7.1%), RVEEH residents (16.7%), first-year registrars (5.1%), second-year registrars (7.1%), third-year registrars (7.7%), fourth-year registrars (0%), senior registrars (6.9%), fellows (0%) and consultants (8.3%). Conclusions The misdiagnosis rates in our study were comparable to general medical diagnostic error rates of 10-15%. This study acts as a novel pilot; in the future, a larger-scale multi-centre audit of ophthalmic presentations to general emergency departments should be undertaken to further investigate diagnostic error.

Importance: Few prior studies have described the epidemiology of uveitis in the Australian population., Background: To report the incidence and period prevalence of active uveitis in Melbourne and detail their subtypes and aetiologies., Design: Cross-sectional study using retrospective medical record review in a tertiary hospital., Participants: Patients with a coded diagnosis of uveitis who attended the emergency department or specialist ocular immunology clinic at the Royal Victorian Eye and Ear Hospital between November 2014 through October 2015 (N = 1752)., Methods: Medical records were reviewed to confirm the date of diagnosis and subtype of uveitis. Incidence and prevalence rates were calculated utilizing estimates of the adult population residing in areas of greater Melbourne with more than 30 ocular-related presentations to the emergency department annually., Main Outcomes and Measures: Presence and date of onset, anatomical distribution and aetiology of uveitis., Results: During the study period, 734 new cases of uveitis and 502 cases of pre-existing uveitis requiring active treatment were confirmed. These figures yielded an incidence of 21.54 (CI 20.03, 23.15) per 100 000 person-years and a period prevalence of 36.27 (CI 34.30, 38.35) per 100 000 persons. The distribution of prevalent uveitis cases was anterior (75%), intermediate (6%), posterior (15%) and panuveitis (4%). An infectious aetiology accounted for 13.4% of cases, a systemic associated disease for 26.4% of cases, and no cause was identified in 60.2% of cases., Conclusion and Relevance: The incidence and prevalence rates of uveitis in urban Australia were lower than recent studies from the United States and Europe., (© 2019 Royal Australian and New Zealand College of Ophthalmologists.)

Background: Recent publications have suggested that  topical anaesthetic eye drops can be used safely and are effective in providing pain relief for the treatment of corneal abrasions. Complications resulting from the injudicious prescribing of topical anaesthetic eye drops are seen with some frequency in the Royal Victorian Eye and Ear Hospital's (RVEEH's) emergency department., Objective: The aim of this article is to review the literature and provide a clinical perspective to challenge the safety of topical anaesthetic eye drops for corneal abrasions., Discussion: The literature relevant to this clinical question is reviewed, with an emphasis on a critical evaluation of the publications in question. Cases from the RVEEH are used for illustrative purpose. An alternative option for analgesia is suggested.

Objective: To assess the efficacy and safety of a virtual reality distraction for needle pain in 2 common hospital settings: the emergency department (ED) and outpatient pathology (ie, outpatient laboratory). The control was standard of care (SOC) practice., Study Design: In 2 clinical trials, we randomized children aged 4-11 years undergoing venous needle procedures to virtual reality or SOC at 2 tertiary Australian hospitals. In the first study, we enrolled children in the ED requiring intravenous cannulation or venipuncture. In the second, we enrolled children in outpatient pathology requiring venipuncture. In the ED, 64 children were assigned to virtual reality and 59 to SOC. In pathology, 63 children were assigned to virtual reality and 68 to SOC; 2 children withdrew assent in the SOC arm, leaving 66. The primary endpoint was change from baseline pain between virtual reality and SOC on child-rated Faces Pain Scale-Revised., Results: In the ED, there was no change in pain from baseline with SOC, whereas virtual reality produced a significant reduction in pain (between-group difference, -1.78; 95% CI, -3.24 to -0.317; P = .018). In pathology, both groups experienced an increase in pain from baseline, but this was significantly less in the virtual reality group (between-group difference, -1.39; 95% CI, -2.68 to -0.11; P = .034). Across both studies, 10 participants experienced minor adverse events, equally distributed between virtual reality/SOC; none required pharmacotherapy., Conclusions: In children aged 4-11 years of age undergoing intravenous cannulation or venipuncture, virtual reality was efficacious in decreasing pain and was safe., Trial Registration: Australia and New Zealand Clinical Trial Registry: ACTRN12617000285358p., (Copyright © 2019 Elsevier Inc. All rights reserved.)