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There is heightened intrigue surrounding the application of arts-based pedagogy in medical education. Art encompasses multiple forms of expression and is used to convey specific meaning and emotion, whereas provoking critical reflection. Our aim was to explore the effectiveness of art and reflective practice in medical education, in the context of the ED.Longitudinal methodological study design. Prior to the first, and after the final clinical practicum, medical students watched a 3-min film: 'The Art of the ED'. Written reflections focused on changing perceptions towards the film during their medical education programme. Data were thematically analysed.Three themes were collected from 25 written reflections and included: 'professional growth' exploring personal and professional development across the medical programme; seeing 'patients are people'; and the purpose, structure and function of an ED exposed in 'the reality of ED'. Results highlight that arts-based pedagogy can facilitate meaningful and critical reflection in medical students, whereas also fostering professionalism. Reflecting on the film broadened their perspective into a realm of new possibilities, challenging them to identify implicit bias around ED, and promote professional identity formation.The combination of art and reflection in medical education enhances reflective learning and can lead to transformative change, including the development of core doctoring values of service, empathy and respect for patient. There are clear benefits to medical education incorporating more arts-based pedagogy that promotes reflective exploration and interpretation of the psychosocial context of health and illness, delivery of more holistic models of care and their role as doctors.

The often unknown nature of acute drug intoxication, especially with illicit drugs and emerging novel psychoactive substances, can present a significant challenge for emergency clinicians. Less experienced clinicians are particularly vulnerable to the diagnostic dilemmas of complex toxicology emergencies. We sought to better understand the confidence of junior doctors in assessing and managing toxicological emergencies across two emergency departments in Perth, Australia.An online survey was conducted between August 2020 and February 2021. Self-rated confidence was measured on a five-point Likert Scale across 10 statements. Two open-ended questions were included to capture perceived barriers and facilitators impacting clinical confidence. Quantitative data were analysed using descriptive methods and Fisher's exact test. Free-text responses were analysed using content analysis.A total of 104 surveys were completed (19.2% interns, 40.4% resident medical officers and 40.4% registrars). Self-rated confidence varied across statements and by staff type. The lowest confidence rating was for managing a patient who had overdosed from an unknown substance (31.7%) and the highest rating for referring a patient to psychiatry following deliberate self-poisoning (86.6%). Confidence increased with greater clinical experience for all statements. Qualitative analysis revealed perceptions of clinical preparedness, complexity of patients and a safe and supportive culture as key factors impacting confidence.Overcoming perceived deficits in knowledge and clinical experience were key to building confidence. Our findings highlight the need for improved access to toxicology-specific curricula and training, and strategies to ensure adequate supervision from senior clinicians.

Purpose International guidelines recommend targeting normocapnia in mechanically ventilated out-of-hospital cardiac arrest (OHCA) survivors, but the optimal arterial carbon dioxide (PaCO2) target remains controversial. We hypothesised that the relationship between PaCO2 and survival is non-linear, and targeting an intermediate level of PaCO2 compared to a low or high PaCO2 in the first 24-h of ICU admission is associated with an improved survival to hospital discharge (STHD) and at 12-months. Methods We conducted a retrospective multi-centre cohort study of adults with non-traumatic OHCA requiring admission to one of four tertiary hospital intensive care units for mechanical ventilation. A four-knot restricted cubic spline function was used to allow non-linearity between the mean PaCO2 within the first 24 h of ICU admission after OHCA and survival, and optimal PaCO2 cut-points were identified from the spline curve to generate corresponding odds ratios. Results We analysed 3769 PaCO2 results within the first 24-h of ICU admission, from 493 patients. PaCO2 and survival had an inverted U-shape association; normocapnia was associated with significantly improved STHD compared to either hypocapnia ( 45 mmHg) (aOR 0.45, 95% CI 0.24−0.84). Of the twelve predictors assessed, PaCO2 was the third most important predictor, and explained >11% of the variability in survival. The survival benefits of normocapnia extended to 12-months. Conclusions Normocapnia within the first 24-h of intensive care admission after OHCA was associated with an improved survival compared to patients with hypocapnia or hypercapnia.

Deliberate clinical inertia is the art of doing nothing as a positive response. Individual clinicians can promote deliberate clinical inertia through teaching, re-framing the act of 'doing nothing' as 'doing something' and engaging in shared decision making. Behaviour change on a larger scale requires a systematic approach. Nudging is a subtle change to the decision-making context to prompt specific choices. A nudge unit is a team of relevant professionals who engage with various multidisciplinary teams within a health service who help test and implement nudge interventions in a clinical environment. A nudge unit could be used to design environments to prompt clinicians to re-think before ordering unnecessary tests or treatments. Nudge units could improve knowledge translation, support continuous quality improvement and help build a learning health system. They could also boost collaboration and empower staff to evaluate their workplace decision-making frameworks.

ObjectiveWe tested the hypothesis that patients with a potential acute coronary syndrome (ACS) and very low levels of high-sensitivity cardiac troponin I can be efficiently and safely discharged from the emergency department after a single troponin measurement.MethodsThis prospective cohort study recruited 2255 consecutive patients aged ≥18 years presenting to the Emergency Department, Royal Perth Hospital, Western Australia, with chest pain without high-risk features but requiring the exclusion of ACS. Patients were managed using a guideline-recommended pathway or our novel Single Troponin Accelerated Triage (STAT) pathway. The primary outcome was the percentage of patients discharged in ResultsThe study enrolled 1131 patients to the standard cohort and 1124 to the STAT cohort. Thirty-eight per cent of the standard cohort were discharged directly from emergency department compared with 63% of the STAT cohort (pConclusionsAmong low-risk patients with a potential ACS, a pathway which incorporates early discharge based on a single very low level of high-sensitivity cardiac troponin increases the proportion of patients discharged directly from the emergency department, reduces length of stay and is safe.Trial registration numberACTRN12618000797279.

Background Studies to identify safe oxygenation targets after out-of-hospital cardiac arrest (OHCA) have often assumed a linear relationship between arterial oxygen tension (PaO2) and survival, or have dichotomised PaO2 at a supra-physiological level. We hypothesised that abnormalities in mean PaO2 (both high and low) would be associated with decreased survival after OHCA. Methods We conducted a retrospective multicentre cohort study of adult OHCA patients who received mechanical ventilation on admission to the intensive care unit (ICU). The potential non-linear relationship between the mean PaO2 within the first 24 -hs of ICU admission and survival to hospital discharge (STHD) was assessed by a four-knot restricted cubic spline function with adjustment for potential confounders. Results 3764 arterial blood gas results were available for 491 patients in the first 24-hs of ICU admission. The relationship between mean PaO2 over the first 24-hs and STHD was an inverted U-shape, with highest survival for those with a mean PaO2 between 100 and 180 mmHg (reference category) compared to a mean PaO2 of 180 mmHg (aOR 0.41, 95% CI 0.18, 0.92). Mean PaO2 within 24 -hs was the third most important predictor and explained 9.1% of the variability in STHD. Conclusion The mean PaO2 within the first 24-hs after admission for OHCA has a non-linear association with the highest STHD seen between 100 and 180 mmHg. Randomised controlled trials are now needed to validate the optimal oxygenation targets in mechanically ventilated OHCA patients.

Objective To determine if a combination of the Charlson Comorbidity Index (CCI) and quick-Sequential Organ Failure Assessment (qSOFA) score is superior to qSOFA alone for predicting the outcome of ED patients with suspected infection. Methods A prospective, observational single-centre study recruited consecutive adult patients who underwent blood culture collection in the ED and were admitted to hospital. The primary outcome was 28-day in-hospital mortality, and the secondary outcome a composite of mortality and/or ICU admission ≥72 h duration. The qSOFA and CCI were combined using logistic regression models, and the resulting area under the receiver operating characteristic curve (AUROC) compared to that for qSOFA alone. Results Of 551 patients recruited, 18 (3%) died and 27 (5%) attained the composite outcome. The AUROC for qSOFA/CCI versus qSOFA for the primary outcome is 0.79 versus 0.72 (95% confidence interval 0.71-0.88 vs 0.62-0.82, P = 0.055) and 0.80 versus 0.76 (95% confidence interval 0.73-0.86 vs 0.68-0.84, P = 0.048). Deaths among patients not admitted to ICU (12/495) accounted for most of the overall differences in AUROC. Conclusions This generates the hypothesis that age and comorbid disease status augment the qSOFA score for predicting adverse outcome among patients with suspected infection in the ED. The results may reflect the predominance of these factors in determining suitability for admission to ICU. Reported limitations of qSOFA to detect the risk of adverse outcome may reflect the influence of unmeasured patient factors.

Background Large, multicentre studies are required in emergency medicine to advance clinical care and improve patient outcomes. The Australasian College for Emergency Medicine clinical trials network is available to researchers to assist with facilitating large, multicentre research. However, there is no current information about the research capacity of emergency departments (EDs) in Australia and New Zealand. Methods All EDs accredited for emergency medicine training in Australia and New Zealand were eligible to participate. Research leads or ED directors were invited via email and telephone to complete a survey. Data were collected regarding the presence of a research lead; their research experience; available research resources including colleagues, funding, departmental paid research time; publications; and research culture. Results One hundred and twelve responses were received on behalf of 122 (84%) sites (10 satellite plus main) from a possible 143 sites with all types of hospitals and regions represented. Research leads were identified at 66 (59%) sites; 32 (29%) had a director of emergency medicine research. A wide range of research was underway. Ninety-six sites (66%) contributed data to multicentre projects. Twenty-one centres (17%) were highly productive with multiple resources (skilled colleagues, funding, staffing), a positive research culture and high-volume output. Sixty to seventy centres (50–58%) had limited resources, experienced an unsupportive research culture and authored manuscripts infrequently. Paid time for research directors was associated with increased research outputs. Discussion ACEM sites have the capacity to undertake large multicentre studies with a varied network of sites and researchers. While some sites are well equipped for research, the majority of EDs had minimal research output.

Objectives To describe haemodynamic resuscitation practices in ED patients with suspected sepsis and hypotension. Methods This was a prospective, multicentre, observational study conducted in 70 hospitals in Australia and New Zealand between September 2018 and January 2019. Consecutive adults presenting to the ED during a 30‐day period at each site, with suspected sepsis and hypotension (systolic blood pressure

Influenza is a common cause of acute respiratory infection, and is a major cause of morbidity and mortality. This report summarises the epidemiology of hospitalisations with laboratory-confirmed influenza during the 2019 influenza season. The Influenza Complications Alert Network (FluCAN) is a sentinel hospital-based surveillance program that operates at sites in all jurisdictions in Australia. Cases were defined as patients hospitalised at any of the 17 sentinel hospitals with influenza confirmed by nucleic acid detection. Data were also collected on a frequency matched control group of influenza-negative patients admitted with acute respiratory infection. During the period 1 April to 31 October 2019 (the 2019 influenza season), there were 4,154 patients admitted with confirmed influenza to one of 17 FluCAN sentinel hospitals. Of these, 44% were elderly (≥ 65 years), 21% were children (< 16 years), 7.7% were Aboriginal and Torres Strait Islander peoples, 1.7% were pregnant and 73% had chronic comorbidities. Most admissions were due to influenza A infection (85%). Estimated vaccine coverage was 75% in the elderly, 49% in non-elderly adults with medical comorbidities, and 27% in young children (< 5 years). The estimated vaccine effectiveness in the target adult population was 42% (95% confidence interval [95% CI]: 36%, 49%). There were a larger number of hospital admissions detected with confirmed influenza in this national observational surveillance system in 2019 than in 2018.

Introduction Influenza is a common cause of acute respiratory infection, and is a major cause of morbidity and mortality. Coronavirus disease 2019 (COVID-19) is an acute respiratory infection that emerged as a pandemic worldwide before the start of the 2020 Australian influenza season. This report summarises the epidemiology of hospitalisations with laboratory-confirmed influenza and COVID-19 during the 2020 influenza season in a sentinel surveillance system. Methods The Influenza Complications Alert Network (FluCAN) is a sentinel hospital-based surveillance program that operates at sites in all jurisdictions in Australia. Influenza and COVID-19 cases were defined as patients hospitalised at sentinel hospitals and confirmed by nucleic acid detection. Results There were 448 patients with COVID-19 admitted between 16 March and 31 December 2020, and only 20 patients with influenza admitted between 1 April and 30 November 2020, to one of 22 FluCAN hospitals. Of the COVID-19 cases, 173 (39%) were > 65 years of age, 36 (8%) were children (< 16 years), 6 (1%) were Aboriginal and Torres Strait Islander peoples, 4 (1%) were pregnant and 289 (65%) had chronic comorbidities. COVID-19 hospital admissions peaked between weeks 13 and 15 (first wave) nationally, and again between weeks 31 and 35 (Victoria), with most admissions represented by those above 40 years of age. Discussion There was an unusually low number of hospital admissions with laboratory-confirmed influenza in this season, compared to recent seasons. This is likely to be due to effective public health interventions and international border closures as a result of a rise in COVID-19 respiratory infections and associated hospitalisations.

Background: This study investigated trends in computed tomography (CT) utilization across different triage categories of injury presentations to tertiary emergency departments (EDs) and associations with diagnostic yield measured by injury severity, hospitalization and length of stay (LOS), and mortality. Methods: A total of 411,155 injury-related ED presentations extracted from linked records from Western Australia from 2004 to 2015 were included in the retrospective study. The use of CT scanning and diagnostic yield measured by rate of diagnosis with severe injury, hospitalizations and LOS, and mortality were captured annually for injury-related ED presentations. Multivariable regression models were used to calculate the annual adjusted rate of CT scanning for injury presentations and hospitalizations across triage categories, diagnosis with severe injury, LOS, and mortality. The significance of changes observed was compared among patients with CT imaging relative to those without CT. Results: While the number of ED presentations with injury increased by 65% from 2004 to 2015, the use of CT scanning in these presentations increased by 176%. The largest increase in CT use was among ED presentations triaged as semi-/nonurgent (+256%). Injury presentations with CT, compared to those without, had a higher rate of diagnosis with moderate/severe injury and hospitalization but no difference in LOS and mortality. The probability/rate observed in the outcomes of interest had a greater decrease over time in those with CT scanning compared with those without CT scanning across triage categories. Conclusions: The reduction in diagnostic yield in terms of injury severity and hospitalization found in our study might indicate a shift toward overtesting using CT in ED for injury or a higher use of CT to assist in the management of injuries. This helps health care policymakers consider whether the current increase in CT use meets the desired levels of quality and efficient care.

Antifragility is a property of things that benefit from shocks, randomness and uncertainty and love adventure and risk. This describes emergency medicine. Improving evidence-based medicine requires a learning health system, where the whole system is constructed to advance patient care via research driven excellence. So we need to develop our own evidence base by embedding research into everyday practice. Clinical research is messy but the repeated stress testing of clinical practice via research enhances our antifragility. This is even more important because our world is complex, as are humans. Unfortunately, the human brain is hard wired for simplicity, making us disinclined to challenge the status quo. Yet probably

EDs are noisy and the noise levels exceed regulatory recommendations. Noise distracts us during any task and can saturate our attentional demand and impair our thinking and decision-making. This is a systematic problem that is consistently ignored by accreditation bodies. Many of our patients are vulnerable to the adverse impact of noise including the elderly, people with mental health problems, migraine and those with sensory impairments. Our noise levels are equivalent to a noisy restaurant. When noise levels are reduced, staff report less stress and better work conditions. Noise is a patient safety issue, as excessive noise impairs good communication, which is essential for patient care. Good acoustic design and management is achievable, but needs to be explicitly assessed as a part of accreditation standards. This would promote wellness for both patients and staff.

Sepsis is acute organ dysfunction in the setting of infection. An accurate diagnosis is important to guide treatment and disposition. Tissue oxygen saturation (StO2) can be estimated noninvasively by near-infrared spectroscopy (NIRS), and may be an indicator of microcirculatory dysfunction in early sepsis. We aimed to determine the utility of StO2 for sepsis recognition and outcome prediction among patients presenting to the emergency department (ED) with infection.A multicentre, prospective, observational cohort study recruited patients who were being admitted to hospital with infection. StO2 was measured in the ED using a handheld NIRS device, Inspectra 300. Outcomes were sepsis, defined as an increase in sequential organ failure assessment score of at least 2 points within 72 h, and composite in-hospital mortality/ICU admission at least 3 days.A cohort of 323 participants, median age 64 (interquartile range: 47-77) years, was recruited at three Australian hospitals. 143 (44%) fulfilled the criteria for sepsis and 22 (7%) died within 30 days. The mean ± SD StO2 was 74 ± 8% in sepsis and 78 ± 7% in nonsepsis (P 0.0001). StO2 correlated with the peak sequential organ failure assessment score (Spearman's ρ -0.27, P 0.0001). Area under the receiver operating characteristic curve was 0.66 (95% confidence interval: 0.60-0.72) for sepsis and 0.66 (0.58-0.75) for the composite outcome. StO2 less than 75% had an odds ratio of 2.67 (1.45-4.94; P = 0.002), for the composite outcome compared with StO2 at least 75%.NIRS-derived StO2 correlates with organ failure and is associated with outcome in sepsis. However, its ability to differentiate sepsis among ED patients with infection is limited. NIRS cannot be recommended for this purpose.

OBJECTIVE To describe the characteristics and outcomes of older adult (≥65 years) major trauma patients in comparison with younger adults (16-64 years). To determine whether older age is associated with a reduced likelihood of transport (directly or indirectly) to a major trauma centre and whether this is associated with in-hospital mortality. METHODS A retrospective cohort study of major trauma patients transported to hospital by St John Ambulance paramedics in Perth, Western Australia, between 1 January 2013 and 31 December 2016. Multivariate logistic regression was used to test the relationship between age and major trauma centre transport. Multivariate logistic regression analysis using inverse probability of treatment weighting was used to determine if major trauma centre transport was associated with in-hospital mortality in older adults. RESULTS One thousand six hundred and twenty-five patients were included; of these 576 (35%) were ≥65 years. In comparison with younger adults, older adults had more falls as their mechanism of injury (n = 358 [62%] versus n = 102 [10%], P ≤ 0.001) and more major head injuries (n = 472 [82%] versus n = 609 [58%], P ≤ 0.001). Older adults had lower odds (adjusted odds ratio 0.52, 95% confidence interval [CI] 0.35-0.78) of major trauma centre transport and this was associated with 1.7 times the likelihood of in-hospital mortality (95% CI 1.04-2.7). CONCLUSIONS Older adults who were not transported to the trauma centre had an increased odds of in-hospital mortality. However, older age was associated with a significantly reduced likelihood of trauma centre transport. With the aging population, the development of specific prehospital triage criteria to enable the complexities of this higher-risk population to be identified is important.

BACKGROUND Anaphylaxis is a severe, potentially life-threatening allergic reaction driven primarily by the activation of mast cells. We still fail to understand factors underlying reaction severity. Furthermore, there is currently no reliable diagnostic test to confirm anaphylaxis in the emergency department (ED). OBJECTIVE This study sought to explore gene expression changes associated with anaphylaxis severity in peripheral blood leucocytes and evaluate biomarker potential. METHODS Microarray analysis (total RNA) was performed using peripheral blood samples from ED patients with moderate (n = 6) or severe (n = 12) anaphylaxis and sepsis (n = 20) at presentation (T0) and one hour later (T1). Results were compared between groups and healthy controls (n = 10 and n = 11 matched to anaphylaxis and sepsis patients, respectively). Changes in gene expression were determined using R programming language, and pathway analysis applied to explore biological processes and pathways associated with genes. Differentially expressed genes were validated in an independent cohort of anaphylaxis (n = 30) and sepsis (n = 20) patients, and healthy controls (n = 10), using quantitative reverse transcription-polymerase chain reaction (qRT-PCR). RESULTS Significant up-regulation of small nucleolar RNAs (snoRNAs) was demonstrated in anaphylaxis compared to sepsis patients in the microarray cohort, at T0 and T1. qRT-PCR analysis of the validation cohort showed five genes: SNORD61, SNORD8, SNORD69, SNORD119 and HIST1H1D to be significantly up-regulated (adjusted p

TITLE Alcohol-related harm in emergency departments: linking to subsequent hospitalizations to quantify under-reporting of presentations. AIMS To quantify the proportion of emergency department (ED) presentations that could be identified as alcohol-related when linking to a patient's subsequent hospitalization, compared with using ED data alone, and to assess that comparison according to the change in alcohol harm rates over time and potential variations within subpopulations. DESIGN A retrospective study using linked hospital administrative data to identify ED patients who had subsequent alcohol-related hospitalizations. SETTING Western Australia. PARTICIPANTS A total of 533 816 Western Australian young people (246 866 females and 286 950 males), aged 12-24 years. MEASUREMENTS Whether or not presentations of young people to ED could be identified as alcohol-related, and for those that were not, how many had a subsequent alcohol-related hospitalization. Rates and proportions of alcohol-related harm for both methods of ascertainment were estimated by sex and Aboriginality across different age groups. FINDINGS Alcohol-related hospitalizations that followed an initial presentation at ED allowed the identification of an additional 19 994 alcohol-related presentations (95% increase). Linking to additional hospitalization information also resulted in significant variation in alcohol-related harm trends. In particular, trends in alcohol-related ED presentations for 21-24-year-old males were stable to slightly increasing using only ED data, but decreased after linking with hospitalization data (P

Background The defibrillator prompt, which directs callers to retrieve a defibrillator during out-of-hospital cardiac arrest, is crucial to the emergency call because it can save lives. We evaluated communicative effectiveness of the prompt instated by the Medical Priority Dispatch System™ Version 13, namely: if there is a defibrillator (AED) available, send someone to get it now, and tell me when you have it. Methods Using Conversation Analysis and descriptive statistics, we examined linguistic features of the defibrillator sequences (call-taker prompt and caller response) in 208 emergency calls where non-traumatic out-of-hospital cardiac arrest was confirmed by the emergency medical services, and they attempted resuscitation, in the first six months of 2019. Defibrillator sequence durations were measured to determine impact on time to CPR prompt. The proportion of cases where bystanders retrieved defibrillators was also assessed. Results There was low call-taker adoption of the Medical Priority Dispatch System™ Version 13 prompt (99/208) compared to alternative prompts (86/208) or no prompt (23/208). Caller responses to the Version 13 prompt tended to be longer, more ambiguous or unrelated, and have more instances of repair (utterances to address comprehension trouble). Defibrillators were rarely brought to the scene irrespective of defibrillator prompt utilised. Conclusion While the Version 13 prompt aims to ensure the use of an available automatic external defibrillator, its effectiveness is undermined by the three-clause composition of the prompt and exclusion of a question structure. We recommend testing of a re-phrased defibrillator prompt in order to maximise comprehension and caller action.

ObjectiveTo compare the efficacy of continuous positive airway pressure (CPAP) versus usual care for prehospital patients with severe respiratory distress.MethodsWe conducted a parallel group, individual patient, non-blinded randomised controlled trial in Western Australia between March 2016 and December 2018. Eligible patients were aged ≥40 years with acute severe respiratory distress of non-traumatic origin and unresponsive to initial treatments by emergency medical service (EMS) paramedics. Patients were randomised (1:1) to usual care or usual care plus CPAP. The primary outcomes were change in dyspnoea score and change in RR at ED arrival, and hospital length of stay.Results708 patients were randomly assigned (opaque sealed envelope) to usual care (n=346) or CPAP (n=362). Compared with usual care, patients randomised to CPAP had a greater reduction in dyspnoea scores (usual care −1.0, IQR −3.0 to 0.0 vs CPAP −3.5, IQR −5.2 to −2.0), median difference −2.0 (95% CI −2.5 to −1.6); and RR (usual care −4.0, IQR −9.0 to 0.0 min-1 vs CPAP −8.0, IQR −14.0 to −4.0 min-1), median difference −4.0 (95% CI −5.0 to −4.0) min-1. There was no difference in hospital length of stay (usual care 4.2, IQR 2.1 to 7.8 days vs CPAP 4.8, IQR 2.5 to 7.9 days) for the n=624 cases admitted to hospital, median difference 0.36 (95% CI −0.17 to 0.90).ConclusionsThe use of prehospital CPAP by EMS paramedics reduced dyspnoea and tachypnoea in patients with acute respiratory distress but did not impact hospital length of stay.Trial registration numberACTRN12615001180505.

Objective: To determine the association between prehospital time and outcomes in adult major trauma patients, transported by ambulance paramedics.Methods: A retrospective cohort study of major trauma patients (Injury Severity Score >15) attended by St John Ambulance paramedics in Perth, Western Australia, who were transported to hospital between 1st January 2013 and 31st December 2016. Inverse probability of treatment weighting (IPTW) using the propensity score was performed to limit selection bias and confounding. The primary outcome was 30-day mortality and the secondary outcome was the length of hospital stay (LOS) for 30-day survivors. Multivariate logistic and log-linear regression analyses with IPTW were used to determine if prehospital time of more than the one hour (from receipt of the emergency call to arrival at hospital) or any individual prehospital time interval (response, on-scene, transport or total time) was associated with 30-day mortality or LOS.Results: A total of 1,625 major tr...

There is uncertainty about the optimal i.v. fluid volume and timing of vasopressor commencement in the resuscitation of patients with sepsis and hypotension. We aim to study current resuscitation practices in EDs in Australia and New Zealand (the Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In Emergency Department Sepsis [ARISE FLUIDS] observational study). ARISE FLUIDS is a prospective, multicentre observational study in 71 hospitals in Australia and New Zealand. It will include adult patients presenting to the ED during a 30 day period with suspected sepsis and hypotension (systolic blood pressure This multicentre, observational study will provide insight into current haemodynamic resuscitation practices in patients with sepsis and hypotension as well as estimates of practice variation and patient outcomes. The results will inform the design and feasibility of a multicentre phase III trial of early haemodynamic resuscitation in patients presenting to ED with sepsis and hypotension.

Introduction Major trauma patients are often perceived as being young males injured by high energy transfer mechanisms. The aim of this study was to describe the demographics of major trauma patients who were transported to hospital by ambulance. Methods This is a retrospective cohort study of adult major trauma (injury severity score >15) patients transported to hospital by St John Western Australia emergency ambulance in metropolitan Perth, between 1 January 2013 and 31 December 2016. To describe the cohort, median and interquartile range (IQR) were used for continuous variables and counts and percentages for categorical variables. Differences between mechanism of injury groups were assessed using the Kruskal-Wallis test. Trauma deaths were defined as early (declared deceased within 24 hours) or late (declared deceased within 30 days). Results A total of 1625 patients were included. The median age was 51 years (IQR 30-75) and 1158 (71%) were male. Falls from standing were the most common mechanism of injury (n=460, 28%) followed by motor vehicle crashes (n=259, 16%). Falls from standing were responsible for the majority of early (n=45/175, 26%) and late deaths (n=69/158, 44%). A large number of early deaths also resulted from motorbike crashes (n=32/175, 18%) with a median age of 34 years (IQR 21-46, pConclusion Major trauma is not only a disease of the young. More than half of the cohort was more than 51 years of age and the most common cause was a fall from standing. Pre-hospital care must evolve to address the needs of a changing trauma patient demographic.

Collaboration with consumers is an emerging focus for medical researchers worldwide. Public involvement is increasingly encouraged, and in some cases stipulated by funding bodies, in order to secure financial support. While consumer involvement could be viewed as another hurdle in the funding application process, it can add immense value to research outcomes. However, given the diverse and transient nature of our consumer group, how can we develop meaningful public engagement in emergency medicine research?

To determine if a regimen of restricted fluids and early vasopressor compared to usual care is feasible for initial resuscitation of hypotension due to suspected sepsis. A prospective, randomised, open-label, clinical trial of a restricted fluid resuscitation regimen in the first 6 h among patients in the emergency department (ED) with suspected sepsis and a systolic blood pressure under 100 mmHg, after minimum 1000 ml of IV fluid. Primary outcome was total fluid administered within 6 h post randomisation. There were 99 participants (50 restricted volume and 49 usual care) in the intention-to-treat analysis. Median volume from presentation to 6 h in the restricted volume group was 2387 ml [first to third quartile (Q1–Q3) 1750–2750 ml]; 30 ml/kg (Q1–Q3 32–39 ml/kg) vs. 3000 ml (Q1–Q3 2250–3900 ml); 43 ml/kg (Q1–Q3 35–50 ml/kg) in the usual care group (p

Objective An ever-increasing number of novel psychoactive substances are being detected worldwide. These emerging drugs have been demonstrated to cause toxicity in clusters, and deaths have been reported. We urgently need to learn more about their effects. We report the protocol for the Western Australian Illicit Substance Evaluation (WISE) study, a research project investigating illicit drug use in the ED. Methods Patients can be enrolled if the treating clinician strongly suspects they are currently intoxicated with a stimulant, hallucinogenic or cannabinoid drug; and an i.v. cannula or blood tests are required for routine clinical care. Patients are enrolled under a waiver of consent. A single additional blood tube is collected, de-identified and frozen on site. A temporary link between patient identification number and study identification number is retained for up to 10 business days post-hospital discharge to allow for clinical data collection, before this is destroyed and the patients become permanently de-identified. Samples are transported for external liquid chromatography-mass spectrometry analysis in batches once de-identified. Results The key outcome will be identification of any psychoactive drugs present in the blood sample, together with their respective concentration. This will be linked to the clinical effects, as well as being compared with the substance the patient believed they had taken. Conclusion We consider the novel approach outlined forms a template for an early warning system for emerging drugs of concern, while also providing vital and comprehensive information on current drugs of abuse, their clinical effects and their impact on the health system.

Purpose Endocan, a component of the endothelial glycocalyx (EG), has been linked with respiratory failure in sepsis. This study explored the temporal patterns of three EG biomarkers, including endocan, and their relationships with inflammation and respiratory failure. Materials and methods Plasma endocan, syndecan-1, and hyaluronan concentrations were measured in Emergency Department (ED) patients with sepsis due to pneumonia (n = 44) on ED arrival (T0), 1 h (T1), 3 h (T3) and 12–24 h (T24) later, with change over time tested using mixed regression models. Biomarker associations with inflammatory cytokine concentrations and with respiratory failure on days 1, 2 or 3, need for mechanical ventilation and 30-day mortality were also tested. Results Endocan concentration significantly decreased over time (T0–T24, P = 0.003) whereas both syndecan-1 (T0–T3, P = 0.010; T0–T24, P

Objective: The implementation of the time target policy (Four-Hour Rule/National Emergency Access Target [4HR/NEAT]) constituted a major change for ED, and potentially on quality of care. The present study aimed to understand perceptions and experiences of ED staff during 4HR/NEAT implementation. Methods: A semi-structured interview was used to explore views and perceptions of 119 ED staff from 16 EDs in New South Wales, Australian Capital Territory, Queensland and Western Australia. The interviews covered aspects such as perceived changes in quality of clinical care, whether the capacity to deliver education was diminished or enhanced and whether the policy affected access to care. Interviews were transcribed, imported to NVivo 11 and analysed using content and thematic analysis. Results: Three themes were identified: quality and safety of care; access block and overcrowding; and medical education and training. Participants described both positive and negative aspects of the policy. Although some reported negative impacts on care quality and access block, more cited overall improvements in these areas. The majority perceived that medical education and training was negatively affected, mainly because of restricted training opportunities and reduced time for procedural skills. Conclusions: ED staff perceived important effects on quality and safety of care; access block and overcrowding; and medical education and training. In relation to an optimised ED role, quality of care and access block were overall felt to be improved, while education and training deteriorated. Our study increases understanding of the complexity of policy implementation processes and its impact on staff. Staff perceptions are a valuable measure of system performance and should be incorporated into system change evaluations.

Objective It has been 10 years since the ACEM Access Block Solutions Summit and 5 years since the introduction of the Four-Hour Rule/National Emergency Access Target (4HR/NEAT) policy. The impact of this policy on ED management and on ED staff has been poorly understood. The aim of the present study was to identify changes in ED management resulting from the policy based on ED staff experiences. Methods Semi-structured interviews were conducted and transcribed, imported to NVivo 11 and analysed using a combination of content, thematic analysis and phenomenological focus within a theoretical framework known as the 'logic model'. Results One hundred and nineteen ED staff participated in 2015-2016 to assess the impact of the policy implementation. Participants were drawn from 16 EDs in New South Wales, Queensland, Western Australia and Australian Capital Territory. In relation to ED management, three themes were identified: changes in ED management; activities and changes driven by the hospital in relation to 4HR/NEAT; and participant experiences in relation to policy compliance by staff. Conclusions Policy implementation is a complex process that had both positive and negative consequences on how ED staff managed the implementation of the 4HR/NEAT policy and how it changed their work environment. Understanding the perceptions of staff involved in policy implementation has significance for the design of future implementation strategies. The biggest insight from the present study is that ED management is very complex and the policy generated multiple positive and negative changes demonstrating the wide range of processes involved in this area of health services research.

Objective Previous research reported strong associations between ED overcrowding and mortality. We assessed the effect of the Four‐Hour Rule (4HR) intervention (Western Australia (WA) 2009), then nationally rolled out as the National Emergency Access Target (Australia 2012) policy on mortality and patient flow. Methods A longitudinal cohort study of a population‐wide 4HR, for 16 hospitals across WA, New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD). Mortality trends were analysed for 2–4 years before and after 4HR using interrupted time series technique. Main outcomes included the effect of 4HR on patient flow markers; admitted 30 day mortality trends; and patient flow marker performance during the study period. Results There were 40 281 deaths from 952 726 emergency admissions. All jurisdictions, except ACT, had improved flow and access block after 4HR. Age‐standardised mortality was decreasing before the intervention. Post‐intervention, WA had a significant reduction in mortality rate of −0.28 per 1000 patients per quarter (P = 0.040) while QLD had mixed results and NSW/ACT trends did not change significantly. Meta‐regression of aggregated data for hospitals grouped on flow performances did not show significant mortality changes associated with the policy. Conclusions The 4HR was introduced as a means of driving hospital performance by applying a time target. Patient flow improved, but the evidence for mortality benefit is controversial with improvement only in WA. Further research with more representative data from a larger number of hospitals over a longer time across Australia is needed to increase statistical power to detect long‐term effects of the policy.

Appropriate deliberate clinical inertia refers to the art of doing nothing as a positive clinical response. It includes shared decision‐making to improve patient care with the use of clinical judgement. We discuss common clinical scenarios where the use of deliberate clinical inertia can occur. The insertion of peripheral intravenous cannulae, investigating patients with suspected renal colic and the investigation of low risk chest pain are all opportunities for the thoughtful clinician to ‘stand there’ and use effective patient communication to avoid low value tests and procedures. Awareness is key to identifying these opportunities to practice deliberate clinical inertia, as many of the situations may be so much a part of our environment that they are hidden in plain view.

It can be difficult to avoid unnecessary investigations and treatments, which are a form of low-value care. Yet every intervention in medicine has potential harms, which may outweigh the potential benefits. Deliberate clinical inertia is the art of doing nothing as a positive response. This paper provides suggestions on how to incorporate deliberate clinical inertia into our daily clinical practice, and gives an overview of current initiatives such as 'Choosing Wisely' and the 'Right Care Alliance'. The decision to 'do nothing' can be complex due to competing factors, and barriers to implementation are highlighted. Several strategies to promote deliberate clinical inertia are outlined, with an emphasis on shared decision-making. Preventing medical harm must become one of the pillars of modern health care and the art of not intervening, that is, deliberate clinical inertia, can be a novel patient-centred quality indicator to promote harm reduction.

Background and aims: Emergency department (ED) alcohol‐related presentation data are not routinely collected in Australia and New Zealand. It is likely that previous research has underestimated the numbers of patients presenting with alcohol‐related conditions. This study aimed to quantify the level of alcohol harm presenting to EDs in Australia and New Zealand [Correction added on 23 Jan 2018, after first online publication: The ‘aims’ section was missing and is updated in this version]. Design: Multi‐centre, prospective study. Patients were screened prospectively for alcohol‐related presentations during a 7‐day period in December 2014. Part 1 involved screening to determine alcohol‐positive ED presentations and data collection of patient demographic and clinical information. Part 2 involved a consent‐based survey conducted with patients aged ≥ 14 years to perform Alcohol Use Disorders Identification Test (AUDIT) scores. Setting: Eight EDs in Australia and New Zealand, representing differing hospital role delineations. Participants: A total of 8652 patients aged ≥ 14 years attended and 8435 (97.5%) were screened. Measurements: The main outcome measure was the proportion of patients who had an alcohol‐related presentation termed ‘alcohol‐positive’, using pre‐defined criteria. It included injuries, intoxication, medical conditions and injuries caused by an alcohol‐affected third party. Secondary outcomes included demographic and clinical information, the type of alcohol‐related presentations and AUDIT scores. Findings: A total of 801 [9.5%; 95% confidence interval (CI) = 8.9–10.1%] presentations were identified as alcohol‐positive, ranging between 4.9 and 15.2% throughout sites. Compared with alcohol‐negative patients, alcohol‐positive patients were more likely to be male [odds ratio (OR) = 1.90, 95% CI = 1.63–2.21], younger (median age 37 versus 46 years, P < 0.0001), arrive by ambulance (OR = 1.94, 95% CI = 1.68–2.25) or police/correctional vehicle (OR = 4.56, 95% CI = 3.05–6.81) and require immediate treatment (OR = 3.20, 95% CI = 2.03–05.06). The median AUDIT score was 16 (interquartile range = 10–24). Conclusions: Almost one in 10 presentations to emergency departments in Australia and New Zealand are alcohol related.

Endothelial glycocalyx (EG) shedding may promote organ failure in sepsis. This study describes temporal changes in EG biomarkers from Emergency Department (ED) arrival, and associations with clinical characteristics.This prospective observational study included 23 patients with simple infection, 86 with sepsis and 29 healthy controls. Serum EG biomarkers included syndecan-1, syndecan-4 and hyaluronan. Samples were taken on enrolment in the ED (T0), 1 hour (T1), 3 hours (T3) and 12 to 24 hours (T24) later.Syndecan-1 concentration increased incrementally over time (T0-T24, both patient groups, P.001) whereas hyaluronan concentration peaked at T3 (T0-T3, sepsis group, P.001). Hyaluronan was positively associated with cumulative fluid volumes (P.001) at T0, T1, and T3, independent of illness severity. Both syndecan-1 (OR 1.04, 95% CI 1.01-1.07, P = .017) and hyaluronan (OR 1.83, 95% CI 1.46-2.30, P.001) were associated with organ failure, independent of age and comorbidity. Syndecan-4 concentration was not different between groups or over time.In contrast to previous ICU studies, EG biomarkers increased during the first 24 hours of sepsis treatment and were associated with fluid volumes and organ failure. Further investigation is required to determine if interventions delivered in the ED contribute to EG shedding.

OBJECTIVES To determine the priorities for emergency medicine research of patients currently in an ED and to compare their priorities with those of ACEM researchers. METHODS A survey of current patients in the EDs of Royal Perth Hospital and Armadale Health Service. Patients gave their reason for presentation, suggested three important research priorities for emergency medicine and ranked their top 5 choices from a pre-specified list published by the ACEM researchers. Results were analysed using qualitative and quantitative research methods. RESULTS A total of 430 patients completed the survey, of which 218 were men (50.7%), with median age 44 years (interquartile range [IQR] 30-61 years, range 18-92 years). The top 5 priorities suggested by patients were cardiology, trauma, ED processes, mental health and haematology/oncology. The top 5 patient rankings of the ACEM researcher list were resuscitation, trauma, cardiology, infectious diseases and paediatrics. Older age groups tended to rank cardiology high, while trauma and resuscitation were ranked high among all age groups. There was moderate agreement between patients and ACEM researchers (ρ = 0.51, P = 0.03). CONCLUSIONS The top 5 emergency medicine research priorities nominated by patients in ED were cardiology, trauma, ED processes, mental health and haematology/oncology, although many 'system priorities' were identified as well. These priorities were generally consistent with ACEM researchers, but patients also suggested alternative directions for future research.

Objective To quantify and describe alcohol-related presentations to our ED, as part of the binational Alcohol Harm in Emergency Departments study. Methods A prospective observational study at Royal Perth Hospital of every patient attending ED for the 168-h period commencing 08.00 hours Monday 1 December 2014. Patient presentations were classified as alcohol-related (alcohol-positive) using predefined criteria. These patients were compared to alcohol-negative patients on a range of demographic and clinical descriptors. Results Two hundred and thirteen (15.2%) of 1403 patients screened were alcohol-positive. Compared with alcohol-negative patients, alcohol-positive patients were more likely to be male (148/213, 69.5% vs 636/1190, 53.4%, P

Objective Integrating arts and humanities-based pedagogy into curricula is of growing interest among medical educators, particularly how it promotes reflection and empathy. Our aim was to explore whether a 2.50 min film titled ‘The Art of the ED’ stimulated reflective learning processes in a group of first year medical students. Methods The film was shown prior to their first clinical placement in an ED. Student participation was voluntary and not assessable. Using an exploratory qualitative research approach, this study drew on data collected from students’ individual written reflections, exploring their perceptions towards clinical experience in an emergency medicine (EM) attachment. Results A total of 123 (51% of 240) students submitted a reflection. The qualitative data revealed three main themes: the opportunity for students to preview EM (‘While watching the film, I felt like I was the patient and the doctor all at once, in that I was living the experience both from within and as an observer …’); exposed the reality of ED; and fostered a growing awareness of the fragility of human life. Conclusions These findings highlight how visual methodologies (like film) create a safe, non-threatening space to access, experience and process emotion around their perceptions towards EM, and to anticipate and emotionally prepare for their impending clinical experience in the ED. These data support the use of visual methodologies to foster reflective processes that assist medical students to integrate the ‘art’ of EM, and the development and commitment of core doctoring values of empathy, service and respect for patients.

This chapter will discuss the context within which traumatic brain injury (TBI) and in particular mild TBI is investigated principally in an emergency setting. It provides background in relation to health system burden and discusses the cognitive processes involved in the assessment and follow-up of patients with TBI. This then leads to a discussion of the information gaps in such assessment pathways and how biomarkers are needed to fill these crucial information gaps in order to provide optimized acute and follow-up patient care.