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Objectives: To explore the unique impact the first COVID‐19 national lockdown in New Zealand (NZ) had on the utility of computed tomography (CT)‐head scanning in patients presenting to the ED with head injuries. Methods: Retrospective observational study of CT‐head use in head‐injured patients presenting to the ED during the 2020 COVID‐19 lockdown compared to the corresponding time period in 2019. Results: During the lockdown period in 2020, the total number of ED presentations reduced by 30.3% (95% confidence interval [CI] 28.8–31.6) from 13 477 to 9403. The total number of head injury presentations also reduced by 32% (95% CI 27–36.7) from 523 to 356. The proportion of head‐injured patients remained similar (3.9% [n = 523] in 2019 vs 3.8% [n = 356] in 2020). Of the head injured patients, 185 (51.9%, 95% CI 44.5–59.4) had CT‐head scans performed in 2020 compared to 269 (51.4%, 95% CI 45.2–57.5) in 2019; a reduction of 31.2% (95% CI 24.5–37.9). The proportion of patients who had a CT‐head scan remained similar (51.4% [95% CI 45.2–57.5] in 2019 vs 51.9% [95% CI 44.5–59.4] in 2020). There were no significant differences in the proportion of CT‐head scans with acute traumatic pathology (13.0% [95% CI 8.7–17.3] in 2019 vs 12.4% [95% CI 7.4–17.5] in 2020, P = 0.86). Conclusions: During the first COVID‐19 lockdown in NZ, the total number of patients presenting to the ED decreased by one third. Reassuringly, the proportion of patients who presented with head injuries, had a CT‐head scan performed, and had positive CT‐head findings remained the same as the previous year. [ABSTRACT FROM AUTHOR]

Objective: Concussion is a common ED complaint, but diagnosis is challenging as there are no validated objective measures. Use of concussion tools derived from sports medicine is common, but these tools are not well validated in ED settings. The aim of this study was to assess the ability of the Sport Concussion Assessment Tool 5th Edition (SCAT5) to identify concussion in ED patients presenting following head injury. Methods: We conducted a prospective observational study of head‐injured adult patients presenting to ED between March and July 2021. ED diagnosis of concussion was used as the diagnostic standard, and we assessed the diagnostic performance of the SCAT5 test and its three subsections (Standardised Assessment of Concussion (SAC), Post‐Concussion Symptom Scale (PCSS) and Modified Balance Error Scoring System (mBESS)) against this. Results: Thirty‐two head‐injured participants were enrolled, 19 of whom had a discharge diagnosis of concussion, alongside 17 controls. Median time for SCAT5 testing was 21 (interquartile range 16–27) min. Fifteen (30.6%) participants were interrupted during testing. Area under the curve (AUC) (95% confidence interval) for the SAC, PCSS and mBESS were 0.51 (0.34–0.68), 0.92 (0.84–0.99) and 0.66 (0.47–0.85), respectively. Sensitivity and specificity of sections were as follows: entire SCAT5 (100.0%, 20.0%), SAC (48.1%, 60.0%), PCSS (89.7%, 85.0%) and mBESS (83.3%, 58.8%). Using PCSS alone would have identified 17 of 19 concussions. Conclusion: The SCAT5 test had a low specificity, was long and was frequently interrupted. We suggest it is not an ideal assessment to use in ED. The PCSS score performed well and was easy to complete. It may be useful as a standalone tool to simplify ED concussion identification. [ABSTRACT FROM AUTHOR]

Background: Traumatic brain injury is a common ED presentation. CT-head utilisation is escalating, exacerbating resource pressure in the ED. The biomarker S100B could assist clinicians with CT-head decisions by excluding intracranial pathology. Diagnostic performance of S100B was assessed in patients meeting National Institute of Health and Clinical Excellence Head Injury Guideline (NICE HIG) criteria for CT-head within 6 and 24 hours of injury.Methods: This multicentre prospective observational study included adult patients presenting to the ED with head injuries between May 2020 and June 2021. Informed consent was obtained from patients meeting NICE HIG CT-head criteria. A venous blood sample was collected and serum was tested for S100B using a Cobas Elecsys-S100 module; >0.1 µg/mL was the threshold used to indicate a positive test. Intracranial pathology reported on CT-head scan by the duty radiologist was used as the reference standard to review diagnostic performance.Results: This study included 265 patients of whom 35 (13.2%) had positive CT-head findings. Within 6 hours of injury, sensitivity of S100B was 93.8% (95% CI 69.8% to 99.8%) and specificity was 30.8% (22.6% to 40.0%). Negative predictive value (NPV) was 97.3% (95% CI 84.2% to 99.6%) and area under the curve (AUC) was 0.73 (95% CI 0.61 to 0.85; p=0.003). Within 24 hours of injury, sensitivity was 82.9% (95% CI 66.4% to 93.44%) and specificity was 43.0% (95% CI 36.6% to 49.7%). NPV was 94.29% (95% CI 88.7% to 97.2%) and AUC was 0.65 (95% CI 0.56 to 0.74; p=0.046). Theoretically, use of S100B as a rule-out test would have reduced CT-head scans by 27.1% (95% CI 18.9% to 36.8%) within 6 hours and 37.4% (95% CI 32.0% to 47.2%) within 24 hours. The risk of missing a significant injury with this approach would have been 0.75% (95% CI 0.0% to 2.2%) within 6 hours and 2.3% (95% CI 0.5% to 4.1%) within 24 hours.Conclusion: Within 6 hours of injury, S100B performed well as a diagnostic test to exclude significant intracranial pathology in low-risk patients presenting with head injury. In theory, if used in addition to NICE HIGs, CT-head rates could reduce by one-quarter with a potential miss rate of <1%. [ABSTRACT FROM AUTHOR]

Introduction: The use of CT head scanning for traumatic brain injury (TBI) is a vital diagnostic tool, guided by risk stratification tools. This study aims to review the use of CT head scans and adherence to guidelines for TBI in two New Zealand emergency departments (EDs). Methods: Retrospective observational study of patients referred for head CT from EDs to exclude a significant intracranial injury between 1st September 2018 and 31st August 2019. Clinical data were collected regarding presenting patterns, identification of injuries on CT scan and adherence to National Institute of Clinical Excellence (NICE) CT head guidelines. Results: Out of 425 included cases, 41 (10%) patients had an intracranial injury seen on their CT head scan. Patients who reported loss (32% vs 20%, p < 0.05) or possible loss of consciousness (34% vs 22%, p < 0.05) and had a Glasgow Coma Score (GCS) <13 (17% vs 8%, p < 0.05) or focal neurology (10% vs 3%, p < 0.05) were more likely to have an intracranial injury on CT. Interestingly, 17 (41%) patients with CT diagnosed injuries had a GCS 15 and no focal neurology. NICE guidelines were adhered to in 364 (86%) of CT requests. In the 14% of cases that did not meet guideline criteria, all CT head scans were negative. Conclusion: CT head scans are a valuable tool in TBI, and guidelines successfully identify those with significant intracranial injuries. However, the rate of significant injury for the total population requiring head CT remains low, with over 90% of head CTs in the population normal, despite high guideline compliance, perhaps identifying a role for novel objective tests in ED guidelines internationally. [ABSTRACT FROM AUTHOR]

Objective: Early sepsis recognition and treatment are essential in order to reduce the burden of disease. Initial assessment of patients with infection is often undertaken by ED nurses and resident doctors. This descriptive qualitative study aimed to explore their perceptions and perspectives regarding the factors that impede the identification and management of patients with sepsis. Methods: This was a qualitative study conducted between 30 January 2020 and 27 February 2020. Semi‐structured focus group interviews were performed to collect data. All participants provided written informed consent and completed a basic demographic and work experience form. Two study investigators facilitated the interviews. Interviews were audio‐recorded and later transcribed. Thematic analysis was performed with the aid of NVivo 12 software. Results: Six focus group interviews were conducted involving 40 ED nurses and doctors. Interview length ranged from 27 to 38 min (mean 33.5 min). Three major themes were identified: (i) clinical management; (ii) challenges and delays; and (iii) communication. Each of these themes was broken down into subthemes, which are presented in more detail. Conclusion: ED nurses and doctors have identified important factors that limit and enhance their capacity to recognise and respond to patients with sepsis. Complex interactions exist between clinical and organisational structures that can affect the care of patients and the ability of clinicians to provide optimal care. The three major themes and specific subthemes provide a useful framework and stimulus for service improvements and research that could help foster future sepsis management improvement strategies. [ABSTRACT FROM AUTHOR]

Objective: Smartglasses are a wearable computer technology that has potential to facilitate remote supervision to junior doctors working in different clinical settings. The present study aimed to explore the feasibility of smartglass technology to enable remote supervision of junior clinicians by senior clinicians during emergency simulation scenarios. Methods: This was a feasibility simulation study using high-fidelity mannequins and standardised patients. Trainee interns (TIs) and supervising clinicians (SCs) were invited to participate in two scenarios: a trauma case and a stroke case. There was a pre-sim questionnaire. The TI wore the smartglasses in a simulated ED bay and performed patient assessment and management. Remote supervision was provided by the SC via a livestream on a remote computer. Upon completion, participants completed a survey regarding their experience comprising of Likert scale and free-text questions. Results: Fifteen TIs and 19 SCs participated. In general feedback from TIs and SCs was positive. TIs were able to identify and treat the key diagnostic problems set during the scenarios. Free-text survey responses provided specific feedback about what did and did not work when using the glasses. Conclusion: The present study demonstrates that smartglasses facilitated remote assistance has promise as an emergent technology and warrants further investigation in simulated and non-simulated environments. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion To evaluate gender authorship trends in the official journal of the Australasian College for Emergency Medicine (ACEM), Emergency Medicine Australasia (EMA).A bibliometric review of author gender in EMA during the 10‐year period 2013–2022. The gender of first/last authors were determined by www.genderize.io, or a manual internet search where gender was not determined with at least 90% certainty. Descriptive statistics were used with percentages of women as first and last author compared to current percentages of ACEM Fellows (FACEMs) who identify as women.The final analysis included 1703 articles. Women accounted for 27.4% fewer authors than men (36.3% vs 63.7%). Women were outnumbered by men by 20.0% among first authors (40% vs 60%), and 36.2% (31.9% vs 68.1%) for last authors. When the last author was a woman, there was a similar rate of women (49.2%) and men (50.8%) as first authors. However, when the last author was a man, first authors were 37.1% women versus 62.9% men. If the last author was a woman, there was a 60% greater probability that the first author was also a woman (odds ratio 1.6, 95% CI 1.3–2.1). First authorship rate by women was equal to or exceeds the proportion of women FACEMs, however, last authorship by women still lags behind.The emergency medicine community in Australasia must continue to tackle existing gender disparities which exist in our specialty. A creative and active strategy on the part of publishers, editors, academics and authors is needed to redress this balance. [ABSTRACT FROM AUTHOR]

Objective: Empowering a senior nurse in a shared leadership role has been proposed as a more efficient set up for the cardiac arrest team in ED. In this model, a senior nurse leads the cardiac arrest algorithm which allows cognitive off‐loading of the lead emergency physician. The emergency physician is then more available to perform tasks such as echocardiography and exclude reversible causes. Simulation provides an opportunity for training and practice of this shared leadership model. We hypothesised that a structured simulation training programme that focused on implementing a nurse and doctor shared leadership model for cardiopulmonary resuscitation (CPR), would improve leadership and teamwork quality in the setting of cardiac arrest as measured by a Trauma Non‐technical Skills (T‐NOTECHS) teamwork scale. Methods: Fifteen senior ED nurses participated in this pre‐interventional post‐observational study. Training consisted of a didactic course on team leadership and crisis resource management (CRM) followed by 4 × 10‐min resuscitation scenarios with a structured debrief focusing on team leadership skills and CRM. The primary outcome was measured on scenarios 1 and 4 using a modified T‐NOTECHS teamwork scale. Results: A statistically significant increase in the T‐NOTECHS scale was detected for the measures of leadership (P = 0.0028), CRM (P = 0.0001), adherence to New Zealand Resuscitation Council ALS algorithm (P = 0.0088) and situational awareness (P = 0.0002). Conclusion: The present study shows that a short simulation training programme improved nurse leadership and teamwork performance in the setting of a shared leadership model for CPR in the ED which could easily be replicated in other departments. Empowering a senior nurse in a shared leadership role has been proposed as a more efficient setup for the cardiac arrest team in ED. We hypothesised that a structured simulation training programme that focused on implementing a nurse and doctor shared leadership model for CPR, would improve leadership and teamwork quality in the setting of cardiac arrest as measured by a Trauma Non‐technical Skills (T‐NOTECHS) teamwork scale. The present study showed that a short simulation training programme improved nurse leadership and teamwork performance in the setting of a shared leadership model for CPR in the ED which could easily be replicated in other departments. [ABSTRACT FROM AUTHOR]

Background: Traumatic brain injury is a common ED presentation. CT-head utilisation is escalating, exacerbating resource pressure in the ED. The biomarker S100B could assist clinicians with CT-head decisions by excluding intracranial pathology. Diagnostic performance of S100B was assessed in patients meeting National Institute of Health and Clinical Excellence Head Injury Guideline (NICE HIG) criteria for CT-head within 6 and 24 hours of injury., Methods: This multicentre prospective observational study included adult patients presenting to the ED with head injuries between May 2020 and June 2021. Informed consent was obtained from patients meeting NICE HIG CT-head criteria. A venous blood sample was collected and serum was tested for S100B using a Cobas Elecsys-S100 module; >0.1 µg/mL was the threshold used to indicate a positive test. Intracranial pathology reported on CT-head scan by the duty radiologist was used as the reference standard to review diagnostic performance., Results: This study included 265 patients of whom 35 (13.2%) had positive CT-head findings. Within 6 hours of injury, sensitivity of S100B was 93.8% (95% CI 69.8% to 99.8%) and specificity was 30.8% (22.6% to 40.0%). Negative predictive value (NPV) was 97.3% (95% CI 84.2% to 99.6%) and area under the curve (AUC) was 0.73 (95% CI 0.61 to 0.85; p=0.003). Within 24 hours of injury, sensitivity was 82.9% (95% CI 66.4% to 93.44%) and specificity was 43.0% (95% CI 36.6% to 49.7%). NPV was 94.29% (95% CI 88.7% to 97.2%) and AUC was 0.65 (95% CI 0.56 to 0.74; p=0.046). Theoretically, use of S100B as a rule-out test would have reduced CT-head scans by 27.1% (95% CI 18.9% to 36.8%) within 6 hours and 37.4% (95% CI 32.0% to 47.2%) within 24 hours. The risk of missing a significant injury with this approach would have been 0.75% (95% CI 0.0% to 2.2%) within 6 hours and 2.3% (95% CI 0.5% to 4.1%) within 24 hours., Conclusion: Within 6 hours of injury, S100B performed well as a diagnostic test to exclude significant intracranial pathology in low-risk patients presenting with head injury. In theory, if used in addition to NICE HIGs, CT-head rates could reduce by one-quarter with a potential miss rate of <1%., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)