ORCID Profile
0000-0002-1443-557X
Current Organisations
Monash University
,
Alfred Health
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Publisher: Wiley
Date: 14-06-2015
Publisher: British Editorial Society of Bone & Joint Surgery
Date: 10-2013
DOI: 10.1302/0301-620X.95B10.32134
Abstract: We describe the routine imaging practices of Level 1 trauma centres for patients with severe pelvic ring fractures, and the interobserver reliability of the classification systems of these fractures using plain radiographs and three-dimensional (3D) CT reconstructions. Clinical and imaging data for 187 adult patients (139 men and 48 women, mean age 43 years (15 to 101)) with a severe pelvic ring fracture managed at two Level 1 trauma centres between July 2007 and June 2010 were extracted. Three experienced orthopaedic surgeons classified the plain radiographs and 3D CT reconstruction images of 100 patients using the Tile/AO and Young–Burgess systems. Reliability was compared using kappa statistics. A total of 115 patients (62%) had plain radiographs as well as two-dimensional (2D) CT and 3D CT reconstructions, 52 patients (28%) had plain films only, 12 (6.4%) had 2D and 3D CT reconstructions images only, and eight patients (4.3%) had no available images. The plain radiograph was limited to an anteroposterior pelvic view. Patients without imaging, or only plain films, were more severely injured. A total of 72 patients (39%) were imaged with a pelvic binder in situ. Interobserver reliability for the Tile/AO (Kappa 0.10 to 0.17) and Young–Burgess (Kappa 0.09 to 0.21) was low, and insufficient for clinical and research purposes. Severe pelvic ring fractures are difficult to classify due to their complexity, the increasing use of early treatment such as with pelvic binders, and the absence of imaging altogether in important patient sub-groups, such as those who die early of their injuries. Cite this article: Bone Joint J 2013 -B:1396–1401.
Publisher: Wiley
Date: 04-09-2016
Abstract: To compare chief complaints of the Medical Priority Dispatch System in terms of the match between dispatch priority and patient condition. This was a retrospective whole-of-population study of emergency ambulance dispatch in Perth, Western Australia, 1 January 2014 to 30 June 2015. Dispatch priority was categorised as either Priority 1 (high priority), or Priority 2 or 3. Patient condition was categorised as time-critical for patient(s) transported as Priority 1 to hospital or who died (and resuscitation was attempted by paramedics) else, patient condition was categorised as less time-critical. The χ There were 211 473 cases of dispatch. Of 99 988 cases with Priority 2 or 3 dispatch, 467 (0.5%) were time-critical. Convulsions/seizures and breathing problems were highlighted as having more false negatives (time-critical despite Priority 2 or 3 dispatch) than expected from the overall false omission rate. Of 111 485 cases with Priority 1 dispatch, 6520 (5.8%) were time-critical. Our analysis highlighted chest pain, heart problems/automatic implanted cardiac defibrillator, unknown problem/collapse, and headache as having fewer true positives (time-critical and Priority 1 dispatch) than expected from the overall positive predictive value. Scope for reducing under-triage and over-triage of ambulance dispatch varies between chief complaints of the Medical Priority Dispatch System. The highlighted chief complaints should be considered for future research into improving ambulance dispatch system performance.
Publisher: Wiley
Date: 07-11-2017
Abstract: The aim of the present study was to describe the trauma case review process and its role in a regionalised trauma system. Victoria has a population of 5.9 million people, accounting for 26% of Australia's population. Victoria has been serviced by an inclusive, organised trauma system since 2000 comprising 138 health services with trauma designations and three major trauma services. Pre- and interhospital guidelines prescribe the timely transport of patients to the appropriate level of trauma service. A review of the role and contribution of 10 years of operation of the trauma case review group (CRG) was undertaken to describe the aims, processes and governance surrounding the implementation of an in idual case review for specified major trauma patients. Specified patients were those identified by the Victorian State Trauma Registry as being managed outside of established Victorian State Trauma System prehospital and interhospital guidelines. A state-wide trauma case review process was implemented across the trauma system using data-informed detection flags and screening criteria. Using data from the Victorian State Trauma Registry, detection flags were correlated with patients at risk of a poorer outcome, thereby ensuring that all patients managed outside of the requirements of established trauma triage and transfer guidelines were subject to review. The CRG provides an in idual review process as a technique for assessing and monitoring major trauma patient care and compliance with trauma system triage and transfer guidelines. The process has been effective as a quality and safety strategy by improving clinician knowledge of major trauma triage and transfer guidelines and facilitating improved compliance, particularly with interhospital transfers. Strong compliance has been achieved from health services with the requirement to internally review and respond to CRG concerns regarding 'high-risk' trauma cases. Anecdotal feedback from health services regarding participation in the CRG process has been positive. The trauma case review process is an embedded feature of the Victorian State Trauma System that aims to improve compliance with major trauma guidelines by reviewing major trauma cases that have been managed outside of established triage and transfer guidelines. All trauma-designated Victorian health services, Ambulance Victoria and Victorian adult and paediatric patient retrieval services might receive trauma cases for review. The process is also an integral component of trauma system clinical governance, which enables the identification of system-level issues for escalation to the State Trauma Committee and the Victorian Department of Health and Human Services.
Publisher: Wiley
Date: 12-09-2020
Publisher: Wiley
Date: 20-04-2022
Abstract: To assess the feasibility of an ED presenting complaint (PC) tool that categorised all ED PCs into 10 categories. A retrospective analysis of 1445 consecutive patient encounters was conducted. The primary outcome was the frequency of use of the 10 PC categories. 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%). The PC tool captured the majority of presenting complaints in 10 categories. External validation is recommended.
Publisher: Wiley
Date: 08-2017
DOI: 10.1111/JEBM.12256
Abstract: This systematic review aimed to determine the effect of prehospital notification systems for major trauma patients on overall (<30 days) and early (<24 hours) mortality, hospital reception, and trauma team presence (or equivalent) on arrival, time to critical interventions, and length of hospital stay. Experimental and observational studies of prehospital notification compared with no notification or another type of notification in major trauma patients requiring emergency transport were included. Risk of bias was assessed using the Cochrane ACROBAT-NRSI tool. A narrative synthesis was conducted and evidence quality rated using the GRADE criteria. Three observational studies of 72,423 major trauma patients were included. All were conducted in high-income countries in hospitals with established trauma services, with two studies undertaking retrospective analysis of registry data. Two studies reported overall mortality, one demonstrating a reduction in mortality (adjusted odds ratio (OR) 0.61, 95% confidence interval (CI) 0.39 to 0.94, 72,073 participants) and the other demonstrating a nonsignificant change (OR 0.61, 95% CI 0.23 to 1.64, 81 participants). The quality of this evidence was rated as very low. Limited research on the topic constrains conclusive evidence on the effect of prehospital notification on patient-centered outcomes after severe trauma. Composite interventions that combine prehospital notification with effective actions on arrival to hospital such as trauma bay availability, trauma team presence, and early access to definitive management may provide more robust evidence towards benefits of early interventions during trauma reception and resuscitation.
Publisher: Elsevier BV
Date: 05-2008
DOI: 10.1016/J.INJURY.2007.10.021
Abstract: To characterise patients who were admitted to the ward following Emergency Department (ED) management for thoracic injury yet went on to require Intensive Care Unit (ICU) admission. To identify risk factors for failed ward management. All patients admitted to the ward following chest trauma from 2002 to 2006 were identified from the Alfred Hospital trauma database. Patients who went on to require ICU admission were compared to those admitted to and discharged from the ward without requiring ICU. Possible predictors of ICU admission were analysed. There were 764 patients during the study period who were admitted to the ward following chest trauma. Of these, 70 patients went on to require Intensive Care admission. Patients requiring ICU admission spent a significantly longer time in hospital and required significantly more rehabilitation. Multivariate analysis using stepwise logistic regression confirmed intercostal catheter (ICC) insertion and higher injury severity scores as significant independent variables associated with ICU admission. Associated abdominal injury, along with multiple rib fractures and flail were also predictive of failed ward management. This study demonstrated that intercostal catheter insertion (tube thoracostomy) was an independent risk factor for deterioration following admission along with multiple rib fractures and certain associated injuries. This should be considered when admitting patients to the ward.
Publisher: Elsevier BV
Date: 09-2010
DOI: 10.1016/J.INJURY.2010.01.002
Abstract: In Germany, physician-operated emergency medical services (EMS) manage most pre-hospital trauma care. Australia uses a different EMS system, deploying highly trained paramedics for road and air transport of trauma patients. The effect of these different systems on secondary insults to traumatic brain injury (TBI) patients is unclear. There is conflicting evidence regarding which system is preferable. To add to the body of evidence, we compared the profile of injury, pre-hospital management and outcomes of TBI patients from both populations. Cases aged > or = 16 years, with AIS head > or = 3, AIS other body parts < or = 3, recorded in the Victorian State Trauma Registry (VSTR) and Trauma Registry of the German Society of Trauma Surgery (TR-DGU) from 2002 to 2007 were compared. 10,183 cases (5665 German, 4518 Australian) were included. No difference in sex or median age was observed. There were major between-registry differences in type of injury, trauma circumstance, intent and severity of injury. German cases sustained more serious injury and received more pre-hospital interventions. Mortality was significantly higher amongst German patients even when adjusted for demographics, injury severity and in- and pre-hospital parameters. German patients had a longer hospital and ICU stay. There were clear differences in injury characteristics and outcomes in TBI patients between Germany and Australia. As differences in coding, data collection and patient selection are evident, firm conclusions regarding the contribution of variations in pre-hospital care are not possible. The differences in outcome deserve further exploration in prospective studies.
Publisher: AMPCo
Date: 04-2014
DOI: 10.5694/MJA13.10412
Abstract: An increasing weight of evidence is demonstrating that sleep deprivation and circadian rhythm disruption in doctors are associated with human error and harm to both patients and doctors. The increasing junior doctor workforce entering the hospital system in Australia provides a rare opportunity for workplace and roster reforms. There are cultural, educational and industrial challenges to reforming working hours. Any changes should be evidence-based and monitored to ensure that training for junior doctors and patient care are not compromised.
Publisher: Oxford University Press (OUP)
Date: 22-12-2011
DOI: 10.1002/BJS.7754
Abstract: Valid and reliable measures of trauma system performance are needed to guide improvement activities, benchmarking and public reporting, future investment and research. Traditional measures of in-hospital mortality fail to take into account prehospital and posthospital care, recovery after discharge, and the nature and costs of long-term disability. Drawing on recent systematic reviews, an overview was conducted of existing and emerging trauma care performance indicators. Changes in the nature and purpose of indicators were assessed. Among a large number of existing, mostly locally developed performance indicators, only peer review of deaths has evidence of validity or reliability. The usefulness of the traditional performance measure of in-hospital mortality has been challenged. There is an emerging shift in focus from mortality to non-mortality outcomes, from hospital-based to long-term community-based outcome assessment, and from single measures of trauma centre performance to measures better suited to monitoring the performance of systems of care spanning the entire patient journey. As a result, a new generation of indicators is emerging that are both feasible and potentially more useful for commissioners and payers of population-based services. A global endeavour is now under way to agree on a set of standardized performance indicators that are meaningful to patients, carers, clinicians, managers and service funders, are likely to contribute to desired outcomes, and are valid, reliable and have a strong evidence base.
Publisher: Wiley
Date: 27-06-2022
Abstract: To determine the sensitivity of the Interagency Integrated Triage Tool to identify severe and critical illness among adult patients with COVID‐19. A retrospective observational study conducted at Port Moresby General Hospital ED during a three‐month Delta surge. 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). 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.
Publisher: Wiley
Date: 10-2008
DOI: 10.1111/J.1445-2197.2008.04684.X
Abstract: Although the incidence of hip replacement surgery is rapidly increasing, there are few data describing the hospital resource utilization associated with these procedures. We aimed to examine the in-hospital outcomes and resource utilization of primary and revision hip replacement. We analysed data from the 2005/2006 Victorian Admitted Episodes Database that included one or more of the International Classification of Diseases procedure codes for hip replacement. Demographic parameters and in-hospital outcomes, including length of stay, duration of intensive/coronary care and discharge destination, were examined. A total of, 7724 separations had a hip replacement. Primary procedures accounted for 86.8% of all separations. Of these, 79.3% were total hip replacements and the remainder were partial hip replacements. Most partial hips were managed (81.6%) and funded (60.0%) within the public system, whereas revisions were largely managed privately (59.0%). Revisions had less satisfactory outcomes than primary total hips, with 22.9% more revisions remaining in hospital for more than a week (P < 0.0001), 14.6% more requiring intensive care (P < 0.0001) and 10.9% less being discharged to a private residence (P < 0.001) (adjusting for confounders). Although primary partial and revision replacements accounted for only 16.8 and 13.2% of all hip replacements, they utilised up to 27.5 and 34.6% of hospital resources, respectively. Partial and revision hip replacements are resource intensive for the public and private health-care systems, respectively. It is imperative that strategies to reduce the incidence of these procedures are implemented, as failure to do so will have important implications for the allocation of health-care funding.
Publisher: Wiley
Date: 10-1993
DOI: 10.1111/J.1445-2197.1993.TB00342.X
Abstract: All trauma cases flown over a 3.5 year period by the Metropolitan Helicopter Ambulance (MHA) from the accident scene to the Alfred Hospital were analysed. The MHA carries paramedics trained in advanced life support and is not under direct medical control. There were 254 patients (226 males, 28 females, mean age 34 years) of whom 242 had sustained blunt trauma. The mean distance from the accident scene to hospital was 28 nautical miles. The mean time from dispatch of the MHA to arrival at the Alfred was 82 min. The mean ground time at the scene was 32 min. Major trauma (an injury severity score (ISS) of 15 or more) was present in 62% of patients, and the mean ISS was 22.4. The major treatments at the accident scene by the paramedics were insertion of an intravenous (i.v.) cannula (242 cases), application of splints (197 cases), endotracheal intubation (35 patients) and needle thoracostomy to exclude tension pneumothorax (18 cases). There were 25 patients with a Glasgow Coma Score (GCS) less than 8 who were not intubated at the scene. Review of paramedic management identified four cases where prehospital care could have been improved but it is unlikely the final outcome would have changed: delay in transport (1 case), inadequate i.v. fluid resuscitation (2 cases) and delay in intubation (1 case). There was 1 case of undiagnosed tension pneumothorax that contributed to the patient's death and 1 case of non-intubation where the outcome may have been altered. Overall there were 38 deaths (14% mortality), which was not significantly different from the predicted mortality of 17%.(ABSTRACT TRUNCATED AT 250 WORDS)
Publisher: Wiley
Date: 04-2009
Publisher: Elsevier BV
Date: 02-2018
DOI: 10.1016/J.RESUSCITATION.2017.12.019
Abstract: Although increasing patient delays between symptom onset and activation of emergency medical services (EMS) can lead to poorer outcomes following acute myocardial infarction, its effect in out-of-hospital cardiac arrest (OHCA) populations is unclear. Between 1st January 2003 and 31st December 2011, we included adult patients with anginal warning symptoms and subsequent EMS witnessed OHCA of presumed cardiac aetiology from the Victorian Ambulance Cardiac Arrest Registry. Multivariable logistic regression was used to assess the impact of patient delay time (i.e. symptom onset to EMS call time) on survival to hospital discharge. A total of 1056 EMS witnessed OHCA were screened, of which 515 (48.8%) reported chest pain or anginal equivalent symptoms. The median patient delay time was 25min (interquartile range [IQR] 9-89min), and did not differ across survivors and non-survivors. However, patients in lowest quartile of patient delay (≤8min) also experienced significantly higher rates of non-shockable arrest rhythms and circulatory compromise. A total of 16 baseline and clinical characteristics were tested in a multivariable model of survival to hospital discharge, of which, only six were retained in the final model, including: age, dyspnoea, vomiting, shockable arrest rhythm, systolic blood pressure, and patient delay time. Every 30min increase in patient delay time was independently associated with a 2.3% (95% CI: 0.4%, 4.1% p=0.02) reduction in the odds of survival to hospital discharge. Among patients with ST-segment deviation on the pre-arrest ECG, every 30min increase in patient delay time was associated with a 3.4% reduction in the odds of survival (OR 0.966, 95% CI: 0.937, 0.996 p=0.03). Increasing delays in activating EMS before the onset OHCA may be associated with reduced survival. Future research could explore whether increasing public awareness of the warning symptoms leads to earlier medical contact for OHCA.
Publisher: Elsevier BV
Date: 12-2006
DOI: 10.1016/J.INJURY.2006.07.011
Abstract: Assessing outcomes in the paediatric trauma population is important. Identifying suitable instruments can be problematic. This article highlights the commonly used outcome measures for assessing functional status and health related quality of life in paediatric trauma patients. Child specific characteristics which impact upon instrument development and selection are reviewed. An electronic database search was conducted to identify suitable English language measures used for outcome assessment in paediatric trauma patients from 1966 to present. Nine suitable instruments were identified, the child health questionnaire (CHQ), Glasgow outcome scale (GOS), paediatric overall performance category (POPC), PedsQL 4.0 generic core scales, paediatric evaluation of disability inventory (PEDI), functional independence measure (FIM), WeeFIM and an unnamed paediatric trauma specific measure [Gofin R, Hass T, Adler B, The development of disability scales for childhood and adolescent injuries. J Clin Epidemiol 1995 :977-84]. Each instrument was found to have advantages and disadvantages for assessing outcomes in a paediatric trauma population. The PedsQL 4.0 generic core scale could be feasible for administration as a routine outcome measure for paediatric trauma groups. For very young children an additional measure such as that proposed by Gofin et al. [Gofin R, Hass T, Adler B, The development of disability scales for childhood and adolescent injuries. J Clin Epidemiol 1995 :977-84] may be indicated. Future use of these instruments in the paediatric population would benefit from further psychometric evaluation.
Publisher: Wiley
Date: 13-05-2007
DOI: 10.1111/J.1742-6723.2007.00960.X
Abstract: To determine whether MRI of the cervical spine resulted in a change in management of patients with blunt trauma and normal plain X-ray (XR)/CT of the cervical spine. An explicit chart review was conducted of patients seen at a Level 1 trauma centre over a 1 year period. Clinical details were extracted from the charts of patients with blunt trauma who had a normal plain XR and CT scan of the cervical spine and who underwent cervical spine MRI. A comparison of clinical details was made between those with a normal/abnormal MRI secondary to the acute injury. One hundred and thirty-four patients met entry criteria. Discharge non-operative management of the cervical spine was associated with a change in management by the MRI result (P < 0.0001) where MRI of the cervical spine occurred a median of 3 days (interquartile range 0-4.5, range 0-137) after the injury. The MRI occurred before discharge 90% of the time in both groups. Operative management occurred in three patients and was delayed until after first outpatient review in two patients. An abnormal MRI after normal plain XR and CT cervical spine studies resulted in a change in non-operative management at discharge. Early MRI resulted in one patient receiving surgery before discharge. No unstable injuries were detected by MRI that were not evident on plain XR or CT cervical spine.
Publisher: Elsevier BV
Date: 2013
DOI: 10.1016/J.APMR.2012.07.026
Abstract: There is little research literature on patient flow in rehabilitation. Accepted definitions of barriers to discharge and agreed performance measures are needed to support research and understanding of this topic. The potential of improved patient flow in rehabilitation to assist relieving demand pressures in acute hospitals underscores its importance. This study develops a definition of barriers to discharge from postacute care and classifies their causes using a multiphased iterative consultation and feedback process involving physiatrists, aged-care physicians, and senior nursing and allied health clinicians. Key performance indicators (KPIs) for postacute patient flow are then proposed, the development of which were informed by the available literature and a survey (n=101) of physiatrists, aged-care physicians, and hospital managers with responsibility for patient flow who were questioned about the use of relevant KPIs in this setting. Most (>70%) respondents believed that using KPIs (eg, waiting time from acceptance by postacute care and ready for transfer until admission, percentage of postacute bed days occupied by inpatients with a discharge barrier) to measure aspects of patient flow could improve processes, but few reported collecting this information (45% admission KPIs, 19% discharge KPIs). By using the definition and classification of discharge barriers prospectively to document and address barriers, in conjunction with appropriate KPIs, postacute patient flow and the efficiency of hospital resource utilization can potentially be improved. Our commentary aims to stimulate interest among others to develop a more robust evidence base for improved flow through postacute care.
Publisher: Wiley
Date: 05-03-2008
DOI: 10.1111/J.1365-2702.2007.02038.X
Abstract: The aim of this study was to evaluate the impact of the introduction of Emergency Nurse Practitioner Candidates (ENPC) on waiting times and length of stay of patients presenting to a major urban Emergency Department (ED) in Melbourne, Australia. As part of a Victorian state funded initiative to improve patient outcomes, the role of the Emergency Nurse Practitioner has been developed. The integration and implementation of this role, is not only new to the Alfred Emergency and Trauma Centre but to EDs in Melbourne, Australia, with aims of providing holistic and comprehensive care for patients. A retrospective case series of all patients with common ED diagnostic subgroups were included. The ENPC group (n = 572) included all patients managed by the ENPC and the Traditional Model (TM) group (n = 2584) included all patients managed by the traditional medical ED model of care. Outcome measures included waiting times and length of stay. Statistically significant differences were evident between the two groups in waiting times and length of stay in the ED. The overall median waiting time for emergency patients to be seen by the ENPC was less than for the TM group [median (IQR): ENPC 12 (5.5-28) minutes TM 31 (11.5-76) minutes (Wilcoxon p < 0.001)]. Length of stay in the ED was also significantly reduced in the ENPC group [median (IQR): ENPC 94 (53.5-163.5) minutes TM 170 (100-274) minutes (Wilcoxon p < 0.001)]. The comparison of overall waiting times for ENPC shifts vs. non-ENPC shifts revealed significant differences [median (IQR): ENPC rostered 24 (9-52) minutes ENPC not rostered 33 (13-80.5) minutes (Wilcoxon p < 0.001)]. This study has demonstrated that ENPCs implementation in Melbourne, Australia were associated with significantly reduced waiting times and length of stay for emergency patients. Emergency Nurse Practitioners should be considered as a potential long term strategy to manage increased service demands on EDs. Relevance to clinical practice. This study is the first in Australia with a significant s le size to vigorously compare ENPC waiting times and length of stay outcomes with the TM model of care in the ED. The study suggests that ENPCs can have a favourable impact on patient outcomes with regard to waiting times and length of stay.
Publisher: Springer Science and Business Media LLC
Date: 21-01-2017
Publisher: Radiological Society of North America (RSNA)
Date: 08-2003
Publisher: Elsevier BV
Date: 05-2012
Publisher: Elsevier BV
Date: 12-2006
DOI: 10.1016/J.INJURY.2006.07.015
Abstract: Risk-adjusted survival rates have been the principle mode of comparison between trauma systems. In mature trauma systems, it is possible that there will be further improvements in survival but these are likely to be small. In the future, the largest gains will come from quality of life and improved function of the survivors. The issues related to measuring quality of survival for trauma systems are reviewed, including feasibility, ethical considerations, risk adjustment of outcomes of survivors, and challenges for selection of instruments and administration. In addition, the preliminary experiences of measuring outcomes in survivors through the Victorian State Trauma Registry are discussed. Although function and quality of life have been identified as important factors to measure in trauma populations, a standardised protocol has not been established. The experience in Victoria suggests that monitoring of population-based outcomes in survivors is feasible and may create the basis for benchmarking the level of morbidity in survivors.
Publisher: Elsevier BV
Date: 05-2007
Publisher: Elsevier BV
Date: 12-2011
DOI: 10.1016/J.ANNEMERGMED.2011.06.008
Abstract: We aim to determine the prevalence and factors associated with cervical discoligamentous injuries detected on magnetic resonance imaging (MRI) in acute, alert, neurologically intact trauma patients with computed tomography (CT) imaging negative for acute injury and persistent midline cervical spine tenderness. We present the cross-sectional analysis of baseline information collected as a component of a prospective observational study. Alert, neurologically intact trauma patients presenting to a Level I trauma center with CT negative for acute injury, who underwent MRI for investigation of persistent midline cervical tenderness, were prospectively recruited. Deidentified images were assessed, and injuries were identified and graded. Outcome measures included the presence and extent of MRI-detected injury of the cervical ligaments, intervertebral discs, spinal cord and associated soft tissues. There were 178 patients recruited during a 2-year period to January 2009. Of these, 78 patients (44%) had acute cervical injury detected on MRI. There were 48 single-column injuries, 15 two-column injuries, and 5 three-column injuries. Of the remaining 10 patients, 6 had isolated posterior muscle edema, 2 had alar ligamentous edema, 1 had epidural hematoma, and 1 had atlanto-occipital edema. The injuries to 38 patients (21%) were managed clinically 33 patients were treated in cervical collars for 2 to 12 weeks, and 5 patients (2.8%) underwent operative management, 1 of whom had delayed instability. Ordinal logistic regression revealed that factors associated with a higher number of spinal columns injured included advanced CT-detected cervical spondylosis (odds ratio [OR] 11.6 95% confidence interval [CI] 3.9 to 34.3), minor isolated thoracolumbar fractures (OR 5.4 95% CI 1.5 to 19.7), and multidirectional cervical spine forces (OR 2.5 95% CI 1.2 to 5.2). In patients with cervical midline tenderness and negative acute CT findings, we found that a subset of patients had MRI-detected cervical discoligamentous injuries and that advanced cervical spine degeneration evident on CT, minor thoracolumbar fracture, and multidirectional cervical spine forces were associated with increased injury extent. However, a larger study is required to validate which variables may reliably predict clinically important injury in such patients, thereby indicating the need for further radiographic assessment.
Publisher: Elsevier BV
Date: 07-2012
Publisher: Wiley
Date: 09-05-2020
Publisher: Wiley
Date: 21-04-2020
Publisher: Wiley
Date: 09-10-2021
Abstract: 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. 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. 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 .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. 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.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2006
Publisher: Wiley
Date: 09-2002
DOI: 10.1046/J.1442-2026.2002.00340.X
Abstract: To ascertain the level of knowledge of heart attack symptoms in the Victorian public. This was a cross sectional telephone survey conducted during 2000-01. The questionnaire contained sections regarding participant demographics and knowledge of heart attack symptoms. A total of 1489 people completed the questionnaire (79% of eligible participants). The mean number of correct heart attack symptoms was 2.5 (95% CI 2.45, 2.60) (median three out of 10). Only 4.2% of participants reported at least five correct symptoms and 4.1% could not report any symptoms. A total of 84.6% of respondents reported chest pain as a symptom of heart attack. The Victorian public appears to lack the knowledge of the varied range of heart attack symptoms. Methods of disseminating information regarding symptoms and ways to reduce prehospital delay need to be devised, particularly methods which target the older 'at risk' population.
Publisher: Elsevier BV
Date: 06-2022
DOI: 10.1016/J.INJURY.2022.03.044
Abstract: In Australia, people living in rural areas, compared to major cities are at greater risk of poor health. There is much evidence of preventable disparities in trauma outcomes, however research quantifying geographic variations in injuries, pathways to specialised care and patient outcomes is scarce. (i) To analyse the Australia New Zealand Trauma Registry (ATR) data and report patterns of serious injuries according to rurality of the injury location ii) to examine the relationship between rurality and hospital mortality and iii) to compare ATR death rates with all deaths from similar causes, Australia-wide. A retrospective cohort study of patients in the ATR from 1 Compared to major cities, rural patients were younger, more likely to have spinal cord injuries, and sustain traffic-related injuries that are 'off road'. Injuries occurring outside people's homes are more likely. Mortality risk was greater for patients sustaining severe traumatic brain injury (TBI) spinal cord injury (SCI) and head trauma in addition to intentional injuries. Compared to the ATR data, Australian population-wide trauma mortality rates showed erging trends according to rurality. The ATR only captures 14.1% of all injury deaths occurring in major cities and, respectively, 6.3% and 3.2% of deaths in regional and remote areas. Compared to major cities, injuries occurring in rural areas of Australia often involve different mechanisms and result in different types of severe injuries. Patients with neurotrauma and intentional injuries who survived to receive definitive care at a MTC were at higher risk of hospital death. To inform prevention strategies and reduce morbidity and mortality associated with rural trauma, improvements to data systems are required that involve data linkage and include information about patient care from pre-hospital providers, regional hospitals and major trauma centres.
Publisher: BMJ
Date: 11-06-2015
Publisher: Wiley
Date: 13-09-2021
Abstract: 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.
Publisher: Elsevier BV
Date: 06-2005
DOI: 10.1016/S1440-2440(05)80007-6
Abstract: Injuries sustained during golf rarely receive the recognition given to injuries from sports perceived as more violent or strenuous. However, golfing injuries are believed to occur frequently. The aim of this study was to explore the injury profile of female golfers, including treatment sought and the impact of the injury on performance and participation. Forty-one team captains were given questionnaires to distribute to their players. A total of 522 golfers participating in the Victorian Women's Pennant Competition in Victoria, Australia, from both the Metropolitan and Country competitions, completed the study. Over one-third (35.2%) of the golfers reported having sustained a golfing injury within the previous 12 months, with the lower back being the most commonly injured body region. Strains were the most frequent type of injury (67.9%). Of the 184 injuries reported, 154 sought treatment from a health professional. Physiotherapists were the most common health professional consulted. Performance was affected in 78.9% of cases, with 69.7% of the injured golfers missing games or practice sessions due to injury. Golfing injuries appear common and have a substantial impact upon the injured golfer. As lower back strains are the most common injury, strategies such as performing an appropriate warm-up could be investigated to determine the possible injury prevention benefits for golfers. This study has also highlighted that the majority of treatments are from allied health professionals, suggesting that a complete epidemiological description of golf injuries requires information from broader settings than general practice clinics and hospitals.
Publisher: BMJ
Date: 03-2004
Abstract: To determine outcomes and markers of serious illness for febrile patients presenting to an adult emergency department. A prospective cohort study of patients presenting to the emergency department with a temperature >or=38 degrees C. Medical staff obtained demographic data and risk factor profiles while assessing each febrile patient. All were followed up to determine death, admission to intensive care, length of stay in hospital, or subsequent admission to hospital within 30 days. Univariate and multivariate analysis determined which factors were markers of serious illness. For febrile adults admitted to hospital 3.0% died, 6.1% were admitted to intensive care, median length of stay in hospital was 7.2 days. Independent risk factors were-death: age (OR = 1.04), respiratory rate (OR = 1.06), white cell count (OR = 1.02), cardiac disease (OR = 3.3), and jaundice (OR = 21.4). Admission to intensive care: respiratory rate (OR = 1.1), pulse rate (OR = 1.03), and jaundice (OR = 5.1). Increased length of hospital stay: age (p<0.01), jaundice (p<0.01), respiratory rate (p = 0.01), focal neurological signs (p = 0.01), and changed mental state (p = 0.04). For febrile adults sent home 7.9% required admission to hospital within 30 days. Risk factors were respiratory rate (OR = 1.2), being female (OR = 5.36), malignancy (OR = 15.3), and cardiac disease (OR = 19.7). Initially having no focus of infection was protective (OR = 0.13). No febrile patient sent home from the emergency department died or required admission to intensive care. Few febrile adults presenting to the emergency department suffer an adverse outcome suggesting effective risk stratification is occurring. The identification of factors associated with adverse events may further improve this process.
Publisher: Elsevier BV
Date: 2013
DOI: 10.1016/J.INJURY.2012.05.010
Abstract: The pathophysiology and time-course of coagulopathy post major burns are inadequately understood. The aims of this study were to review the incidence of acute coagulopathy post major burns, potential contributing factors associated with this coagulopathy and outcome of patients who developed early coagulopathy. A retrospective review of all patients with major burns (≥20% total body surface area (TBSA)) presenting to a tertiary burns referral centre was conducted. Data on demographic, injury characteristics and fluid resuscitation practices were recorded and tested for association with coagulopathy (INR>1.5 or aPTT>60 s) at hospital presentation and within 24 h of burns injury. Mortality, intensive care unit (ICU) admission, mechanical ventilation and blood and blood product usage were primary endpoints. There were 99 patients who met the inclusion criteria with 36 (16) %TBSA burns. Coagulopathy was present in only three patients on presentation, but 37 (37%) patients developed early onset (within 24 h of injury) coagulopathy. Early onset coagulopathy was independently associated with %TBSA burnt (p<0.001) and volume of fluid administered (p=0.005). Early onset coagulopathy was associated with higher volumes of blood and blood product administration, ICU admission and prolonged mechanical ventilation. Post major burns, a very low proportion of patients presented with coagulopathy, but a substantial proportion of patients developed coagulopathy within 24 h. This and the association of coagulopathy with the volume of fluid resuscitation suggest dilution as a major cause of the early coagulopathy of major burns.
Publisher: Elsevier BV
Date: 08-2014
DOI: 10.1093/BJA/AEU231
Abstract: Trauma systems have been successful in saving lives and preventing disability. Making sure that the right patient gets the right treatment in the shortest possible time is integral to this success. Most trauma systems have not fully developed trauma triage to optimize outcomes. For trauma triage to be effective, there must be a well-developed pre-hospital system with an efficient dispatch system and adequately resourced ambulance system. Hospitals must have clear designations of the level of service provided and agreed protocols for reception of patients. The response within the hospital must be targeted to ensure the sickest patients get an immediate response. To enable the most appropriate response to trauma patients across the system, a well-developed monitoring programme must be in place to ensure constant refinement of the clinical response. This article gives a brief overview of the current approach to triaging trauma from time of dispatch to definitive treatment.
Publisher: Wiley
Date: 04-09-2016
Abstract: To examine the ability of paramedics to identify patients who could be managed in the community and to identify predictors that could be used to accurately identify patients who should be transported to EDs. Lower acuity patients who were assessed by paramedics in the Perth metropolitan area in 2013 were studied. Paramedics prospectively indicated on the patient care record if they considered that the patient could be treated in the community. The paramedic decisions were compared with actual disposition from the ED (discharge and admission), and the occurrence of subsequent events (ambulance request, ED visit, admission and death) for discharged patients at the scene was investigated. Decision tree analysis was used to identify predictors that were associated with hospital admission. In total, 57 183 patients were transported to the ED, and 10 204 patients were discharged at the scene by paramedics. Paramedics identified 2717 patients who could potentially be treated in the community among those who were transported to the ED. Of these, 1455 patients (53.6%) were admitted to hospital. For patients discharged at the scene, those who were indicated as suitable for community care were more likely to experience subsequent events than those who were not. The decision tree found that two predictors (age and aetiology) were associated with hospital admission. Overall discriminative power of the decision tree was poor the area under the receiver operating characteristic curve was 0.686. Lower acuity patients who could be treated in the community were not accurately identified by paramedics. This process requires further evaluation.
Publisher: BMJ
Date: 07-2017
Publisher: Wiley
Date: 09-1993
Publisher: Elsevier BV
Date: 06-2006
DOI: 10.1016/J.JSAMS.2006.03.026
Abstract: The practice of warming up prior to exercise is advocated in injury prevention programs, but this is based on limited clinical evidence. It is hypothesised that warming up will reduce the number of injuries sustained during physical activity. A systematic review was undertaken. Relevant studies were identified by searching Medline (1966-April 2005), SPORTDiscus (1966-April 2005) and PubMed (1966-April 2005). This review included randomised controlled trials that investigated the effects of warming up on injury risk. Studies were included only if the subjects were human, and only if they utilised other activities than simply stretching. Studies reported in languages other than English were not included. The quality of included studies was assessed independently by two assessors. Five studies, all of high quality (7-9 (mean=8) out of 11) reported sufficient data (quality score>7) on the effects of warming up on reducing injury risk in humans. Three of the studies found that performing a warm-up prior to performance significantly reduced the injury risk, and the other two studies found that warming up was not effective in significantly reducing the number of injuries. There is insufficient evidence to endorse or discontinue routine warm-up prior to physical activity to prevent injury among sports participants. However, the weight of evidence is in favour of a decreased risk of injury. Further well-conducted randomised controlled trials are needed to determine the role of warming up prior to exercise in relation to injury prevention.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2011
Publisher: Wiley
Date: 09-09-2020
Publisher: Elsevier BV
Date: 09-2014
DOI: 10.1016/J.INJURY.2014.02.028
Abstract: To describe the association between increasing age, pre-hospital triage destination compliance, and patient outcomes for adult trauma patients. A retrospective data review was conducted of adult trauma patients attended by Ambulance Victoria (AV) between 2007 and 2011. AV pre-hospital data was matched to Victorian State Trauma Registry (VSTR) hospital data. Inclusion criteria were adult patients sustaining a traumatic mechanism of injury. Patients sustaining secondary traumatic injuries from non-traumatic causes were excluded. The primary outcomes were destination compliance and in-hospital mortality. These outcomes were evaluated using multivariable logistic regression. There were 326,035 adult trauma patients from 2007 to 2011, and 18.7% met the AV pre-hospital trauma triage criteria. The VSTR classified 7461 patients as confirmed major trauma (40.9%>55 years). Whilst the trauma triage criteria have high sensitivity (95.8%) and a low under-triage rate (4.2%), the adjusted odds of destination compliance for older trauma patients were between 23.7% and 41.4% lower compared to younger patients. The odds of death increased 8% for each year above age 55 years (OR: 1.08 95% CI: 1.07, 1.09). Despite effective pre-hospital trauma triage criteria, older trauma patients are less likely to be transported to a major trauma service and have poorer outcomes than younger adult trauma patients. It is likely that the benefit of access to definitive trauma care may vary across age groups according to trauma cause, patient history, comorbidities and expected patient outcome. Further research is required to explore how the Victorian trauma system can be optimised to meet the needs of a rapidly ageing population.
Publisher: Wiley
Date: 21-01-2018
Abstract: The Prevent Alcohol and Risk-Related Trauma in Youth (P.A.R.T.Y.) Program at The Alfred uses vivid clinical reality to build resilience and prevent injury by following a trauma patient's journey through hospital. The present study aims to analyse the effect of P.A.R.T.Y. on safety perceptions of driving after alcohol, seat belt use and risk-taking activities. Pre-programme, immediately post-programme and 3-5 months post-programme surveys with questions focused on the programme aims were distributed to all consented participants. There were 2502 participants during the study period and 1315 (53%) responses were received. The mean age was 16.2 (SD 0.8) years, 724 (56%) were women and 892 (68%) possessed a learner's permit for driving. Pre-programme, 1130 (86%) participants reported 'definitely not' likely to drive after drinking alcohol, that improved to 1231 (94%) immediately post-programme and 1215 (93%) at 3-5 months post-programme (P < 0.01). Designating a safe driver after drinking was reported by 1275 (97%) pre-programme, 1295 (98%) immediately post-programme and 1286 (98.2%) 3-5 months post-programme (P = 0.02). The perception of sustaining 'definite' injury after a motor vehicle crash without a seat belt increased from 780 (60%) pre-programme to 1051 (80%) immediately post-programme and 886 (69%) 3-5 months post-programme (P < 0.01). The possibility of sustaining 'definite' injury after risk-taking activities was reported by 158 (12%) pre-programme, 467 (36%) post-programme and 306 (23%) 3-5 months post-programme (P < 0.01). The P.A.R.T.Y. Program at The Alfred engaged substantial numbers of youths and achieved significant improvements among key outcome measures. Objectives were sustained at 3-5 months post-programme, but demonstrated decay, highlighting the importance of continual reinforcement.
Publisher: Wiley
Date: 12-1995
Publisher: Wiley
Date: 06-2004
Publisher: Springer Science and Business Media LLC
Date: 26-06-2012
Publisher: Wiley
Date: 27-06-2016
Publisher: Wiley
Date: 25-02-2017
Abstract: Multiply injured patients represent a particularly demanding subgroup of trauma patients as they require urgent simultaneous clinical assessments using physical examination, ultrasound and invasive monitoring together with critical management, including tracheal intubation, thoracostomies and central venous access. Concurrent access to multiple body regions is essential to facilitate the concept of 'horizontal' resuscitation. The current positioning of trauma patient, with arms adducted, restricts this approach. Instead, the therapeutic cruciform positioning, with arms abducted at 90°, allows planning and performing of multiple life-saving interventions simultaneously. This positioning also provides a practical surgical field with improved sterility and procedural access.
Publisher: Elsevier BV
Date: 07-2015
DOI: 10.1016/J.JTCVS.2015.03.015
Abstract: To assess whether introduction of universal leukodepletion (ULD) of red blood cells (RBCs) for transfusion was associated with improvements in cardiac surgery patient outcomes. Retrospective study (2005-2010) conducted at 6 institutions. Associations between leukodepletion and outcomes of mortality, infection, and acute kidney injury (AKI) were modeled by logistic regression, and intensive care unit length of stay (LOS) in survivors was explored using linear regression. To examine trends over time, odds ratios (ORs) for outcomes of transfused were compared with nontransfused patients, including a comparison with nontransfused patients who were selected based on propensity score for RBC transfusion. We studied 14,980 patients, of whom 8857 (59%) had surgery pre-ULD. Transfusions of RBCs were made in 3799 (43%) pre-ULD, and 2525 (41%) post-ULD. Administration of exclusively leukodepleted, versus exclusively nonleukodepleted, RBCs was associated with lower incidence of AKI (adjusted OR 0.80, 95% confidence interval [CI] 0.65-0.98, P = .035), but no difference in mortality or infection. For post-ULD patients, no difference was found in mortality (OR 0.96, 95% CI 0.76-1.22, P = .76) or infection (OR 0.91, 95% CI 0.79-1.03, P = .161) however, AKI was reduced (OR 0.79 95% CI 0.68-0.92, P = .003). However, ORs for post-ULD outcomes were not significantly different in nontransfused, versus transfused, patients. Furthermore, those who received exclusively nonleukodepleted RBCs were more likely to have surgery post-ULD. Universal leukodepletion was not associated with reduced mortality or infection in transfused cardiac surgery patients. An association was found between ULD and reduced AKI however, this reduction was not significantly different from that seen in nontransfused patients, and other changes in care most likely explain such changes in renal outcomes.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2013
Publisher: Elsevier BV
Date: 09-2011
Publisher: Wiley
Date: 29-08-2020
Publisher: BMJ
Date: 20-10-2011
Abstract: Emergency departments (EDs) in many developed countries are experiencing increasing pressure due to rising numbers of patient presentations and emergency admissions. Reported increases range up to 7% annually. Together with limited inpatient bed capacity, this contributes to prolonged lengths of stay in the ED disrupting timely access to urgent care, posing a threat to patient safety. The aim of this review is to summarise the findings of studies that have investigated the extent of and the reasons for increasing emergency presentations. To do this, a systematic review and synthesis of published and unpublished reports describing trends and underlying drivers associated with the increase in ED presentations in developed countries was conducted. Most published studies provided evidence of increasing ED attendances within developed countries. A series of inter-related factors have been proposed to explain the increase in emergency demand. These include changes in demography and in the organisation and delivery of healthcare services, as well as improved health awareness and community expectations arising from health promotion c aigns. The factors associated with increasing ED presentations are complex and inter-related and include rising community expectations regarding access to emergency care in acute hospitals. A systematic investigation of the demographic, socioeconomic and health-related factors highlighted by this review is recommended. This would facilitate untangling the dynamics of the increase in emergency demand.
Publisher: Springer Science and Business Media LLC
Date: 10-08-2011
Publisher: SAGE Publications
Date: 19-04-2019
Abstract: Despite the reliance on administrative data in epidemiological studies, there is little information on the completeness of co-morbidities in administrative data coded from medical records. The aim of this study was to quantify the agreement between the International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) administrative coding of mental health, drug and alcohol co-morbidities and medical records in a severely injured patient population. A random s le of patients ( n = 500) captured by the Victorian State Trauma Registry and definitively managed at the state’s adult major trauma services was selected for the study. Retrospective medical record review was conducted to collect data about documented co-morbidities. The agreement between ICD-10-AM data generated from routine hospital coding and medical record–based co-morbidities was determined using Cohen’s κ and prevalence-adjusted bias-adjusted kappa (PABAK) statistics. The percentage of agreement between the medical record and ICD-10-AM coding for mental health, drug and alcohol co-morbidities was 72.8%, and the PABAK showed moderate agreement (PABAK = 0.46 95% confidence interval (CI): 0.37, 0.54). There was no difference in agreement between unintentional injury patients (PABAK = 0.52 95% CI: 0.42, 0.62) compared with intentional injury patients (PABAK = 0.36, 95% CI: 0.23, 0.49), and no change in agreement for patients admitted before (PABAK = 0.40 95% CI: 0.30, 0.50) and after the introduction of mandatory co-morbidity coding (PABAK = 0.46 95% CI: 0.37, 0.54). Despite documentation in the medical record, a large proportion of mental health, drug and alcohol conditions were not coded in ICD-10-AM. Acknowledgement of these limitations is needed when using ICD-10-AM coded co-morbidities in research studies and health policy development. This work has implications for researchers of drug and alcohol abuse mental health accidents and injuries workers' compensation health workforce health services and policy decisions for healthcare, emergency services, insurance industry, national productivity and welfare costings reliant on those research outcomes.
Publisher: BMJ
Date: 11-2004
Publisher: Wiley
Date: 20-01-2011
DOI: 10.1111/J.1445-2197.2010.05635.X
Abstract: Severe burns represent a challenging and complex clinical presentation, requiring highly specialized burns centres that are staffed and equipped appropriately. The integration of burns care into trauma systems has been recommended. This study describes the profile, transfer and outcomes of severe burns within an inclusive, regionalized trauma system. A retrospective analysis of prospectively collected data from the Victorian State Trauma Registry for the period July 2001–June 2009 was performed. Major trauma cases with any burn injury were analysed. A severe burns case was defined as a total body surface area (TBSA) burned ≥20%. Descriptive statistics were used to define the profile of severe burns cases, their management and in-hospital outcomes. For the 315 cases, the mean (standard deviation) age was 39 (22) years, and 73% were male. Fire/flames was the predominant cause (72%), and 39% sustained an inhalation injury. All paediatric (n = 37) and 98% of adult cases with a %TBSA ≥20 were managed at the state's burn services. Half of the cases experienced an inter-hospital transfer. Sixty-seven percent of cases were admitted to the intensive care unit, 22% died in-hospital and the median length of stay was 31 days. An inclusive trauma system with burns services co-located at the major trauma services resulted in almost complete referral of severe burns cases to burns services for management. Half of the cases arrived at the burns services directly from the scene of injury, highlighting the importance of ongoing clinical education about the initial management of severe burns at non-burns service hospitals.
Publisher: Elsevier BV
Date: 09-2011
DOI: 10.1016/J.INJURY.2010.08.007
Abstract: During trauma resuscitation, blind catheterization of an injured urethra may aggravate the injury by disrupting a partially torn urethra. In busy trauma centers, retrograde urethrograms (RUG) prior to catheterisation for all patients with unstable pelvic fractures presents a challenge during trauma resuscitation, and the procedure is not commonly practiced despite Advanced Trauma Life Support (ATLS) and World Health Organisation recommendations. The aim of this study was to determine the presenting clinical features of patients with urethral injuries and to predict major trauma patients needing further investigation to exclude this injury. A retrospective review of adult major trauma patients diagnosed with urethral injuries during an 8-year period at a major trauma centre, was conducted. There were 998 major trauma patients with fractures of the pelvis over the study period, of whom 223 had pubic symphysis disruption. There were 29 patients with urethral injuries. The sensitivity of any one of the traditional signs of urethral trauma was 66.7% (95% CI: 46.0-82.8). After exclusion of patients with penetrating trauma and iatrogenic injuries, pubic symphysis disruption on initial pelvis AP X-ray and/or the clinical signs of urethral injury had a sensitivity of 100% (95% CI: 84.4-100.0) for urethral trauma. Reliance on clinical features alone to predict urethral injury results in a substantial proportion of missed injuries in major trauma patients. RUGs did not appear to be needed in patients with no disruption of the pubic symphysis on initial pelvis X-ray or where no signs of urethral injury are present. In the absence of clinical signs and pubic symphysis disruption, blind urethral catheterisation may be attempted.
Publisher: Wiley
Date: 15-04-2012
DOI: 10.1111/J.1537-2995.2012.03648.X
Abstract: Critically bleeding trauma patients require coordinated and efficient decision-making processes to ensure optimal management of their massive transfusion (MT) requirements. Human factors (HFs) is a discipline that investigates factors influencing work processes from the organizational, group, and in idual levels. Given the complexity of trauma resuscitation, implementing any intervention for decision support in MT is challenging and may benefit from a HFs-assisted approach. A systematic review was performed to identify reports of the introduction of any type of decision support for the provision of MT in critically bleeding adult trauma patients. Crucial contributions reported to influence design and uptake of the intervention were categorized into four HFs categories (environment, human, machine, and task). Extracted information was supplemented by surveying the contact authors. Evidence of clinical practice changes resulting from the intervention was also considered. We identified nine studies that had reported an intervention implementing new practice guidelines or a MT protocol. All were before-and-after comparative cohort studies and used historical controls as the preintervention cohort. Based on the identified reports, this review provides a HFs-assisted approach to aid clinicians and policy makers with the implementation of decision support for MT in the trauma care setting.
Publisher: Wiley
Date: 14-09-2020
Abstract: 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. 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. 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. 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.
Publisher: Public Library of Science (PLoS)
Date: 05-07-2017
Publisher: Elsevier BV
Date: 05-2016
Publisher: Elsevier BV
Date: 2014
DOI: 10.1016/J.INJURY.2013.06.010
Abstract: An audit of ambulance service clinical records from 2001 to 2002 in Melbourne, Australia revealed 10 patients with tension pneumothorax on arrival at hospital which had been undetected or untreated by paramedics. The clinical practice guideline for paramedic recognition of tension pneumothorax was subsequently changed to emphasise heightened clinical suspicion of a tension pneumothorax in the setting of chest trauma, especially when patients were managed with positive pressure ventilation. This study was undertaken to determine whether the number of undetected or untreated tension pneumothoraces had decreased after the new clinical practice guideline and associated education program if there were unintended consequences arising from earlier paramedic intervention and what effect, if any, this change had on subsequent hospital treatment. Retrospective case note review of all patients requiring intercostal catheter (ICC) insertion at The Alfred Hospital, Melbourne, Australia, using records from Ambulance Victoria, the Alfred Trauma Registry and the National Coronial Information System. In 2001-2002 paramedics treated 22 patients with suspected tension pneumothorax before transport to the Alfred Hospital. In 2006-2007 this number had increased to 81. There was a decrease from ten to four in the number of unrecognised or untreated tension pneumothoraces between the two time periods. No unintended or adverse consequences of prehospital needle decompression could be found. However, there was an increase in the number of patients who had prehospital needle decompression that needed further treatment for tension pneumothorax on arrival at hospital. This need for further treatment was associated with use of shorter cannulas and unilateral needle decompression by paramedics. A small change in clinical practice guidelines, supported by an education and audit program, led to a reduction in unrecognised untreated tension pneumothoraces by paramedics without an increase in complications. Paramedics should be aware that a shorter cannula may fail to reach the pleural space and that both sides of the chest may require decompression.
Publisher: CSIRO Publishing
Date: 2011
DOI: 10.1071/AH09866
Abstract: Background. Increased ambulance utilisation is closely linked with Emergency Department (ED) attendances. Pressures on hospital systems are widely acknowledged with ED overcrowding reported regularly in the media and peer-reviewed literature. Strains on ambulance services are less well-documented or studied. Aims. To review the literature to determine the trends in utilisation of emergency ambulances throughout the developed world and to discuss the major underlying drivers perceived as contributing to this increase. Method. A search of online databases, search engines, peer-reviewed journals and audit reports was undertaken. Findings. Ambulance utilisation has increased in many developed countries over the past 20 years. Annual growth rates throughout Australia and the United Kingdom are similar. Population ageing, changes in social support, accessibility and pricing, and increasing community health awareness have been proposed as associated factors. As the extent of their contribution has not yet been established these factors were reviewed. Conclusion. The continued rise in utilisation of emergency ambulances is placing increasing demands on ambulance services and the wider health system, potentially compromising access, quality, safety and outcomes. A variety of factors may contribute to this increase and targeted strategies to reduce utilisation will require an accurate identification of the major drivers of demand. What is known about the topic? Ambulance utilisation is increasing annually throughout the developed world, with previous research suggesting numerous underlying factors. What does this paper add? These factors have not been previously synthesised in the international literature. This narrative review clearly articulates the underlying problems. What are the implications for practitioners? This paper outlines the need for further research of the causes of increased emergency ambulance utilisation, to enable the development of appropriate strategies to manage demand in the future.
Publisher: Elsevier BV
Date: 05-2014
DOI: 10.1016/J.INJURY.2014.01.011
Abstract: Acute traumatic coagulopathy (ATC) has been reported in the setting of isolated traumatic brain injury (iTBI) and associated with high mortality and poor outcomes. The aim of this systematic review was to examine the incidence and outcome of patients with ATC in the setting of iTBI. We conducted a search of the MEDLINE database and Cochrane library, focused on subject headings and keywords involving coagulopathy and TBI. Design and results of each study were described. Studies were assessed for heterogeneity and the pooled incidence of ATC in the setting of iTBI determined. Reported outcomes were described. There were 22 studies selected for analysis. A statistically significant heterogeneity among the studies was observed (p<0.01). Using the random effects model the pooled proportion of patients with ATC in the setting of iTBI was 35.2% (95% CI: 29.0-41.4). Mortality of patients with ATC and iTBI ranged between 17% and 86%. Higher blood transfusion rates, longer hospital stays, longer ICU stays, decreased ventilator free days, higher rates of single and multiple organ failure and higher incidence of delayed injury and disability at discharge were reported among patients with ATC. ATC is commonly associated with iTBI and almost uniformly associated with worse outcomes. Any disorder of coagulation above the normal range appears to be associated with worse outcomes and therefore a clinically important target for management. Earlier identification of patients with ATC and iTBI, for recruitment into prospective trials, presents avenues for further research.
Publisher: Elsevier BV
Date: 09-2014
DOI: 10.1016/J.INJURY.2014.01.016
Abstract: Older age and blood transfusion have both been independently associated with higher mortality post trauma and the combination is expected to be associated with catastrophic outcomes. Among patients who received a massive transfusion post trauma, we aimed to investigate mortality at hospital discharge of patients ≥65 years old and explore variables associated with poor outcomes. A retrospective review of registry data on all major trauma patients presenting to a level I trauma centre between 2006 and 2011 was conducted. Mortality at hospital discharge among patients ≥65 years old was compared to the younger cohort. A multivariable logistic regression model was constructed to determine independent risk-factors for mortality among older patients. There were 51 (16.4%) patients of age ≥65 years who received a massive transfusion. There were 20 (39.2%) deaths, a proportion significantly higher than 55 (21.1%) deaths among younger patients (p<0.01). Pre-hospital GCS, the presence of acute traumatic coagulopathy and higher systolic blood pressure on presentation were independently associated with higher mortality. Age and volume of red cells transfused were not significantly associated with higher mortality. Survival to hospital discharge was demonstrated in elderly patients receiving massive transfusions post trauma, even in the presence of multiple risk factors for mortality. Restrictive resuscitation or transfusion on the basis of age alone cannot be supported. Early aggressive resuscitation of elderly trauma patients along specific guidelines directed at the geriatric population is justified and may further improve outcomes.
Publisher: Hamad bin Khalifa University Press (HBKU Press)
Date: 14-11-2016
Abstract: Background: Point-of-care ultrasound (POCUS) is an invaluable tool in the diagnosis and management of conditions presenting to emergency departments across the world. It has also improved the success rate of invasive bedside procedures. Objectives: This study aimed to investigate the current utilization of POCUS in a large tertiary care emergency department in the Middle East and to identify barriers to its utilization. Methods: A cross-sectional survey of emergency physicians' experience with ultrasound was conducted, which included examining the training, exposure, and barriers to use. This paper-based survey was completed by the participants in the presence of the authors of this study to improve compliance. Data were collected over a period of two months, from October to November 2014. Results: A total of 105 physicians participated in the survey. Of these participants, 56 had undergone prior training in ultrasonography by successfully completing courses approved by the Royal College of Emergency Medicine in the United Kingdom, and the Royal College of Physicians and Surgeons of Canada. Twenty-two physicians had completed other non-accredited ultrasound courses. An improvement in ultrasound procedural skills was reported by all those who completed training. A perceived lack of time in the emergency department was the main barrier to scanning patients. Other shortcomings included a deficiency of trained personnel for guidance, shortage of equipment, and a lack of experience and interest among physicians. Hands-on training was considered the preferred method among physicians for enhancing ultrasonography skills. Conclusions: The study identified an underutilization of POCUS by emergency physicians. Availability of dedicated time, equipment, supervision, and training may help to increase its usage.
Publisher: Elsevier BV
Date: 09-2009
DOI: 10.1016/J.INJURY.2009.05.034
Abstract: Traumatic brain injury (TBI) is the single largest cause of death and disability following injury worldwide. While TBI in older adults is less common, it still contributes to significant morbidity and mortality in this group. Understanding the patient characteristics that result in good and poor outcome after TBI is important in the clinical management and prognosis of older adult TBI patients. This population-based study investigated predictors of mortality and longer term functional outcomes following serious TBI in older adults. All older adults (aged>64 years), isolated moderate to severe TBI cases from the population-based Victorian State Trauma Registry for the period July 2005 to June 2007 (inclusive) were extracted for analysis. Demographic, injury event, injury diagnosis, management and comorbid status information were obtained and the outcomes of interest were in-hospital mortality, and the Glasgow Outcome Scale-Extended (GOS-E) score at 6 months post-injury. Multivariate logistic regression analyses were used to identify independent predictors of in-hospital mortality and independent living (GOS-E>4) status at 6 months. Of the 428 isolated, older adult TBI cases, the majority were the result of a fall (88%), male (55%), and aged>74 years (76%). The in-hospital death rate was 28% and increasing age (p=0.009), decreasing GCS (p<0.001) and injury type (p=0.002) were significant independent predictors of in-hospital mortality. Of the 310 patients who survived to discharge, 65% were successfully followed-up 6 months following injury. There was no difference between patients lost to follow-up and those successfully followed-up with respect to the key population indicators of age, gender, or head injury severity. Younger (<75 years) patients, and those with an SBP on arrival at hospital of 131-150mmHg, were at increased odds of living independently at follow-up. No patients with a GCS<9 had a good 6-month outcome, and most of them died. The survival rate for brainstem injury was also low (21%). In this population-based study, we found that age, GCS, brainstem injury, and systolic blood pressure were the most important factors in predicting outcome in older adults with an isolated moderate to severe TBI.
Publisher: AMPCo
Date: 11-2012
DOI: 10.5694/MJA12.11089
Publisher: BMJ
Date: 22-07-2009
Abstract: Severe pain is a common presenting symptom for emergency patients. One major challenge in the management of severe pain is the objective measurement of pain. Due to the subjective nature of pain, it can be very difficult for clinicians to quantify pain intensity and measure the qualitative features of the pain experience. A number of measurement tools have been validated in the acute care setting, with some appropriate for use in the prehospital setting. This paper reviews the characteristics required of a prehospital acute pain measure and appraises the relative utility of a number of currently used pain measures. At present, the verbal numerical rating scale appears the most appropriate pain measure to administer in the prehospital setting for adult patients as it is practical and valid. Either the Oucher scale or the faces pain scale is suitable for prehospital care providers to assess pain in children.
Publisher: Wiley
Date: 12-1995
Publisher: Wiley
Date: 02-2004
DOI: 10.1111/J.1742-6723.2004.00532.X
Abstract: To evaluate the psychological health of ACEM Fellows and the important factors that impact on this health. A cross-sectional, mail survey utilizing validated psychological instruments. Three hundred and twenty-three (63.5%) of 510 physicians responded. Most were recently graduated males. Compared to a general population s le, their psychological health was good with greater optimism and mastery (P < 0.001), less anxiety, depression and physical symptoms (P < 0.001), better life satisfaction (P = 0.04) and similar perceived stress (P = 0.20). The mean work stress score (1 = low, 10 = high) was 5.6 +/- 2.1 (moderate stress) although 63 (19.5%) had very high scores (8-10). The mean work satisfaction score was 6.3 +/- 2.1 (moderate satisfaction) although 43 (13.3%) had very low scores (1-3). Perceptions of control over hours worked and mix of professional activities were positively associated with work and life satisfaction (P < 0.001) and negatively associated with work stress and measures of wellbeing (P < 0.001). Most employed adaptive coping strategies. However, maladaptive strategies (alcohol/drugs, denial, disengagement) were positively associated with anxiety, depression and stress (P < 0.001). Most physicians are psychologically healthy. However, there appears to be a subgroup that is not thriving. Workplace stress should be addressed promptly and greater flexibility provided over hours worked and mix of professional activities.
Publisher: Elsevier BV
Date: 05-2016
DOI: 10.1016/J.INJURY.2015.12.016
Abstract: The incidence of ladder-related falls is increasing, and this represents a disturbing trend, particularly in the context of increased life expectancy and the impending retirement of the populous 'baby-boomer' generation. To date, there have been no critical illness-focused studies reporting on the incidence, severity and outcomes of severe ladder-related injuries requiring ICU management. Major trauma patients admitted to ICU over a 5year period to June 2011 after ladder falls >1m were identified from prospectively collected trauma data at a Level 1 trauma service. Demographic and ICU clinical management data were collected and non-parametric statistical analyses were used to explore the relationships between variables in hospital mortality/survival. There were 584 ladder fall admissions, including 194 major trauma cases, of whom 29.9% (n=58) fell >1m and were admitted to ICU. Hospital mortality was 26%, and fatal cases were almost entirely older males in domestic falls of ≤3m who died as a result of traumatic brain injury. Non-survivors had lower GCS at the scene (p=0.02), higher AIS head code (p=0.01), higher heart rate and lower mean arterial pressure (p<0.01) in the initial 24h period in ICU, and were ≥55years of age (p=0.05). Only 46% of patients available for follow-up were living at home at 12months without requiring additional care. The incidence of ladder falls requiring ICU management is increasing, and severe traumatic brain injury was responsible for the majority of deaths and for poor outcomes in survivors. In-hospital costs attributable to the care of these patients are high, and fewer than half were living independently at home at 12months post-fall. A concerted public health c aign is required to alert the community to the potential consequences of this mechanism of injury. The use of helmets for ladder users in domestic settings, where occupational health and safety regulations are less likely to be applied, is strongly recommended to mitigate the risk of severe brain injury. The benefits of this simple strategy far outweigh any mild inconvenience for the wearer, and may prevent catastrophic injury.
Publisher: Oxford University Press (OUP)
Date: 12-2002
Abstract: The aim of the project was to bring together 17 major emergency departments across Victoria, Australia, and the Australian Capital Territory to work together over an 8-month period to reduce both clinical and operational waits and delays, and to improve patient satisfaction. The collaborative was based on the Institute for Healthcare Improvement's Breakthrough Series, and utlilized their intellectual property and methodology adapted for the Australian setting. The largest (by annual attendances) 17 emergency departments in the State of Victoria and one hospital in the Australian Capital Territory participated. Each hospital sent a team of three to five persons, which included the Emergency Department Medical Director and Nurse in Charge, and an Executive Sponsor to each learning session. The teams were required to attend four learning sessions, to participate during the action period in both clinical and operational improvement activities, and to report regularly in the form of data reports and conference calls. Each team selected at least one or two clinical topics for improvement and at least one operational project to undertake during the life of the collaborative. A patient satisfaction survey was commenced towards the end of the project. Forty-seven clinical projects were nominated during the life of the collaborative and 32 of these were completed, with 31 resulting in significant improvement or achieving target. Thirty-nine operational projects were nominated, 30 of which were completed, with 24 of these achieving improvement or target. Numerous additional achievements occurred, which evolved from the framework of supported collaboration. The spread of knowledge and innovation can be best facilitated rapidly by teams working together using a structured program in a supported environment.
Publisher: Springer Science and Business Media LLC
Date: 04-2015
DOI: 10.1017/CEM.2014.79
Publisher: Wiley
Date: 04-2010
DOI: 10.1111/J.1742-6723.2010.01272.X
Abstract: To describe and identify the relationship between ED length of stay (LOS) and mortality after ICU admission. We undertook a retrospective cohort study of records from the Australian and New Zealand Intensive Care Society Adult Patient Database (from 1 January 2000 to 31 December 2006). Data from 45 hospitals and 48 803 ED patients directly transferred to ICU were included. Patients were ided into ED LOS or=8 h. Univariate and multivariate analyses were performed. Median ED LOS was 3.9 h (interquartile range 2.0-6.8). Patients transferred within 8 h (80.9%) were younger (P or=8 h. There was no clear relationship between ED LOS and hospital survival for patients admitted directly to ICU (odds ratio=1.01 per hour, 95% confidence intervals 0.99-1.02). Although 20% of critically ill patients spend more than 8 h in ED before transfer to ICU, we were unable to demonstrate an adverse relationship between time in ED and hospital mortality.
Publisher: Wiley
Date: 18-05-2020
Publisher: Elsevier BV
Date: 11-2016
DOI: 10.1016/J.IJCARD.2016.08.299
Abstract: Out-of-hospital cardiac arrest (OHCA) studies from the Middle East and Asian region are limited. This study describes the epidemiology, emergency health services, and outcomes of OHCA in Qatar. This was a prospective nationwide population-based observational study on OHCA patients in Qatar according to Utstein style guidelines, from June 2012 to May 2013. Data was collected from various sources the national emergency medical service, 4 emergency departments, and 8 public hospitals. The annual crude incidence of presumed cardiac OHCA attended by EMS was 23.5 per 100,000. The age-sex standardized incidence was 87.8 per 100,000 population. Of the 447 OHCA patients included in the final analysis, most were male (n=360, 80.5%) with median age of 51years (IQR=39-66). Frequently observed nationalities were Qatari (n=89, 19.9%), Indian (n=74, 16.6%) and Nepalese (n=52, 11.6%). Bystander cardiopulmonary resuscitation (CPR) was carried out in 92 (20.6%) OHCA patients. Survival rate was 8.1% (n=36) and multivariable logistic regression indicated that initial shockable rhythm (OR 13.4, 95% CI 5.4-33.3, p=0.001) was associated with higher odds of survival while male gender (OR 0.27, 95% CI 0.1-0.8, p=0.01) and advanced cardiac life support (ACLS) (OR 0.15, 95% CI 0.04-0.5, p=0.02) were associated with lower odds of survival. Standardized incidence and survival rates were comparable to Western countries. Although expatriates comprise more than 80% of the population, Qataris contributed 20% of the total cardiac arrests observed. There are significant opportunities to improve outcomes, including community-based CPR and defibrillation training.
Publisher: Wiley
Date: 24-07-2020
Publisher: Elsevier BV
Date: 09-1996
DOI: 10.1016/S0196-0644(96)70036-7
Abstract: The binding of alkali metal cations with two tertiary-amide lower-rim calix[4]arenes was studied in methanol,
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2010
Publisher: Wiley
Date: 10-2003
Publisher: Wiley
Date: 11-09-2012
DOI: 10.1111/J.1742-6723.2012.01609.X
Abstract: To describe the trends in emergency admissions over 10 years in terms of volume, age-specific rates, hospital length of stay (LOS) and clinical reasons. A retrospective analysis of population-based linked Department of Health ED and hospital admission data for metropolitan Melbourne 1999/2000 to 2008/2009 was conducted. Outcome measures included: hospital admission numbers (total, single day/overnight, ≥2 days LOS) admission rates per 1000 person-years (total, single day/overnight, ≥2 days LOS) hospital LOS. The volume of patients admitted to hospital through EDs rose by 56% over the 10 years to June 2009. The number of same day/overnight admissions rose by 60%, equating to a 6.1% average annual increase beyond that accounted for by demographic change (95% CI 5.7-6.5%). The volume of patients admitted for ≥2 days also increased however, the admission rate per 1000 persons for these longer-stay patients declined over the decade by 9% (95% CI 5-12%). The most frequent discharge diagnoses were injury or poisoning, and disorders of the circulatory, respiratory or digestive systems. The numbers and mortality rate for ED admissions declined over the decade. Emergency hospital admissions have risen over the last decade even after adjustment for population changes. There was a disproportionate rise in same day/overnight admissions, with overrepresentation of the elderly. This is possibly related to changes in ED models of care, including introduction of short-stay units, improved diagnostic and therapeutic capability, and risk-averse management to optimise safe discharge, within the context of time-based performance targets.
Publisher: Wiley
Date: 11-10-2016
Abstract: The present study aimed to describe and examine similarities and differences in the current service provision and resuscitation protocols of the ambulance services participating in the Aus-ROC Australian and New Zealand out-of-hospital cardiac arrest (OHCA) Epistry. Understanding these similarities and differences is important in identifying ambulance service factors that might explain regional variation in survival of OHCA in the Aus-ROC Epistry. A structured questionnaire was completed by each of the ambulance services participating in the Aus-ROC Epistry. These ambulance services were SA Ambulance Service, Ambulance Victoria, St John Ambulance Western Australia, Queensland Ambulance Service, St John Ambulance NT, St John New Zealand and Wellington Free Ambulance. The survey aimed to describe ambulance service and dispatch characteristics, resuscitation protocols and details of cardiac arrest registries. We observed similarities between services with respect to the treatment of OHCA and dispatch systems. Differences between services were observed in the serviced population the proportion of paramedics with basic life support, advanced life support or intensive care training skills the number of OHCA cases attended guidelines related to withholding or terminating resuscitation attempts and the variables that might be used to define 'attempted resuscitation'. All seven participating ambulance services were noted to have existing OHCA registries. There is marked variation between ambulance services currently participating in the Aus-ROC Australian and New Zealand OHCA Epistry with respect to workforce characteristics and key variable definitions. This variation between ambulance services might account for a proportion of the regional variation in survival of OHCA.
Publisher: Wiley
Date: 08-2013
Publisher: Public Library of Science (PLoS)
Date: 26-08-2014
Publisher: Wiley
Date: 09-2013
DOI: 10.1111/IMJ.12227
Abstract: Patient flow is a major problem in hospitals. Delays in accessing inpatient rehabilitation have not been well studied. Measure the time taken for key processes in the patient journey from acute hospital admission through to inpatient rehabilitation admission in order to identify opportunities for improvement. Retrospective open cohort study. All patients admitted over 8- and 10-month periods during 2008 into two inpatient rehabilitation units in Melbourne, Australia. Main outcome measures were the duration of the following key processes: acute hospital admission until referral for rehabilitation, referral until assessment by the rehabilitation service, assessment until deemed ready for transfer to rehabilitation, ready for transfer until rehabilitation admission. Three hundred and sixty patients were in the study s le (females = 186 51.7%) mean age = 58.4 (standard deviation = 15.0) years. There was a median of 7 (interquartile range [IQR] 4-13) days from acute hospital admission till referral for rehabilitation, a median of 1 (IQR 0-1) day from referral till assessment, a median of 0 (IQR 0-2) days from assessment till deemed ready for transfer and a median of 1 (IQR 0-3) day from ready till admission into rehabilitation. Overall, patients spent 12.0% (804/6682) of their acute hospital admission waiting for a rehabilitation bed. There are opportunities to improve the efficiency of key processes in the acute hospital journey for patients subsequently admitted to inpatient rehabilitation in particular, reducing the time from acute hospital admission till referral for rehabilitation and from being deemed ready for transfer to rehabilitation till admission.
Publisher: Massachusetts Medical Society
Date: 15-05-2003
DOI: 10.1056/NEJMOA030685
Publisher: Wiley
Date: 27-06-2020
Publisher: AMPCo
Date: 08-2012
DOI: 10.5694/MJA11.11351
Abstract: To examine trends in mechanism and outcome of major traumatic injury in adults since the implementation of the New South Wales trauma monitoring program, and to identify factors associated with mortality. Retrospective review of NSW Trauma Registry data from 1 January 2003 to 31 December 2007, including patient demographics, year of injury, and level of trauma centre where definitive treatment was provided. 9769 people aged ≥ 15 years hospitalised for trauma, with an injury severity score (ISS) > 15. The NSW Trauma Registry outcome measures included were overall hospital length of stay, length of stay in an intensive care unit and in ospital mortality. There was a decreasing trend in severe trauma presentations in the age group 16-34 years, and an increasing trend in presentations of older people, particularly those aged ≥ 75 years. Road trauma and falls were consistently the commonest injury mechanisms. There were 1328 inhospital deaths (13.6%). Year of injury, level of trauma centre, ISS, head/neck injury and age were all independent predictors of mortality. The odds of mortality was significantly higher among patients receiving definitive care at regional trauma centres compared with Level I centres (odds ratio, 1.34 95% CI, 1.10-1.63). Deaths from major trauma in NSW trauma centres have declined since 2003, and definitive care at a Level 1 trauma centre was associated with a survival benefit. More comprehensive trauma data collection with timely analysis will improve injury surveillance and better inform health policy in NSW.
Publisher: Elsevier BV
Date: 05-2014
DOI: 10.1016/J.JTCVS.2013.10.051
Abstract: Evidence is accumulating of adverse outcomes associated with transfusion of blood components. If there are differences in perioperative transfusion rates in cardiac surgery, and what hospital factors may contribute, requires further investigation. Analysis of 42,743 adult patients who underwent 43,482 procedures from 2005 to 2011 at 25 Australian hospitals, according to the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database. Multiple logistic regression examined associations of patient and hospital characteristics with transfusion of ≥1 red blood cell (RBC) unit platelet (PLT), fresh frozen plasma (FFP), and cryoprecipitate (CRYO) doses and ≥5 RBC units, from surgery until hospital discharge. Procedures included 24,222 (55%) isolated coronary artery bypass grafts, 7299 (17%) isolated valve, 4714 (11%) coronary artery bypass graft and valve, and 7247 (17%) other procedures. After adjustment for various patient and procedure characteristics, transfusion rates varied across hospitals for ≥1 RBC unit from 22% to 67%, ≥5 RBC units from 5% to 25%, ≥1 PLT dose from 11% to 39%, ≥1 FFP dose from 11% to 48% and ≥1 CRYO dose from 1% to 20%. Hospital characteristics, including state or territory, private versus public, and teaching versus nonteaching, were not associated with variation in transfusion rates. Variation in transfusion of all components and large volume RBC was identified, even after adjustment for patient and procedural factors known to influence transfusion, and this was not explained by hospital characteristics.
Publisher: Wiley
Date: 11-2014
DOI: 10.1111/ACEM.12508
Abstract: There is little information available from the Middle Eastern region on adult patients presenting with first seizure. The objectives of this study were to describe epidemiological characteristics of patients presenting to the emergency department (ED) in Doha, Qatar, with first seizure and to determine the incidence of computed tomographic (CT) scan abnormalities. A retrospective cohort study was conducted on all adult patients with first seizure presenting to Hamad General Hospital ED over a 1-year period (June 2012 through May 2013). Electronic patient records were reviewed for demographics, neuroimaging, electroencephalography, laboratory test results, and medications administered. There were 439 patients who satisfied inclusion criteria. Patients were aged a mean of 35.3 years (95% confidence interval [CI] = 33.92 to 36.69 years) with a male-to-female ratio of five to one. CT abnormalities were detected in 154 patients (35.3% 95% CI = 30.81% to 39.82%). Out of reported abnormal scans, 14.7% patients had significant abnormalities such as neurocysticercosis (9.2%) brain metastasis and neoplasm (3.4%) and subarachnoid and subdural hemorrhage, cavernous sinus thrombosis, acute stroke, and brain edema (2.0%). None of the patients had any electrolyte abnormalities, and three patients had hypoglycemia. Patients with initial abnormal CT brain results were more likely to have recurrent seizures (OR = 1.65 95% CI = 1.11 to 2.45) within 6 months. Adults who presented with first seizure to the ED in Qatar had a young male predominance, and a high proportion of brain CT scans were reported as abnormal. It is recommended that all such patients in this population should undergo prompt CT scanning in the ED, but the utility of routine electrolyte tests requires further investigation.
Publisher: BMJ
Date: 2012
Publisher: BMJ
Date: 09-2017
DOI: 10.1136/BMJOPEN-2017-017848
Abstract: Mild traumatic brain injury (mTBI) has been insufficiently researched, and its definition remains elusive. Investigators are confronted by heterogeneity in patients, mechanism of injury and outcomes. Findings are thus often limited in generalisability and clinical application. Serum protein biomarkers are increasingly assessed to enhance prognostication of outcomes, but their translation into clinical practice has yet to be achieved. A systematic review was performed to describe the adult populations included and enrolled in studies that evaluated the prognostic value of protein biomarkers to predict postconcussion symptoms following an mTBI. Searches of MEDLINE, Embase, CENTRAL, CINAHL, Web of Science, PsycBITE and PsycINFO up to October 2016. Two reviewers independently screened for potentially eligible studies, extracted data and assessed the overall quality of evidence by outcome using the Grading of Recommendations Assessment, Development and Evaluation approach. A total of 23 298 citations were obtained from which 166 manuscripts were reviewed. Thirty-six cohort studies (2812 patients) having enrolled between 7 and 311 patients (median 89) fulfilled our inclusion criteria. Most studies excluded patients based on advanced age (n=10 (28%)), neurological disorders (n=20 (56%)), psychiatric disorders (n=17 (47%)), substance abuse disorders (n=13 (36%)) or previous traumatic brain injury (n=10 (28%)). Twenty-one studies (58%) used at least two of these exclusion criteria. The pooled mean age of included patients was 39.3 (SD 4.6) years old (34 studies). The criteria used to define a mTBI were inconsistent. The most frequently reported outcome was postconcussion syndrome using the Rivermead Post-Concussion Symptoms Questionnaire (n=18 (50%)) with follow-ups ranging from 7 days to 5 years after the mTBI. Most studies have recruited s les that are not representative and generalisable to the mTBI population. These exclusion criteria limit the potential use and translation of promising serum protein biomarkers to predict postconcussion symptoms.
Publisher: Springer Science and Business Media LLC
Date: 05-06-2015
DOI: 10.1017/CEM.2015.39
Publisher: AMPCo
Date: 06-2017
DOI: 10.5694/MJA16.00771
Abstract: This study aimed to assess analgesia provided by acupuncture, alone or in combination with pharmacotherapy, to patients presenting to emergency departments with acute low back pain, migraine or ankle sprain. A pragmatic, multicentre, randomised, assessor-blinded, equivalence and non-inferiority trial of analgesia, comparing acupuncture alone, acupuncture plus pharmacotherapy, and pharmacotherapy alone for alleviating pain in the emergency department. Setting, participants: Patients presenting to emergency departments in one of four tertiary hospitals in Melbourne with acute low back pain, migraine, or ankle sprain, and with a pain score on a 10-point verbal numerical rating scale (VNRS) of at least 4. The primary outcome measure was pain at one hour (T1). Clinically relevant pain relief was defined as achieving a VNRS score below 4, and statistically relevant pain relief as a reduction in VNRS score of greater than 2 units. 1964 patients were assessed between January 2010 and December 2011 528 patients with acute low back pain (270 patients), migraine (92) or ankle sprain (166) were randomised to acupuncture alone (177 patients), acupuncture plus pharmacotherapy (178) or pharmacotherapy alone (173). Equivalence and non-inferiority of treatment groups was found overall and for the low back pain and ankle sprain groups in both intention-to-treat and per protocol (PP) analyses, except in the PP equivalence testing of the ankle sprain group. 15.6% of patients had clinically relevant pain relief and 36.9% had statistically relevant pain relief at T1 there were no between-group differences. The effectiveness of acupuncture in providing acute analgesia for patients with back pain and ankle sprain was comparable with that of pharmacotherapy. Acupuncture is a safe and acceptable form of analgesia, but none of the examined therapies provided optimal acute analgesia. More effective options are needed. Australian New Zealand Clinical Trials Registry, ACTRN12609000989246.
Publisher: Elsevier BV
Date: 09-2007
DOI: 10.1016/J.INJURY.2007.03.021
Abstract: To review the massive transfusion practice at a Level I adult Trauma Centre during initial trauma reception and resuscitation. All trauma patients presenting to The Alfred Emergency & Trauma Centre and receiving a transfusion of five units or more of packed red blood cells within 4h of presentation over a 26-month period were included in this study. Patient demographics, clinical characteristics, injuries, surgical management and volume of blood transfused were analysed with mortality as the primary endpoint. Initial clinical features and injuries predictive of massive transfusion were also analysed. There were 119 patients who received a transfusion of five units or more of packed red blood cells (PRBCs) within 4h of presentation. The median Injury Severity Score of this group of patients was 34.0 (IQR 26-48) and mortality was 27.7%. The median number of packed red blood cell transfused was 8.0 (IQR 6-14) in the 1st 4h. Initial clinical features and injuries independently associated with a larger volume of blood transfused were initial hypotension, fractures of the pelvis, kidney injuries, initial acidaemia, and thrombocytopaenia. The Injury Severity Score, initial coagulopathy measured by APTT and the presence of head injuries were the independent predictors of mortality. The volume of blood transfused during trauma resuscitation was not found to be an independent predictor of mortality. Prospective studies into transfusion practice and clinical features of patients during the trauma resuscitation phase requiring massive transfusion are needed to establish evidence-based guidelines for massive transfusion.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2010
DOI: 10.1161/CIRCHEARTFAILURE.109.869438
Abstract: Background— It is often difficult to diagnose heart failure (HF) accurately in patients presenting with dyspnea to the emergency department (ED). This study assessed whether B-type natriuretic peptide (BNP) testing in these patients improved the accuracy of HF diagnosis. Methods and Results— Patients presenting to the Alfred and the Northern Hospital EDs with a chief complaint of dyspnea were enrolled prospectively from August 2005 to April 2007. Patients were randomly allocated to have BNP levels tested or not. The diagnostic gold standard for HF was determined by 1 cardiologist and 1 emergency or respiratory physician who, blinded to the BNP result, independently reviewed all available information. The ED diagnosis of HF in the non-BNP group showed a sensitivity, specificity, and accuracy of 65%, 92%, and 81%, respectively. The BNP group had a similar sensitivity, specificity, and accuracy of 66%, 90%, and 78%, respectively, for the diagnosis of HF in the ED. There was no significant difference between the BNP and non-BNP groups in any of the measures of diagnostic accuracy for HF. Conclusion— In the clinical setting of EDs, availability of BNP levels did not significantly improve the accuracy of a diagnosis of HF. Clinical Trial Registration— clinicaltrials.gov. Identifier: NCT00163709.
Publisher: Public Library of Science (PLoS)
Date: 05-06-2017
Publisher: Wiley
Date: 16-01-2015
Abstract: To evaluate the effect of changes to the pre-hospital management of patients with supraventricular tachycardia (SVT) following intervention with a revised Clinical Practice Guideline (CPG). The major CPG revisions were removal of verapamil, addition of adenosine and an emphasis on Valsalva manoeuvre. We undertook a retrospective case study using data collected by paramedics. All adult patients attended by paramedics from the periods 14 February 2012 to 14 September 2012 (old CPG) and 14 February 2013 to 14 September 2013 (revised CPG) were included. Patients were excluded if SVT was not recorded during initial assessment on a hardcopy ECG. Management guided by the old and revised CPGs was compared: reversion effectiveness, elements of therapy associated with reversion effectiveness and adverse events. Logistic regression determined patient factors significantly associated with reversion. Patients were predominantly women, aged approximately 57 years old and most lived in the Victorian metropolitan region. Vagal manoeuvre use and effectiveness decreased in the post-intervention group. Fewer patients in the post-intervention group (141/420, 33.6%) remained in SVT on arrival at hospital compared with the pre-intervention group (205/403, 50.8%). Initial heart rate >170/min and longer scene time were 2.6 and 1.05 times more likely to result in reversion, respectively. The revised CPG improved pre-hospital SVT reversion success. This expansion of practice has not demonstrated improvements to utilisation or effectiveness of the Valsalva manoeuvre. Adenosine is effective and safe for pre-hospital use.
Publisher: BMJ
Date: 07-2017
Publisher: BMJ
Date: 05-2017
Publisher: Wiley
Date: 06-1993
Publisher: CSIRO Publishing
Date: 2007
DOI: 10.1071/AH070628
Abstract: To establish the use of health care services 6 months following major trauma, 243 blunt major trauma patients were recruited during their acute hospital stay and followed up by telephone interview at 6 months post-injury. Data collected at 6 months included health care service usage and their level of disability according to the Glasgow Outcome Scale ? Extended (GOSE). Ninety-four percent of patients were living in the community at 6 months, and most (69%) reported continued use of health care services. Of those with ongoing disability, non-compensable patients were significantly more likely (OR 3.7 95% CI, 1.6?8.6) to have ceased health care service use than compensable patients, independent of injury severity.
Publisher: American College of Physicians
Date: 07-12-2010
DOI: 10.7326/0003-4819-153-11-201012070-00006
Abstract: Although the accuracy of B-type natriuretic peptide (BNP) testing for diagnosing acute decompensated heart failure has been extensively evaluated, the effect of this test on clinical outcomes remains unclear. To investigate whether BNP testing of patients presenting with acute dyspnea in the emergency department leads to fewer admissions, shorter length of stay, and improved short-term survival compared with usual care without BNP testing. Two reviewers searched Ovid MEDLINE and EMBASE, without language restrictions, to identify pertinent studies published from January 1996 to July 2010. Randomized, controlled trials that compared BNP testing to diagnose heart failure with routine care in patients presenting with acute dyspnea and information about 1 or more of the following outcomes: mortality, admission, or length of hospital stay. Two authors independently reviewed articles, extracted data, and assessed quality and risk for bias of studies. Five trials conducted in 5 countries and involving 2513 patients met inclusion criteria. Study settings had differing emergency department staffing models and used various BNP testing protocols. The pooled estimate of effect of BNP testing on all-cause mortality had wide confidence bounds and was inconclusive (odds ratio, 0.96 [95% CI, 0.65 to 1.41]). Admission rates decreased in the tested group compared with the control group (odds ratio, 0.82 [CI, 0.67 to 1.01]), although this finding was not statistically significant. Length of hospital and critical care unit stay were both modestly reduced in the tested group compared with the control group, with a mean difference of -1.22 days (CI, -2.31 to -0.14 day) and -0.56 day (CI, -1.06 to -0.05 day), respectively. Few relevant trials were studied. Patients included in the trials and the settings in which trials were conducted were heterogeneous. B-type natriuretic peptide testing in the emergency department for patients presenting with acute dyspnea decreased length hospital of stay by about 1 day and possibly reduced admission rates but did not conclusively affect hospital mortality rates. Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
Publisher: Elsevier BV
Date: 02-2015
DOI: 10.1016/J.INJURY.2014.09.010
Abstract: The global burden of injury is enormous, especially in developing countries. Trauma systems in highincome countries have reduced mortality and disability. An important component of trauma quality improvement programmes is the trauma registry which monitors the epidemiology, processes and outcomes of trauma care. There is a severe deficit of trauma registries in developing countries and there are few resources to support the development of trauma registries. Specifically, publicly available information of trauma registry methodology in developed trauma registries is sparse. The aim of this study was to describe and compare trauma registries globally. A survey of trauma registry custodians was conducted. Purposive s ling was used to select trauma registries following a structured review of the literature. Registries for which there were at least two included abstracts over the five-year period were defined as active and selected. Following piloting and revision, a detailed survey covering physical and human resources, administration and methodology was distributed. The survey responses were analysed single hospital and multi-hospital registries were compared. Eighty-four registries were emailed the survey. Sixty-five trauma registries participated, giving a response rate of 77%. Of the 65 participating registries, 40 were single hospital registries and 25 were multi-hospital registries. Fifteen countries were represented more than half of the participating registries were based in the USA. There was considerable variation in resourcing and methodology between registries. A trauma registry most commonly had at least three staff, reported to both the hospital and government, included more than 1000 cases annually, listed admission, death and transfer amongst inclusion criteria, mandated collection of more than 100 data elements, used AIS Version 2005 (2008 update) and used age, the Glasgow Coma Scale and the Injury Severity Score for injury severity adjustment. Whilst some characteristics were common across many trauma registries, the resourcing and methodology varied markedly. The common features identified may serve as a guide to those looking to establish a trauma registry. However much remains to be done for trauma registries to determine the best standardised approach.
Publisher: Informa UK Limited
Date: 25-08-2015
DOI: 10.3109/02688697.2014.950632
Abstract: Acute traumatic coagulopathy (ATC) has been reported in the setting of isolated traumatic brain injury (iTBI) and associated with poor outcomes. Among patients with iTBI, we aimed to select an appropriate definition of ATC, outline the incidence of ATC and examine clinical variables associated with ATC. A retrospective review of The Alfred Trauma Registry was conducted and patients with iTBI (head AIS [Abbreviated Injury Score] ≥ 3 and all other body regions AIS < 3) were selected for analysis. The association of the international normalised ratio (INR) on arrival at hospital with the mortality on hospital discharge was explored, to select an appropriate clinical horizon to define ATC. The incidence of ATC was calculated using this definition. Injury and clinical variables measurable pre-hospital and immediately on arrival at the hospital were analysed to determine independent associations with ATC. There were 1718 patients with iTBI included in the study. The overall mortality was 12%, but significantly greater when initial INR was measured at ≥ 1.3 (45.1% p 50 yrs, SI ≥ 1, or abnormal pupils, was 97.54% (95% CI: 96.6-98.2) specific for ATC. An abnormal initial INR in the setting of iTBI was associated with poor outcomes, regardless of magnitude. The incidence of ATC appears too low to recommend empiric pro-coagulant management for all patients with iTBI. The subgroup of patients older than 50 yrs., with shock or abnormal size of pupils, may be considered for interventional trials of early treatment against ATC.
Publisher: Springer Science and Business Media LLC
Date: 31-03-2016
DOI: 10.1007/S11096-016-0290-9
Abstract: Background The presence of a clinical pharmacist in a hospital's Emergency Department (ED) is important to decrease the potential for medication errors. To our knowledge, no previous studies have been conducted to evaluate the impact of implementing clinical pharmacy services in the ED in Qatar. Objective To characterize the contributions of clinical pharmacists in a short stay unit of ED in order to implement and scale-up the service to all ED areas in the future. Methods A retrospective study conducted for 7 months in the ED of Hamad General Hospital, Qatar. The intervention recommendations were made by clinical pharmacists to the physician in charge during medical rounds. Results A total of 824 documented pharmacist recommendations were analyzed. The interventions included the following: Providing information to the physician (24.4 %) and recommending medication discontinuation (22.0 %), dose adjustment (19.3 %), medication addition (16.0 %), changes in frequency of medications (7.6 %), medication resumption (5.7 %), and patient education (5.0 %). Conclusion Clinical pharmacists in the ED studied play an important role in patient care.
Publisher: Springer Science and Business Media LLC
Date: 20-08-2013
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2011
Publisher: Elsevier BV
Date: 2010
DOI: 10.1016/J.INJURY.2009.06.020
Abstract: To comprehensively examine the inter-hospital transfer of major trauma patients-including the reason for transfer, duration, escorts, interventions and unexpected events. This was an detailed study of the transfer of major trauma cases in the State of Victoria, Australia, between April 16, 2003 and December 31, 2004. Twenty-three hospitals and seven transfer/retrieval services participated. Defined major trauma cases that were transferred between participating hospitals for the purpose of definitive care were eligible for enrolment. The transfer phase extended from 30 min before until 30 min after the transfer. The transferring and receiving hospitals and the transfer escorts were asked to record data on a specifically designed data collection form. A total of 451 cases were enrolled (mean Injury Severity Score 22.2). Transfers originated mainly from Regional Trauma (42.8%) and Metropolitan Trauma (31.3%) Services and most (90.5%) terminated at a Major Trauma Service. Median time from injury to arrival at the receiving hospital was 8 h 30 min. Median time from arrival at referring hospital to request for transfer was 3 h 25 min. Escorts comprised ambulance and medical/nursing staff in 67.0% and 30.4% of cases, respectively. Metropolitan retrieval services were involved in only 10% of cases. Medical escorts were mainly (62.9%) from the referring hospital and the majority of these were registrars (49.4%) and hospital medical officers (HMOs, 16.9%). Overall mortality was 6.2%. Mortality rates for cases escorted by referring hospital doctors, Mobile Intensive Care Ambulance (MICA), non-MICA and any other escorts were 14.5%, 6.0%, 2.6% and 4.3%, respectively. HMO escorts had the highest mortality risk (OR 3.67, 95%CI 1.00-13.49, p<0.001). Mortality risk was greatest for cases that required administration of vasopressor drugs (OR 11.4, 95%CI 3.78-34.36, p<0.001), intubation prior to arrival at the referring hospital (OR 10.36, 95%CI 3.51-30.52, p<0.001), any interventions at the referring hospital (OR 8.3, 95%CI 3.1-22.2, p<0.001), administration of blood at the receiving hospital (OR 4.91, 95%CI 1.5-16.1, p=0.01), and cases using escorts from the referring hospital (OR 3.8, 95%CI 1.69-8.39, p=0.001). Considerable variability in request for transfer and transfer times, transfer escorts and mortality risk exist. The single greatest issue identified that most severely injured group were escorted by the most junior doctors (HMOs) and had the highest mortality. This crucial issue must be addressed by the State Trauma System and by any redesigned retrieval service in Victoria. A detailed review of activation and responsiveness criteria and the nature of the transfer escort is indicated. The establishment of Adult Retrieval Victoria may address many of the concerns raised by this study.
Publisher: BMJ
Date: 20-10-2012
Publisher: Wiley
Date: 30-05-2014
DOI: 10.1111/ANS.12700
Abstract: There is limited evidence describing the long-term outcomes of severe pelvic ring fractures. The aim of this study was to describe the longer term independent living and return to work outcomes following severe pelvic ring fracture. Adult survivors to discharge from two major trauma centres with AO/Tile type B and C fractures were followed up at 6, 12 and 24-months post-injury to capture functional (Glasgow Outcome Scale-Extended [GOS-E]) and return to work data. Multivariable, mixed effects models were used to identify predictors of outcome. A total of 111 of 114 (97%) cases were followed up. The mean (SD) age of participants was 41.9 (18.9) years, 77% were male, 81% were transport-related and 90% were multi-trauma patients. Further, 11% were managed conservatively, 10% with external fixation and 79% with open reduction and internal fixation. At 24 months, 77% were living independently (GOS-E > 4) and 59% had returned to work. Higher Injury Severity Scores (ISS) were associated with lower risk-adjusted odds of return to work (P = 0.04) and independent living (P = 0.06). Post-operative infection was associated with living independently (P = 0.02). Despite the severity of the injuries sustained, 77% of severe pelvic ring fracture patients were living independently and 59% had returned to work, 2-years post-injury. Fracture type and management were not key predictors of outcome. Large-scale multi-centre studies are needed to fully understand the burden of severe pelvic ring fractures and to guide clinical management.
Publisher: BMJ
Date: 12-2016
Publisher: SAGE Publications
Date: 10-07-2016
Abstract: To evaluate the feasibility of Pilates exercise in older people to decrease falls risk and inform a larger trial. Pilot Randomized controlled trial. Community physiotherapy clinic. A total of 53 community-dwelling people aged ⩾60 years (mean age, 69.3 years age range, 61–84). A 60-minute Pilates class incorporating best practice guidelines for exercise to prevent falls, performed twice weekly for 12 weeks. All participants received a letter to their general practitioner with falls risk information, fall and fracture prevention education and home exercises. Indicators of feasibility included: acceptability (recruitment, retention, intervention adherence and participant experience survey) safety (adverse events) and potential effectiveness (fall, fall injury and injurious fall rates standing balance lower limb strength and flexibility) measured at 12 and 24 weeks. Recruitment was achievable but control group drop-outs were high (23%). Of the 20 participants who completed the intervention, 19 (95%) attended ⩾75% of the classes and reported classes were enjoyable and would recommend them to others. The rate of fall injuries at 24 weeks was 42% lower and injurious fall rates 64% lower in the Pilates group, however, was not statistically significant ( P = 0.347 and P = 0.136). Standing balance, lower-limb strength and flexibility improved in the Pilates group relative to the control group ( P 0.05). Estimates suggest a future definitive study would require 804 participants to detect a difference in fall injury rates. A definitive randomized controlled trial analysing the effect of Pilates in older people would be feasible and is warranted given the acceptability and potential positive effects of Pilates on fall injuries and fall risk factors. The protocol for this study is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN1262000224820).
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2008
Publisher: Wiley
Date: 02-04-2014
DOI: 10.1111/VOX.12121
Abstract: The type and clinical characteristics of patients identified with commonly used definitions of massive transfusion (MT) are largely unknown. The objective of this study was to define the clinical characteristics of patients meeting different definitions of MT for the purpose of patient recruitment in observational studies. Data were extracted on all patients who received red blood cell (RBC) transfusions in 2010 at three tertiary Australian hospitals. MT patients were identified according to three definitions: ≥10 units RBC in 24 h (10/24 h), ≥6 units RBC in 6 h (6/6 h) and ≥5 units RBC in 4 h (5/4 h). Clinical coding data were used to assign bleeding context. Data on in-hospital mortality were also extracted. Five hundred and forty-two patients met at least one MT definition, with 236 (44%) included by all definitions. The most inclusive definition was 5/4 h (508 patients, 94%) followed by 6/6 h (455 patients, 84%) and 10/24 h (251 patients, 46%). Importantly, 40-55% of most types of critical bleeding events and 82% of all obstetric haemorrhage cases were excluded by the 10/24 h definition. Patients who met both the 5/4 h and 10/24 h definitions were transfused more RBCs (19 vs. 8 median total RBC units P < 0·001), had longer ventilation time (120 vs. 55 h P < 0·001), median ICU (149 vs. 99 h P < 0·001) and hospital length of stay (23 vs. 18 h P = 0·006) and had a higher in-hospital mortality rate (23·3% vs. 16·4% P = 0·050). The 5/4 h MT definition was the most inclusive, but combination with the 10/24 h definition appeared to identify a clinically important patient cohort.
Publisher: Wiley
Date: 08-02-2017
DOI: 10.1111/VOX.12487
Abstract: Critically bleeding patients requiring massive transfusion (MT) are clinically challenging, and limited data exist to support management decisions. This study describes patient characteristics, transfusion support and clinical outcomes from the Australian and New Zealand (NZ) Massive Transfusion Registry (ANZ-MTR). Retrospective, cohort study of all adult patients receiving MT (≥5 units red blood cells [RBC] in 4 h) at participating ANZ-MTR hospitals, 2011-2015. Mortality information was collected from the Australian National Death Index and NZ Ministry of Health. Associations between patient characteristics and outcomes were modelled using logistic regression. A total of 3560 MT cases were identified. For in-hospital deaths, cardiothoracic surgery was the most frequent bleeding context (24·5%) followed by trauma (18·3%). Age (OR = 1·03 95% CI: 1·02-1·04), more comorbidities (OR = 1·14 95% CI: 1·09-1·21), larger volume of RBC in first 24 h from MT onset (OR = 1·04 95% CI: 1·02-1·06), higher platelet to RBC ratio at 4 h (OR = 2·76 95% CI: 1·14-6·65) and higher activated partial thromboplastin time (OR = 1·02 95% CI: 1·01-1·03) were associated with in-hospital mortality. Patients with more comorbidities, older age, traumatic or surgical bleeding or requiring more blood components had higher in-hospital mortality. These findings provide a basis to evaluate and monitor practice relating to optimal use of blood products, variation in transfusion practices and patient outcomes, and also enable benchmarking of hospital performance for management of MT in specific patient groups.
Publisher: BMJ
Date: 2006
Abstract: Elderly victims of motor vehicle collisions are increasing with the aging population. This study aimed to investigate the injury pattern of elderly victims involved in motor vehicle collisions. This was a retrospective study using data from the Victorian State Trauma Outcome Registry and Monitoring Group (VSTORM) from June 2001 to July 2003, Australian Bureau of Statistics year 2001 population estimates, and Victoria Transport Accident Commission year 2001 total road death toll. Elderly victims were defined as age 65 and above. Comparison of fatality rates and general injury patterns for the elderly and young victims was undertaken. The total fatality rate of the elderly group was almost double that of the younger group. The elderly victims had a higher rate of chest injuries (23.42% v 18.17% p = 0.003). The three most common chest injuries of the elderly victims were rib fractures (23.58%), flail chest (9.55%), and sternum fractures (5.97%). Elderly chest injured patients also had longer intensive care unit stay compared with the younger group (7.96 days v 5.31 days p = 0.048). Elderly victims of motor vehicle collisions have a higher risk of chest injuries, especially of chest wall injuries. Age specific injury patterns are important in determining primary and secondary prevention strategies.
Publisher: Elsevier BV
Date: 06-2011
Publisher: Wiley
Date: 08-2005
DOI: 10.1197/J.AEM.2005.03.527
Abstract: While trauma registries have the potential to collect detailed information about patient outcomes, the most commonly reported outcome, mortality, only represents the outcome from a small proportion of the total trauma population. If trauma registries are to progress to routine monitoring of outcomes in trauma survivors, instruments that measure relevant outcomes in the remainder of the trauma population must be identified and implemented. This report provides an overview of the specific needs of trauma registries with respect to assessing patient outcomes other than mortality. The use of previously recommended outcome assessment instruments is discussed, with a focus on the utility of these instruments for use in routine monitoring of trauma outcomes other than mortality through trauma registries.
Publisher: Elsevier BV
Date: 12-2015
DOI: 10.1016/J.JOCN.2015.05.034
Abstract: This study aims to investigate an association between ethanol exposure and in-hospital mortality among patients with isolated traumatic brain injury (iTBI). Ethanol exposure is associated with a substantially increased risk of sustaining an iTBI. However, once an iTBI has been sustained, it is unclear whether ethanol exposure is neuroprotective or harmful. We conducted a retrospective review of patients who presented between 2006 and 2012 and were entered into the Alfred Hospital trauma registry. The patients who presented with iTBI, as defined by a head abbreviated injury scale (AIS) score ⩾3 and all other body regions with AIS<3, and who had ethanol levels recorded on admission, were eligible for inclusion. The association between ethanol exposure as a continuous variable, and in-hospital mortality, was explored using multivariable logistic regression analysis. There were 1688 patients with iTBI who met the inclusion criteria, 577 (34.2%) of whom tested positive for ethanol. Ethanol exposure was not significantly associated with a change in the in-hospital mortality rate (adjusted odds ratio 1.01 95% confidence interval 1.00-1.02 p=0.19). A substantial proportion of patients with iTBI were exposed to ethanol, but ethanol exposure was not independently associated with a change in mortality rate following iTBI. Any neuroprotection or harm from ethanol exposure was not conclusive, requiring further prospective trials.
Publisher: Elsevier BV
Date: 03-2017
DOI: 10.1016/J.INJURY.2017.01.033
Abstract: Recent research has highlighted the need for improved outcome reporting in younger hip fracture patients. For this population, return to work (RTW) is a particularly important measure against which to evaluate treatment outcomes. However, to date, only two small studies have reported RTW outcomes in young hip fracture patients and neither investigated factors predictive of RTW. The aims of this study were to report return to work (RTW) status and predictors of RTW 12 months after hip fracture in patients <65 years. Two hundred and ninety-one adults aged <65 years, admitted with hip fractures between July 2009 and June 2013 and registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) were included in this prospective cohort study. Twelve-month return to work status was collected through structured telephone interviews conducted by trained interviewers. Multivariate logistic regression was used to identify demographic and injury variables that were important predictors of 12-month work status. Sixty-five per-cent of patients had returned to work 12 months after hip fracture (62% of whom had an isolated hip fracture and 38% of whom had additional injuries). Relative to patients aged 16-24 years, odds of RTW was reduced by 78%-89% for each 10-year increase in age (p=0.02). Relative to patients employed as managers/administrators rofessionals, odds of RTW were 68% to 95% lower for all other workers (p<0.001). For those reporting a pre-injury disability, odds of RTW were 79% lower compared to those without disability (p=0.004) and 69% lower for patients with multiple injuries compared to isolated hip fracture patients (p=0.002). Finally, patients compensated by a work or transport insurer had a 67% lower odds of RTW relative to patients who were not compensated (p=0.02). Approximately one third of patients <65years had not returned to work 12 months after hip fracture. Patients who are older, have multiple injuries or pre-existing disabilities or who work in more physical occupations may need more assistance to RTW following hip fracture. The compensation system should be examined to determine why compensated patients may be at risk of poor RTW outcomes.
Publisher: Elsevier BV
Date: 12-2009
DOI: 10.1111/J.1538-7836.2009.03632.X
Abstract: Recombinant activated factor VII (rFVIIa) is increasingly being used off-license for treating critical bleeding. Guidelines may therefore be useful for improving processes and outcomes. Little is known regarding guidelines for off-license rFVIIa or their association with patient outcomes. To investigate the availability of hospital guidelines for off-license rFVIIa use and the association between these guidelines and mortality. Data were extracted from the Haemostasis Registry, which collects all cases of off-license rFVIIa use in participating institutions in Australia and New Zealand. Contributing hospitals were requested to supply a copy of the institutional guideline relating to off-license rFVIIa administration. The characteristics of patients treated in accordance with all elements of the guidelines were compared with those of patients for who one or more guideline elements had been violated. The relationship between guideline-directed treatment and 28-day mortality was investigated using stepwise logistic regression. Two thousand five hundred and fifty-one patients in 75 hospitals were available for analysis. Of these hospitals, 58 provided a guideline for analysis. Patients complying with all guideline elements (n = 530) did not differ from patients receiving care that violated guidelines (n = 1035) regarding age, size of dose, or gender. Guideline-directed treatment was not found to have an association with 28-day mortality following logistic regression. Few patients are treated in accordance with the criteria of rFVIIa guidelines, despite their availability in the majority of hospitals. Moreover, 28-day mortality does not appear to be associated with the use of guidelines in this patient group. Refinement of guidelines relating to the off-license use of rFVIIa is therefore required.
Publisher: Springer Science and Business Media LLC
Date: 26-01-2013
Publisher: Elsevier BV
Date: 06-2012
DOI: 10.1016/J.INJURY.2011.09.027
Abstract: Accurate prediction of the likelihood of discharge to inpatient rehabilitation following lower limb fracture made on admission to hospital may assist patient discharge planning and decrease the burden on the hospital system caused by delays in decision making. To develop a prognostic model for discharge to inpatient rehabilitation. Isolated lower extremity fracture cases (excluding fractured neck of femur), captured by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), were extracted for analysis. A training data set was created for model development and validation data set for evaluation. A multivariable logistic regression model was developed based on patient and injury characteristics. Models were assessed using measures of discrimination (C-statistic) and calibration (Hosmer-Lemeshow (H-L) statistic). A total of 1429 patients met the inclusion criteria and were randomly split into training and test data sets. Increasing age, more proximal fracture type, compensation or private fund source for the admission, metropolitan location of residence, not working prior to injury and having a self-reported pre-injury disability were included in the final prediction model. The C-statistic for the model was 0.92 (95% confidence interval (CI) 0.88, 0.95) with an H-L statistic of χ(2)=11.62, p=0.17. For the test data set, the C-statistic was 0.86 (95% CI 0.83, 0.90) with an H-L statistic of χ(2)=37.98, p<0.001. A model to predict discharge to inpatient rehabilitation following lower limb fracture was developed with excellent discrimination although the calibration was reduced in the test data set. This model requires prospective testing but could form an integral part of decision making in regards to discharge disposition to facilitate timely and accurate referral to rehabilitation and optimise resource allocation.
Publisher: Elsevier BV
Date: 09-2011
DOI: 10.1016/J.INJURY.2010.03.035
Abstract: There is a paucity of literature comparing trauma patients who meet pre-hospital trauma triage guidelines ('potential major trauma') with trauma patients who are identified as 'confirmed major trauma patients' at hospital discharge. This type of epidemiological surveillance is critical to continuous performance monitoring of mature trauma care systems. The current study aimed to determine if the current trauma triage criteria resulted in under/over-triage and whether the triage criteria were being adhered to. For a 12-month time period there were 45,332 adult (≥16 years of age) trauma patients transported by ambulance to hospitals in metropolitan Melbourne. This retrospective study analysed data from 1166 patients identified at hospital discharge as 'confirmed major trauma patients' and 16,479 patients captured by the current pre-hospital trauma triage criteria, who did not go on to meet the definition of confirmed major trauma. These patients comprise the 'potential major trauma' group. Non-major trauma patients (N=27,687) were excluded from the study. Pre-hospital data was sourced from the Victorian Ambulance Clinical Information System (VACIS) and hospital data was sourced from the Victorian State Trauma Registry (VSTR). Statistical analyses compared the characteristics of confirmed major trauma and potential major trauma patients according to the current trauma triage criteria. The leading causes of confirmed major trauma and potential major trauma were motor vehicle collisions (30.1% vs. 19.2%) and falls (30.0% vs. 48.7%). More than 80% of confirmed major trauma and 24.4% of potential major trauma patients were directly transported to a major trauma service. Overall, similar numbers of confirmed major trauma patients and potential major trauma patients had one or more aberrant vital signs (67.0% vs. 66.4%). Specific injuries meeting triage criteria were sustained by 69.2% of confirmed major trauma patients and 51.4% of potential major trauma patients, while 11.7% of confirmed major trauma patients and 4.6% of potential major trauma patients met the combined mechanism of injury criteria. While the sensitivity of the current pre-hospital trauma triage criteria is high, if paramedics strictly followed the criteria there would be significant over-triage. Triage models using different mechanistic and physiologic criteria should be evaluated.
Publisher: Elsevier BV
Date: 2011
DOI: 10.1016/J.INJURY.2011.10.011
Abstract: A high ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBC) is currently recognised as the standard of care in some centres during massive transfusion post trauma. The aim of this study was to test whether the presumption of benefit held true for severely injured patients who received a massive transfusion, but did not present with acute traumatic coagulopathy. Data collected in The Alfred Trauma Registry over a 6 year period were reviewed. Included patients were sub-grouped by a high FFP:PRBC ratio (≥1:2) in the first 4 h and compared to patients receiving a lower ratio. Outcomes studied were associations with mortality, hours in the intensive care unit and hours of mechanical ventilation. Of 4164 eligible patients, 374 received a massive transfusion and 179 (49.7%) patients who did not have coagulopathy were included for analysis. There were 66 patients who received a high ratio of FFP:PRBC, and were similar in demographics and presentation to 113 patients who received a lower ratio. There was no significant difference in mortality between the two groups (p=0.80), and the FFP:PRBC ratio was not significantly associated with mortality, ICU length of stay or mechanically ventilated hours. A small proportion of major trauma patients received a massive blood transfusion in the absence of acute traumatic coagulopathy. Aggressive FFP transfusion in this group of patients was not associated with significantly improved outcomes. FFP transfusion carries inherent risks with substantial costs and the population most likely to benefit from a high FFP:PRBC ratio needs to be clearly defined.
Publisher: Elsevier BV
Date: 02-2009
DOI: 10.1016/J.PMR.2008.10.004
Abstract: Many sports have neurologic injury from incidental head contact however, combat sports allow head contact, and a potential exists for acute and chronic neurologic injuries. Although each combat sport differs in which regions of the body can be used for contact, they are similar in competitor exposure time. Their acute injury rates are similar thus their injuries can appropriately be considered together. Injuries of all types occur in combat sports, with injuries in between one fifth to one half of all fights in boxing, karate, and tae kwon do. Most boxing injuries are to the head and neck region. In other combat sports, the head and neck region are the second (after the lower limbs) or the first most common injury site.
Publisher: Cambridge University Press (CUP)
Date: 07-2000
DOI: 10.1017/S1355617700655066
Abstract: This study aimed to investigate outcome in adults with mild traumatic brain injury (TBI) at 1 week and 3 months postinjury and to identify factors associated with persisting problems. A total of 84 adults with mild TBI were compared with 53 adults with other minor injuries as controls in terms of postconcussional symptomatology, behavior, and cognitive performance at 1 week and 3 months postinjury. At 1 week postinjury, adults with mild TBI were reporting symptoms, particularly headaches, dizziness, fatigue, visual disturbance, and memory difficulties. They exhibited slowing of information processing on neuropsychological measures, namely the WAIS–R Digit Symbol subtest and the Speed of Comprehension Test. By 3 months postinjury, the symptoms reported at 1 week had largely resolved, and no impairments were evident on neuropsychological measures. However, there was a subgroup of 24% of participants who were still suffering many symptoms, who were highly distressed, and whose lives were still significantly disrupted. These in iduals did not have longer posttraumatic amnesia (PTA) duration. They were more likely to have a history of previous head injury, neurological or psychiatric problems, to be students, females, and to have been injured in a motor vehicle accident. The majority were showing significant levels of psychopathology. A range of factors, other than those directly reflecting the severity of injury, appear to be associated with outcome following mild TBI. ( JINS , 2000, 6 , 568–579.)
Publisher: Elsevier BV
Date: 05-2010
DOI: 10.1016/J.INJURY.2009.07.065
Abstract: The aim of effective clinical handover is seamless transfer of information between care providers. Handover between paramedics and the trauma team provides challenges in ensuring that information loss does not occur. Handover is often time-pressured and paramedics' clinical notes are often delayed in reaching the trauma team. Documentation by trauma team members must be accurate. This study evaluated information loss and discordance as patients were transferred from the scene of an incident to the Trauma Centre. Twenty-five trauma patients presenting by ambulance to a tertiary Emergency and Trauma Centre were randomly selected. Audiotaped (pre-hospital) and videotaped (in-hospital) handover was compared with written documentation. In the pre-hospital setting 171/228 (75%) of data items handed over by paramedics to the trauma team were documented and in the in-hospital handover 335/498 (67%) of information was documented. Information least likely to be documented by trauma team members (1) in the pre-hospital setting related to treatment provided and (2) in the in-hospital setting related to signs and symptoms. While 79% of information was subsequently documented by paramedics, 9% (n=59) of information was not documented either by trauma team members or paramedics and constitutes information loss. Information handed over was not congruent with documentation on seven occasions. Discrepancies included a patient's allergy status and sites of injury (n=2). Demographic details were most likely to be documented but not handed over by paramedics. By documenting where deficits in handover occur we can identify points of vulnerability and strategies to capture this information.
Publisher: Wiley
Date: 03-2010
DOI: 10.1111/J.1445-2197.2010.05209.X
Abstract: There has been a shift from operative to conservative management of splenic injuries in the last two decades, but the current practice in Australia is not known. This study aims to determine the profile of splenic injury in major trauma victims and the approach to treatment in Victoria for the last 2 years. A review of prospectively collected data from the Victorian State Trauma Registry (VSTR) from July 2005 to June 2007 was conducted. Demographic data, details of the event, clinical observations, management and associated outcomes were extracted from the database. The patients were categorized into four groups according to management (conservative, splenectomy, embolization and repair) and were compared accordingly. Multivariate binary logistic regression was performed to identify predictors of treatment (conservative versus splenectomy) on arrival. Of the 318 major trauma patients with splenic injuries, 186 (59%) were treated conservatively, 103 (32%) with splenectomy, 17 (5%) with arterial embolization and 12 (4%) with repair. Of these, 14 (14%) splenectomy cases and 2 (12%) embolization cases did not receive their respective treatments within 24 h. The severity of the spleen injury (as measured by the Abbreviated Injury Scale (AIS)) and age were identified as significant independent predictors of the form of treatment provided. In Victoria, conservative management is the preferred approach in patients with minor (AIS = 2) to moderate (AIS = 3) splenic injuries. The low rates of embolization warrant further research into whether splenectomy is overused.
Publisher: Wiley
Date: 19-10-2020
Publisher: Elsevier BV
Date: 2020
DOI: 10.1016/J.INJURY.2019.09.036
Abstract: Trauma registries are known to drive improvements and optimise trauma systems worldwide. This is the first reported comparison of the epidemiology and outcomes at major centres across Australia. The Australian Trauma Registry was a collaboration of 26 major trauma centres across Australia at the time of this study and currently collects information on patients admitted to these centres who die after injury and/or sustain major trauma (Injury Severity Score (ISS) > 12). Data from 1 July 2016 to 30 June 2017 were analysed. Primary endpoints were risk adjusted length of stay and mortality (adjusted for age, cause of injury, arrival Glasgow coma scale (GCS), shock-index grouped in quartiles and ISS). There were 8423 patients from 24 centres included. The median age (IQR) was 48 (28-68) years. Median (IQR) ISS was 17 (14-25). There was a predominance of males (72%) apart from the extremes of age. Transport-related cases accounted for 45% of major trauma, followed by falls (35.1%). Patients took 1.42 (1.03-2.12) h to reach hospital and spent 7.10 (3.64-15.00) days in hospital. Risk adjusted length of stay and mortality did not differ significantly across sites. Primary endpoints across sites were also similar in paediatric and older adult (>65) age groups. Australia has the capability to identify national injury trends to target prevention and reduce the burden of injury. Quality of care following injury can now be benchmarked across Australia and with the planned enhancements to data collection and reporting, this will enable improved management of trauma victims.
Publisher: Elsevier BV
Date: 11-2012
DOI: 10.1016/J.INJURY.2012.07.185
Abstract: Trauma registry data are almost always incomplete. Multiple imputation can reduce bias in registry analyses but the ideal approach would be to improve data capture. The aim of this study was to identify, using multiple imputation, which type of patients were most likely to have incomplete data. An analysis of prospectively collected regional trauma registry data over one year was performed. Analyses were conducted following complete data estimation using multiple imputation. Variables necessary for TRISS analysis and with incomplete data were analysed. For each variable, logistic regression analyses were performed to identify predictors of missingness. A p-value of less than 0.05 was considered to be statistically significant. There were 2520 cases. The variables with the greatest proportion of missing observations were respiratory rate, GCS, Qualifier (of GCS and respiratory rate) and systolic blood pressure. The Qualifier variable described whether or not the patient was intubated and mechanically ventilated at the time the first hospital GCS and respiratory rate were recorded. GCS and respiratory rate were more likely to be missing (imputed) when abnormal (unadjusted ORs: 8.6 (p<0.001) and 2.1 (p=0.02), respectively). The most important determinant of a valid GCS or respiratory rate was the Qualifier. There was no association between whether the systolic blood pressure and Qualifier were missing (imputed) and whether they were estimated to be abnormal. Following multivariable analysis, data for all four variables were more likely to be missing when the patient died in hospital. Additional independent predictors of a missing GCS or respiratory rate were an abnormal pre-hospital GCS and severe chest injury. The Qualifier and systolic blood pressure were more likely to be missing where the patient was transferred from the primary hospital. The major independent predictor of missing primary hospital physiological variables was death in hospital. An abnormal GCS was more likely to be missing from the regional trauma registry dataset. Predictors of a missing GCS or respiratory rate included whether the patient was intubated, an abnormal pre-hospital GCS and severe chest injury. Augmenting resources to record the initial observations of the more severely injured patients would improve data quality. Multiple imputation can be used to inform data capture.
Publisher: Wiley
Date: 04-10-2017
Abstract: To determine the proportion of non-motorised road users involved in road traffic crashes that presents to hospital intoxicated. We undertook a retrospective cohort study using data collected from the Alfred Trauma Registry. All patients presenting to an adult major trauma centre in Victoria, Australia from July 2009 to June 2014 who were involved in a road traffic crash as a non-motorised road user - pedestrians, pedal-cyclists, non-motorised scooter users, horse riders - were included. Patients who had a blood alcohol measurement were included, and intoxication was defined as a blood alcohol concentration ≥0.05 g/100 mL. There were 1323 patients included for analysis with data on presenting blood alcohol concentration. Alcohol was detected in 248 (18.7% 95% CI: 16.7-20.9) patients, whereas 211 (15.9% 95% CI: 14.1-18.0) were intoxicated. Among all included pedestrians, 161 (24.7%) were intoxicated among all included pedal-cyclists, 47 (7.3%) were intoxicated. Intoxicated patients were significantly younger, and a higher proportion were males and more likely to present after hours and on public holidays (P < 0.01). Survival to hospital discharge and inpatient rehabilitation requirements were similar among intoxicated and non-intoxicated patients. Intoxication was common among non-motorised road users, and the proportion of intoxicated patients in this subgroup appears unchanged over time despite public awareness programmes. The true burden of intoxication in non-motorised road users remains unknown because of a lack of routine testing. Legislation directed at testing for intoxication of non-motorised users and introduction of penalties should be considered to improve safety of all road users.
Publisher: American Medical Association (AMA)
Date: 04-2011
Abstract: It has been suggested that women with traumatic brain injury have more favorable outcomes than do men because of higher levels of circulating estrogen and progesterone that may reduce brain edema. To determine whether there is any association between sex and mortality in TBI patients and whether there is any association between sex and brain edema. Retrospective cohort study using data from 2001 to 2007 collected from a trauma registry in Hong Kong and the Victorian State Trauma Registry. Two regional trauma centers in Hong Kong and 2 adult major trauma centers and 1 pediatric trauma center in Victoria, Australia. Mortality and brain edema. Trauma patients with an Abbreviated Injury Scale score (head) of at least 3 who were aged 12 to 45 years were included. Patients with minor head injury and undisplaced closed skull fracture were excluded. Both the Hong Kong and Victorian data showed no significant difference in sex-related mortality. Increased mortality was associated with decreased systolic blood pressure and Glasgow Coma Scale score and with increased New Injury Severity Score or Injury Severity Score. In Hong Kong, brain edema was associated with female sex (P = .02), and the odds of brain edema in females were greater than for males. However, this association was not found in Victorian patients. This study found no significant association between sex and mortality in either Victoria or Hong Kong and does not support the concept that females have better outcomes after traumatic brain injury.
Publisher: Hamad bin Khalifa University Press (HBKU Press)
Date: 03-2014
Abstract: Benign paroxysmal positional vertigo (BPPV) is a common medical condition that can be managed by emergency physicians. Vertigo sufferers usually complain of the room spinning associated with certain head movements such as getting out of bed, looking up and bending down. BPPV can be diagnosed clinically from history and examination and does not require any investigations. BPPV can be effectively treated at the bedside by using one of the Canalith repositioning maneuvers (particle repositioning maneuvers). This treatment has been proven to be effective in randomised controlled trials and carries minimal risks. The common complications during the procedure include nausea, vomiting and vertigo. There are no absolute contraindications. BPPV can resolve spontaneously but symptoms may last for weeks in most patients, to years in others. Failure to respond to physical maneuvers and an unusual pattern of nystagmus may suggest a central pathology. Diagnostic strategies and physical manoeuvres are described in this narrative review. Future directions and recommendations also discussed.
Publisher: Elsevier BV
Date: 11-2012
DOI: 10.1016/J.INJURY.2012.07.181
Abstract: The costs associated with patients discharged with isolated clinician-elicited persistent midline tenderness and negative computed tomography (CT) findings have not been reported. Our aim was to determine the association of acute and post-acute patient and injury characteristics with health resource costs in such patients following road trauma. In a prospective cohort study, road trauma patients presenting with isolated persistent midline cervical tenderness and negative CT, who underwent additional acute imaging with MRI, were recruited. Patients were reviewed in the outpatient spine clinic following discharge, and were followed up at 6 and 12 months post-trauma. Multivariate linear regression was used to assess the association of injury mechanism, clinical assessment, socioeconomic factors and outcome findings with health resource costs generated in the acute hospital and post-acute periods. There were 64 patients recruited, of whom 24 (38%) had cervical spine injury detected on MRI. Of these, 2 patients were managed operatively, 6 were treated in cervical collars and 16 had the cervical spine cleared and were discharged. At 12 months, there were 25 patients (44%) with residual neck pain, and 22 (39%) with neck-related disability. The mean total cost was AUD $10,153 (SD=10,791) and the median was $4015 (IQR: 3044-6709). Transient neurologic deficit, which fully resolved early in the emergency department, was independently associated with higher marginal mean acute costs (represented in the analysis by the β coefficient) by $3521 (95% CI: 50-6880). Low education standard (β coefficient: $5988, 95% CI: 822-13,317), neck pain at 6 months (β coefficient: $4017, 95% CI: 426-9254) and history of transient neurologic deficit (β coefficient: $8471, 95% CI: 1766-18,334) were associated with increased post-acute costs. In a homogeneous group of road trauma patients with non fracture-related persistent midline cervical tenderness, health resource costs varied considerably. As long term morbidity is common in this population, a history of resolved neurologic deficit may require greater intervention to mitigate costs. Additionally, adequate communication between acute and community care providers is essential in order to expedite the recovery process through early return to normal daily activities.
Publisher: SAGE Publications
Date: 07-2012
DOI: 10.1177/102490791201900405
Abstract: Demand for emergency department (ED) services is increasing worldwide. The fastest growth in ED presentations is by patients aged ≥65 years, currently representing 18% of all attendances. Older patients present with more complex clinical conditions and multiple co-morbidities. This means they are likely to spend more time in ED, are more likely to be admitted to hospital, and are more likely to re-attend. The Safe Elderly Emergency Discharge (SEED) project aims to determine whether current models of emergency care ensure safe discharge and facilitate optimal health outcomes for older patients and develop a tailored evidence-based care framework applicable to Australian and international settings. Risk screening for unsafe discharge will be conducted on patients aged ≥65 years discharged home from ED. Patients will be followed for 6 months post-ED presentation to monitor health outcomes and map their care journey. Demographic, clinical, and functional characteristics will be collected. The primary outcome is unsafe discharge, defined as unplanned re-presentation/admission within 30 days of the index presentation. Secondary outcomes include unplanned ED re-presentation/hospital admission within 6 months patient experience change in functional status functional decline health service utilisation and death within 6 months. The effectiveness of the ED discharge risk screening tools for predicting unsafe discharge will be evaluated at 30 days and 6 months. SEED will determine the risk factors for unplanned ED re-presentation/hospital admission at 30 days for patients aged ≥65 years presenting to ED which will inform the development of an evidence-based older patient care framework for EDs.
Publisher: Springer Science and Business Media LLC
Date: 05-2002
Abstract: Previous studies have demonstrated the high sensitivity and specificity of technetium 99m sestamibi scintigraphy during acute chest pain myocardial perfusion imaging. However, no study has shown that this technique would alter clinical management in practice. One hundred twenty consecutive patients were injected with Tc-99m sestamibi (22 mCi) during pain single photon emission computed tomography was performed 1 to 6 hours later. The population included inpatients and those who arrived at the emergency department with chest pain deemed to be at intermediate risk for myocardial ischemia. The requesting physician completed a questionnaire before the study, indicating the likelihood of cardiac disease and proposed management had the test not been available. Follow-up management was evaluated from medical records. There was a 34% reduction in total admissions and 59% in planned admissions to the coronary care unit (P <.001). Conversely, 7 patients had discharge cancelled and 17 required coronary care purely because of abnormal acute rest myocardial perfusion imaging results. Coronary angiography was reduced by 40% in a selected subgroup. In our population, acute rest myocardial perfusion imaging reduced total admissions and altered resource utilization. This may result in more appropriate triage of in idual patients in the management algorithm, as well as potential cost savings.
Publisher: Wiley
Date: 03-10-2008
DOI: 10.1111/J.1445-5994.2007.01472.X
Abstract: There has been increasing off-label use of recombinant activated factor VII (rFVIIa/NovoSeven Novo Nordisk, Bagsvaerd, Denmark) for patients with critical bleeding. Given the lack of high-level evidence, the clinical indications, observed response and adverse events are important to capture. The Haemostasis Registry collects retrospective and contemporaneous data on all use of rFVIIa at participating institutions for non-haemophiliac patients with critical bleeding (i.e. off-label use). As of October 2006, 694 cases had been reported into the register from 37 hospitals across Australia and New Zealand. These comprise an array of therapeutic categories, including salvage use in: perioperative cardiothoracic surgery (44%), trauma (16%), medical bleeding (9%), obstetric bleeding (4%) and other types of critical bleeding (28%). Patients received a median (interquartile range) dose of 91 mug/kg (75-103) and 83% of patients received a single dose of rFVIIa. The documented response rate to a single dose of rFVIIa was 69%. The 28-day survival was 68%, but varied with clinical category. The rate of adverse events probably or possibly linked to the use of rFVIIa was 6%, with most of the thromboembolic adverse events occurring in the cardiac surgery group. The Haemostasis Registry cannot replace well-designed prospective randomized controlled trials, but in their absence this registry provides a basis for understanding current clinical experience of rFVIIa. Registries continue to be vital in monitoring off-label uses of medications.
Publisher: Wiley
Date: 10-2003
DOI: 10.1046/J.1442-2026.2003.00495.X
Abstract: Objective: To report on the impact of a Severe Acute Respiratory Syndrome (SARS) outbreak on the attendances of a major teaching hospital ED. Methods: Two periods were studied. The first was prior to the closure of the ED due to SARS and the second was after re‐opening of the ED. Data on attendances, discharge against medical advice, triage categories, trauma and ambulance cases were retrieved from the computer and compared with the data in the same periods in 2002. Results: In the first period, when compared with 2002 there was a significant decrease in the mean daily attendance (397 vs 524), trauma cases (68 vs 111), minor cases (category 4: 283 vs 361, and category 5: 20 vs 43). In the second period, there was a significant decrease in the mean daily attendance (265 vs 545), trauma cases (40 vs 111), minor cases (category 4: 181 vs 376, and category 5: 12 vs 45), discharge against medical advice (4 vs 6 daily) and ambulance cases (70 vs 86 daily). Patients requiring immediate care however, remained similar. Conclusion: There was a significant drop in the overall ED attendance, trauma cases and minor cases after the outbreak of SARS. Possible causes include changes in community behaviour, resulting in a lower incidence of trauma and disease and fear of presenting to hospital and contracting SARS.
Publisher: BMJ
Date: 11-08-2017
DOI: 10.1136/EMERMED-2016-206330
Abstract: Given low survival rates in cases of traumatic out-of-hospital cardiac arrest (OHCA), there is a need to identify factors associated with outcomes. We aimed to investigate Utstein factors associated with achieving return of spontaneous circulation (ROSC) and survival to hospital in traumatic OHCA. The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify cases of traumatic OHCA that received attempted resuscitation and occurred between July 2008 and June 2014. We excluded cases aged <16 years or with a mechanism of hanging or drowning. Of the 660 traumatic OHCA patients who received attempted resuscitation, ROSC was achieved in 159 patients (24%) and 95 patients (14%) survived to hospital (ROSC on hospital handover). Factors that were positively associated with achieving ROSC in multivariable logistic regression models were age ≥65 years (adjusted OR (AOR)=1.56, 95% CI: 1.01 to 2.43) and arresting rhythm (shockable (AOR=3.65, 95% CI: 1.64 to 8.11) and pulseless electrical activity (AOR=2.15, 95% CI: 1.36 to 3.39) relative to asystole). Similarly, factors positively associated with survival to hospital were arresting rhythm (shockable (AOR=3.92, 95% CI: 1.64 to 9.41) relative to asystole), and the mechanism of injury (falls (AOR=2.16, 95% CI: 1.03 to 4.54) relative to motor vehicle collisions), while trauma type (penetrating (AOR=0.27, 95% CI: 0.08 to 0.91) relative to blunt trauma) and event region (rural (AOR=0.39, 95% CI: 0.19 to 0.80) relative to urban) were negatively associated with survival to hospital. Few patient and arrest characteristics were associated with outcomes in traumatic OHCA. These findings suggest there is a need to incorporate additional information into cardiac arrest registries to assist prognostication and the development of novel interventions in these trauma patients.
Publisher: Wiley
Date: 16-02-2007
DOI: 10.1111/J.1440-1754.2007.01035.X
Abstract: There is a paucity of population-based studies regarding the spectrum of paediatric head injury from mild through serious to fatal paediatric head injury. The aims of the present study were to determine the incidence, demographics and outcome of significant head injury in a state-wide population of children aged 0-15 years. A secondary aim was to determine if any serious head injuries were being missed under the current management protocols of the state-wide trauma system. A retrospective review of significant head injury in all paediatric patients over a period of 2 years was undertaken. Data were collected from the Victorian State Trauma Outcome Registry and Monitoring database, the Victorian Emergency Minimum Dataset and from the Victorian Institute of Forensic Medicine. The incidence of paediatric head injury in Victoria over the 2-year period was 765 per 100000 per year. The incidence of admitted head injuries was 75 per 100000 per year and the incidence of significant head injury was seven per 100000 or 151 children. Forty-one per cent of these injuries required surgical intervention. Mortality was 1.6 children per 100000. All patients who died presented with a Glasgow Coma Score (GCS) of 3 and had multiple other risk factors. There were no deaths in patients discharged from hospital. Demographic and clinical factors associated with higher mortality and morbidity was determined. The incidence of significant paediatric head injury was low. Deaths occurred early and were always associated with significant early clinical features of severe head injury. This highlights the importance of strategies for the prevention of head injuries. There appeared to be no serious head injuries missed during the study period.
Publisher: Wiley
Date: 06-2000
DOI: 10.1046/J.1440-1762.2000.00370.X
Abstract: Abstract This study describes an Australian emergency department’s (ED) experience with a quality improvement methodology from the USA. The Institute for Health Care Improvement (IHI) conducts collaboratives between clinical groups with similar interests, in this case ED. Their quality improvement model is described. Our involvement with the IHI showed the model to be transferable outside the USA. In applying the model to operational and clinical projects we were successful in meeting our goals to reduce clinical times: for time to analgesia ( P = 0.34), time to thrombolysis ( P = 0.30) and time to antibiotics in neutropenic patients ( P = 0.015). We were unable to reach statistical significance in improvements due to the small s le sizes and s ling techniques. Changes in operational times were not clinically significant but almost reached statistical significance (e.g. median total length of stay in the ED fell 4 min ( P = 0.06)). The near statistical significance of a small change was due to the large numbers of patients s led.
Publisher: Mark Allen Group
Date: 02-12-2016
Publisher: Elsevier BV
Date: 03-2017
DOI: 10.1016/J.INJURY.2017.01.006
Abstract: The measurement of functional outcomes following severe trauma has been widely recognised as a priority for countries with developed trauma systems. In this respect, the Functional Capacity Index (FCI), a multi-attribute index which has been incorporated into the most recent Abbreviated Injury Scale (AIS) dictionary, is potentially attractive as it offers 12-month functional outcome predictions for patients captured by existing AIS-coded datasets. This review paper outlines the development, construction and validation of the predictive form of the FCI (termed the pFCI), the modifications made which produced the currently available 'revised' pFCI, and the extent to which the revised pFCI has been validated and used. The original pFCI performed poorly in validation studies. The revised pFCI does not address many of the identified limitations of the original version, and despite the ready availability of a truncated version in the AIS dictionary, it has only been used in a handful of studies since its introduction several years ago. Additionally, there is little evidence for its validity. It is suggested that the pFCI should be better validated, whether in the narrow population group of young, healthy in iduals for which it was developed, or in the wider population of severely injured patients. Methods for accounting for the presence of multiple injures (of which two have currently been used) should also be evaluated. Many factors other than anatomical injury are known to affect functional outcomes following trauma. However, it is intuitive that any model which attempts to predict the ongoing morbidity burden in a trauma population should consider the effects of the injuries sustained. Although the revised pFCI potentially offers a low-cost assessment of likely functional limitations resulting from anatomical injury, it must be more rigorously evaluated before more comprehensive predictive tools can be developed from it.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2010
Publisher: Elsevier BV
Date: 07-2012
DOI: 10.1016/J.INJURY.2012.03.003
Abstract: The burden of injury is very high in developing countries. Trauma systems reduce mortality the trauma registry is a key driver of improvements in trauma care. Developing countries have begun to develop trauma systems but the level of local trauma registry activity is unclear. The aim of this study was to determine a global estimate of trauma registry activity. A structured review of the literature was performed. All abstracts referring to a trauma registry over a two-year period were included. For the trauma registry described in each abstract, the source country was recorded. An additional search of web pages posted over a one year period was conducted. Those linked to an active trauma registry website were included and the country of the trauma registry was recorded. A selection of trauma registries from countries of different levels of development were identified and compared. 571 abstracts were included in the review. Most articles utilised "general" trauma registries (436(76%)) and were based at a single hospital (279(49%)). Other registries were limited to military or paediatric populations (36(6%) and 35(6%) articles respectively). Most articles sourced registries from the US (288(50%)), followed by Australia (45(8%)), Germany (32(6%)), Canada (27(5%)), UK (13(2%)), China (13(2%)) and Israel (12(2%)). The Americas produced most trauma registry articles and South East Asia the least. The majority of trauma registry articles originated from very highly developed countries 467(82%). Least developed countries had the fewest (5(1%)). The additional search yielded 37 web pages linked to 27 different trauma registry websites. Most of these were based in the US (16(59%)). The basic features of trauma registries, such as inclusion criteria, number and type of variables and injury severity scoring, varied widely depending on the country's level of development. This review, using a combination of the number of trauma registry articles and web pages to locate active trauma registries, demonstrated the disparity in trauma registry activity between the most and least developed countries. The absence of trauma care information systems remains a challenge to trauma system development globally.
Publisher: Elsevier BV
Date: 05-2018
DOI: 10.1016/J.INJURY.2018.03.013
Abstract: Levels of stress post-injury, especially after compensable injury, are known to be associated with worse long-term recovery. It is therefore important to identify how, and in whom, worry and stress manifest post-injury. This study aimed to identify demographic, injury, and compensation factors associated with worry about financial and recovery outcomes 12 months after traumatic injury. Participants (n = 433) were recruited from the Victorian Orthopaedic Trauma Outcomes Registry and Victorian State Trauma Registry after admission to a major trauma hospital in Melbourne, Australia. Participants completed questionnaires about pain, compensation experience and psychological wellbeing as part of a registry-based observational study. Linear regressions showed that demographic and injury factors accounted for 11% and 13% of variance in financial and recovery worry, respectively. Specifically, lower education, discharge to inpatient rehabilitation, attributing fault to another and having a compensation claim predicted financial worry. Worry about recovery was only predicted by longer hospital stay and attributing fault to another. In all participants, financial and recovery worry were associated with worse pain (severity, interference, catastrophizing, kinesiophobia, self-efficacy), physical (disability, functioning) and psychological (anxiety, depression, PTSD, perceived injustice) outcomes 12 months post-injury. In participants who had transport (n = 135) or work (n = 22) injury compensation claims, both financial and recovery worry were associated with sustaining permanent impairments, and reporting negative compensation system experience 12 months post-injury. Financial worry 12 months post-injury was associated with not returning to work by 3-6 months post-injury, whereas recovery worry was associated with attributing fault to another, and higher healthcare use at 6-12 months post-injury. These findings highlight the important contribution of factors other than injury severity, to worry about finances and recovery post-injury. Having a compensation claim, failure to return to work and experiencing pain and psychological symptoms also contribute to elevated worry. As these factors explained less than half of the variance in worry, however, other factors not measured in this study must play a role. As worry may increase the risk of developing secondary mental health conditions, timely access to financial, rehabilitation and psychological supports should be provided to people who are not coping after injury.
Publisher: Wiley
Date: 27-09-2023
Publisher: Elsevier BV
Date: 03-2008
DOI: 10.1016/J.ATHORACSUR.2007.06.076
Abstract: Data from the Australian and New Zealand Haemostasis Registry (ANZHR) were used to report on the efficacy, mortality, and outcomes of a cohort of cardiac surgical cases receiving recombinant activated factor VII (rFVIIa). The ANZHR collects retrospective and contemporaneous data on the use of rFVIIa in patients with critical bleeding from hospitals throughout Australia and New Zealand. Participating centers commit to the collection of data on all patients without hemophilia treated with rFVIIa, which limits bias and prevents the reporting of only positive or anecdotal experiences. At September 2006, the cardiac surgical cohort comprised 304 patients (43%) of a total of 695 cases reported to the ANZHR from 46 hospitals. The 304 cases date from January 2001. The median patient age was 66 years (interquartile range [IQR], 53 to 75 years), and 73% were men. After administration of rFVIIa, all blood product usage was significantly reduced. Patients received a median dose of 93 mug/kg (IQR, 82 to 102), and 85% of patients received a single dose. The documented response rate to a single dose of rFVIIa was 84%, of which 23% reported cessation of bleeding and 61% reported a reduction in bleeding. Patients received a median volume of 6 U of red blood cells before rFVIIa treatment. The median reduction in red blood cells after the rFVIIa dose compared with before was 4 U. Response was reduced in patients with a lower baseline hemoglobin, coagulopathy (determined by international normalized ratio, fibrinogen, and platelets), the number of red blood cell units transfused before rFVIIa, advanced age, more complex operations, hypothermia, and acidosis. Responders had a significantly reduced mortality (p < 0.001). The percentage of patients alive at 28 days was 95% if bleeding ceased after rFVIIa, 86% if bleeding reduced, and 60% for nonresponders. A 7% adverse event rate attributed as "probably" or "possibly" associated with rFVIIa was reported with a 4% reported thromboembolic event rate. Recombinant FVIIa is a potential rescue therapy in severe uncontrollable critical bleeding after cardiac operations. The observed response rate was high, and response was associated with improved mortality. There was an observed reduction in blood product usage after rFVIIa. The adverse event rate reported was similar to documented adverse event rates in complex cardiac surgical patients. In the absence of randomized controlled trials, this registry provides a basis for understanding current clinical practice with rFVIIa in cardiac surgical procedures.
Publisher: Elsevier BV
Date: 10-2007
DOI: 10.1016/J.JSAMS.2007.02.001
Abstract: The promotion of safe sports participation has become a public health issue due to rising obesity rates and the potential for parental concerns about safety to inhibit sports participation. The safety of Australian football and its elite game, the Australian Football League (AFL), is often the focus of media commentary. Participation in the modified version of the game (Auskick) has been shown to be safer but by the time children reach the under-15 age group, adult rules are in place and the umbrella of safety provided by modified rules is gone. Figures released recently by the AFL suggest that injury rates at the elite-level are at an historical low, but equivalent information for the more than 400,000 non-elite participants is not available. Published literature related to preventing injuries in Australian football highlights a significant knowledge gap with respect to the aetiology of injuries in non-elite participants and only a very small evidence base for prevention of injuries in this sport. Gains in reducing the public health impact of football injuries, and injury-related barriers to Australian football participation, will only come from substantial investment in large-scale trials at the non-elite level, and a co-ordinated and multidisciplinary approach to dealing with safety and injury issues across all levels of play. Active and committed collaboration of key stakeholders such as government health agencies, peak sports bodies, sports administrators, clinicians, researchers, clubs, coaches and the participants themselves will be necessary.
Publisher: Frontiers Media SA
Date: 04-05-2017
Publisher: Wiley
Date: 17-09-2023
Publisher: BMJ
Date: 06-01-2016
DOI: 10.1136/HEARTJNL-2015-308636
Abstract: Supplemental oxygen therapy may increase myocardial injury following ST-elevation myocardial infarction (STEMI). In this study, we aimed to evaluate the effect of the dose and duration of oxygen exposure on myocardial injury after STEMI. Descriptive analysis of data from a multicentre, prospective, randomised, controlled trial of 441 patients with STEMI randomised to supplemental oxygen therapy or room air breathing. The primary endpoint was myocardial infarct size as assessed by cardiac biomarkers, troponin (cTnI) and creatine kinase (CK). Oxygen therapy was commenced by paramedics, and continued for up to 12 h postintervention in hospital. Supplemental oxygen exposure was calculated as the area under the dose×time curve for oxygen administration over the first 12 h, and then assessed for its association with cTnI/CK release using multivariable linear regression. The median supplemental oxygen exposure was 1746 L (IQR: 960-2858). After adjustment for potential confounders, every 100 L increase in oxygen exposure in the first 12 h was associated with a 1.4% (95% CI 0.6% to 2.2%, p<0.001) and 1.2% (95% CI 0.7% to 1.8%, p<0.001) increase in the mean peak cTnI and CK, respectively. Excluding patients who developed cardiogenic shock, recurrent myocardial infarction or desaturations (SpO2<94%) during admission, every 100 L increase in oxygen exposure was associated with a 1.2% (95% CI 0.2% to 2.1%, p=0.01) and 1.0% (95% CI 0.3% to 1.7%, p=0.003) increase in the mean peak cTnI and CK, respectively. The median supplemental oxygen exposure of 1746 L would result in a 21% (95% CI 3% to 37%) increase in infarct size according to the cTnI profile. Supplemental oxygen exposure in the first 12 h after STEMI was associated with a clinically significant increase in cTnI and CK release.
Publisher: Elsevier BV
Date: 04-2011
DOI: 10.1016/J.RESUSCITATION.2010.12.016
Abstract: Controversy exists around CPR in the elderly. The characteristics and outcomes of out-of-hospital cardiac arrest (OHCA) in this age group were studied in Melbourne, Australia. The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for all OHCAs not witnessed by Emergency Medical Services (EMS) occurring in those aged 65 years and older. Between 2000 and 2009 there were 30,006 OHCAs of which 9703 (32%) were in people 65-79 years of age, 6430 (21%) in octogenarians, 1530 (5%) in nonagenarian and 40 (0.1%) in centenarians. Rates of attempted resuscitation decreased with advancing age: 48% for those aged 65-79 years, 39% for octogenarians, 31% for nonagenarians and 17% for centenarians. Similarly rates of survival to hospital discharge decreased with age: 8% for those aged 65-79 years, 4% for octogenarians, 2% for nonagenarians for 65-79 year olds, octogenarians and nonagenarians survival if in VF/VT was - 17%, 10% and 4% asystole - 1%, 1% and 0.5% and PEA - 6%, 3% and 3%, respectively. Multivariable logistic regression shows that between 2000 and 2009 rates of transportation with return of spontaneous circulation have improved for both shockable and non-shockable rhythms [OR 95% CI 1.07(1.04-1.10) and 1.16(1.12-1.20), respectively] but survival to hospital discharge has improved in the shockable rhythm group only [OR 1.12(1.07-1.16)]. Outcomes for OHCA with shockable rhythm have improved over the last 10 years for people aged 65 years and over. Quality of life studies should be performed to help inform the community and EMS on appropriate resuscitative efforts.
Publisher: Wiley
Date: 08-2012
Publisher: Elsevier BV
Date: 2014
Publisher: Elsevier BV
Date: 11-2020
Publisher: Wiley
Date: 10-2005
DOI: 10.1111/J.1742-6723.2005.00775.X
Abstract: Objective: Application of the Trauma and Injury Severity Score (TRISS) to a trauma population identifies patients with ‘unexpected survival’. This study used TRISS analysis to identify ‘unexpected survivors’ suffering major thoracic trauma, who survived to hospital discharge. Further analysis determined prehospital interventions that appeared to contribute to ‘unexpected survival’. Methods: The present study was a single‐centre, retrospective case review with comparative statistical analysis. Patients were identified from the Alfred Trauma Registry between 1 July 2002 and 30 June 2003. Results: There were 336 adult trauma patients treated at The Alfred Trauma Centre with an Injury Severity Score (major trauma) and at least one thoracic Anatomical Injury Score of 3 (severe) or greater. Of the eligible patients, 322/336 (95.8%, 95%[confidence interval] CI 95.1–96.5%) had complete data available for analysis. The study population mortality was 42/322 (13.0%, 95% CI 12.3–13.7%). There were 20 ‘unexpected survivors’ (5.9%) and 5 (1.5%) ‘unexpected deaths’ on TRISS analysis. Chest decompression and/or endotracheal intubation prehospital was performed on 16/20 ‘unexpected survivors’. GCS for ‘unexpected survivors’ and ‘expected deaths’ (3.8 vs 3.5, P = 0.27) was not a predictor of survival. Respiratory rate per minute (16.2 vs 8.8, P = 0.01) and systolic blood pressure – mmHg (98 vs 80, P = 0.03) were significantly greater in the ‘unexpected survivors’ group compared with the ‘expected death’ group. Conclusion: For patients sustaining severe thoracic blunt trauma, prehospital intubation and chest decompression appear to be associated with unexpected survival. A low GCS at scene is not predictive of ‘unexpected survival’ or ‘expected death’.
Publisher: Elsevier BV
Date: 08-2020
Publisher: Wiley
Date: 10-2010
DOI: 10.1111/J.1553-2712.2010.00887.X
Abstract: Trauma registry data are usually incomplete. Various methods for dealing with missing data have been used, some of which lead to biased results. One method that reduces bias, multiple imputation (MI), has not been widely adopted. There is no standardization of the approach to missing data across trauma registries. This study examined the effect of using selected methods for handling missing data on a recognized trauma outcome measure. Data from the Victorian State Trauma Registry (VSTR) were used for the period July 2003 to June 2008. Three methods for handling missing data were investigated: complete case analysis, single imputation, and MI. The latter was applied using five distinct models, each with a different combination of variables (Trauma and Injury Severity score [TRISS] variables prehospital Glasgow Coma Scale [GCS], respiratory rate, and systolic blood pressure arrival by ambulance transfer to a second hospital and whether the GCS was "legitimate" according to the TRISS definition). For each method, TRISS analysis (comparing actual and expected deaths) was performed the W-score and Z-statistic were derived. A Z-statistic greater than 1.96 in absolute value was considered statistically significant. Of 10,180 cases, 2,398 (24%) were missing at least one of the component variables necessary for TRISS analysis. With the use of complete case analysis, the W-score was 0.54 unexpected survivors for every 100 cases, with a Z-statistic of -1.96. Using two approaches to single imputation, the W-scores were -1.41, with Z-statistics of -5.19 and -5.30. Applying four of the five combinations of variables used for MI, there was a statistically significant number of unexpected survivors (W = -0.60, Z = -2.23 W = -0.52, Z = -1.97 W = -0.53, Z = -1.97 W = -0.63, Z = -2.24). However, using MI confined to TRISS variables only, there was a statistically significant number of unexpected deaths (W = +0.52, Z = +1.98). Missing data methods can influence the assessment of trauma care performance and need to be reported in all analyses. It is important that validated standardized approaches to dealing with missing data are universally adopted and reported.
Publisher: Wiley
Date: 02-10-2023
Publisher: Springer Science and Business Media LLC
Date: 03-2011
Abstract: To meet a critical and growing need for emergency physicians and emergency medicine resources worldwide, physicians must be trained to deliver time-sensitive interventions and lifesaving emergency care. Currently, there is no globally recognized, standard curriculum that defines the basic minimum standards for specialist trainees in emergency medicine. To address this deficit, the International Federation for Emergency Medicine (IFEM) convened a committee of international physicians, health professionals, and other experts in emergency medicine and international emergency medicine development to outline a curriculum for training of specialists in emergency medicine. This curriculum document represents the consensus of recommendations by this committee. The curriculum is designed to provide a framework for educational programs in emergency medicine. The focus is on the basic minimum emergency medicine educational content that any emergency medicine physician specialist should be prepared to deliver on completion of a training program. It is designed not to be prescriptive but to assist educators and emergency medicine leadership to advance physician education in basic emergency medicine no matter the training venue. The content of this curriculum is relevant not just for communities with mature emergency medicine systems but in particular for developing nations or for nations seeking to expand emergency medicine within the current educational structure. We anticipate that there will be wide variability in how this curriculum is implemented and taught. This variability will reflect the existing educational milieu, the resources available, and the goals of the institutions' educational leadership with regard to the training of emergency medicine specialists.
Publisher: Wiley
Date: 12-1995
DOI: 10.1111/J.1445-2197.1995.TB00574.X
Abstract: Basic demographic and injury data were collected on all major trauma patients (ISS > 15) presenting to 25 Victorian hospitals over a 1 year period (March 1992-February 1993). A total of 1076 patients were identified with an Injury Severity Score (ISS) > 15. Of these, 957 resulted from blunt trauma, 68 from penetrating trauma and 51 from burns. Most serious blunt injury was transport-related (n = 652) but falls made up a significant proportion (n = 206). The pattern of injury in blunt trauma demonstrated in this study showed a preponderance of serious head, thoracic and limb injuries with less frequent occurrences of abdominal, spine and facial injuries. In major penetrating trauma, serious injuries of the thorax and abdomen were more frequent. Head injury is the most common cause of morbidity in major trauma patients. Motor vehicle accidents caused the majority of head injuries but, proportionately, head injury was more common in pedal cycle, pedestrian, motorcycle injuries and falls. The low frequency of major abdominal trauma has important implications for surgical training and resource allocation. In Victoria, various injury prevention interventions have been introduced such as compulsory wearing of bicycle helmets, a safer home environment and behavioral modifications through advertising. Injury prevention strategies must continue to target the populations at risk and assess the impact of interventions by accurate injury surveillance.
Publisher: Elsevier BV
Date: 12-2011
DOI: 10.1016/J.BURNS.2011.08.007
Abstract: Clinical quality indicators are routinely used to benchmark and drive improvements in healthcare. There is a dearth of standardised clinical quality indicators established for management of burns that allow quality of care to be monitored and benchmarked across Australia and New Zealand. Using published quality indicator development processes and clinician experience, the Bi-National Burn Registry (Bi-NBR) working party developed quality indicators for burn care to be included as routine data items in the Bi-NBR. Twenty indicators covering structure, process and outcome measures were identified. Preliminary testing resulted in further revision to the quality indicators to increase validity, reliability and improve data quality. The quality indicators are routinely collected in the Bi-NBR and reported quarterly. This is the first published account of the development and testing of standardised Bi-National clinical quality indicators for burns. The Bi-NBR quality indicators project remains a work in progress and it is hoped that further refinement of the indicators, in conjunction with international collaborators will assist in driving improvements in burn care.
Publisher: Wiley
Date: 04-2012
DOI: 10.1111/J.1445-5994.2011.02502.X
Abstract: A perceived risk of time-limited emergency department (ED) assessment of patients is inadequate workup leading to inappropriate disposition. The aim of this study was to examine the association of time to disposition plan (TDP) on ED length of stay (LOS) and correlate this to mortality. A retrospective review of data collected from ED information systems at three hospitals was conducted between June 2008 and October 2009. Included patients were admitted to a general medical unit. Patients were excluded if admitted to intensive care, coronary care, a cardiac monitored bed or required surgery in first 24 h or had an expected LOS of <48 h. Multivariate regression analysis was used to identify independent associations with mortality. A total of 10,107 patient episodes was analysed, of which 6768 patients (67.0%) had an ED LOS of ≥8 h. There was significant effect modification by ED LOS in the association of TDP and mortality. In the setting of longer ED LOS, a TDP of <4 h was associated with significantly higher mortality (OR 1.57, 95% CI: 1.28-1.92, P < 0.001), corrected for age, gender and triage category. This association was not significant when ED LOS was <8 h (OR 0.88, 95% CI: 0.60-1.27, P = 0.49). In the setting of prolonged ED LOS, completing ED assessment and management within 4 h of presentation was associated with significantly higher mortality. Further prospective studies are required to understand the relationship between rapid decision making in the ED and patient safety.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2006
Publisher: Elsevier BV
Date: 06-2013
DOI: 10.1016/J.EJVS.2013.01.028
Abstract: To evaluate the outcomes following recombinant activated factor VII (rFVIIa) use during abdominal aortic aneurysms (AAA) repair. AAA patients were selected from the Australian and New Zealand Haemostasis Registry (ANZHR) who received off-licence rFVIIa to control critical bleeding. Patient characteristics and outcomes were compared between responders (bleeding stopped/attenuated) and non-responders (bleeding continued) to rFVIIa, stratified by aneurysm status (ruptured (r-AAA) vs. non-ruptured (nr-AAA)). Patients were also scored using POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) and Hardman Index mortality predictive models. In total, 77 AAA patients were included in the analysis. Approximately 73% (n = 56) of them had ruptured aneurysms and about 50% (n = 35/70 with known data) responded positively to rFVIIa. Eleven incidents of thromboembolic adverse events were reported in 9 patients (6 r-AAA and 3 nr-AAA). Responders in both ruptured and non-ruptured groups had significantly lower 28-day mortality than non-responders (r-AAA: 40% (10/25) vs. 92% (24/26) P < 0.001 nr-AAA: 30% (3/10) vs. 67% (6/9) P < 0.01). Mortality predictive models did not show any difference between overall observed and expected mortality in ANZHR patients. Patients who responded to rFVIIa had a lower mortality than those who did not respond to the treatment.
Publisher: BMJ
Date: 10-07-2012
DOI: 10.1136/INJURYPREV-2011-040190
Abstract: Hospitalised sport and active recreation injuries can have serious long-term consequences. Despite this, few studies have examined the long-term outcomes of these injuries. The purpose of this study was to establish whether patients hospitalised with orthopaedic sport and active recreation injuries, have returned to their pre-injury levels of health status and function, 12 months post injury and identify factors associated with poor outcomes. The present work was a cohort study with retrospective assessment of pre-injury status and prospective assessment of outcome at 12 months post injury. Adults with orthopaedic sport and active recreation injuries, captured by the Victorian Orthopaedic Trauma Outcomes Registry were recruited to the study. Pre-injury and 12-month outcomes were assessed using the 36-item Short Form Health Survey (SF-36) and the extended Glasgow Outcome Scale. Differences in pre-injury and post-injury SF-36 scores were examined and demographic, injury, hospital and physical activity variables were assessed for associations with outcome using multivariate linear regression. Of the 324 participants 98% were followed-up at 12 months post injury. At 12 months, participants reported a mean 7.0-point reduction in physical health (95% CI 5.8 to 7.8) and a 2.5-point reduction in mental health (95% CI 1.2 to 3.0), with 58% (95% CI 52.6% to 63.4%) reporting reduced function. Sporting group (p=0.001), Injury Severity Score >15 (p=0.007) and high pre-injury vigorous activity levels (p=0.04), were related to poorer physical health outcomes. At 12 months post injury, most participants reported large reductions in physical health and reduced function. This information is important for furthering our understanding of the burden of sport and active recreation injury and setting priorities for treatment and rehabilitation.
Publisher: BMJ
Date: 23-07-2012
Abstract: Injured patients presenting with hypothermia, acidosis and coagulopathy have been identified at high risk of death. This study aimed to describe the presentation, management and outcome of major trauma patients presenting with the 'triad of death' and identify ways to improve survival. A retrospective, explicit chart review was undertaken on patients presenting to a level I adult major trauma centre with the 'triad of death'. These patients presented directly from the scene, were coagulopathic (international normalised ratio (INR) >1.5), hypothermic (temperature <35°C) and acidotic (pH <7.2) on arrival. There were 90 patients over an 8-year period, with an overall mortality of 47.8%. No significant differences were observed among demographics and injury severity scores between survivors and non-survivors. Extremes of systolic blood pressure and heart rate, a high activated partial thromboplastin time activated partial thromboplastin time, low fibrinogen counts, pH, bicarbonate, base excess and haemoglobin were present among survivors. There were no survivors in our cohort with an initial INR greater than 3.2. Survivors received significantly lower volumes of packed red blood cells. There has been little change in mortality over time in this subgroup of major trauma patients. While the presence of the triad alone does not determine futility, there were no survivors over 8 years with extreme coagulopathy with concurrent hypothermia and acidosis.
Publisher: BMJ
Date: 08-2005
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 13-09-2016
DOI: 10.1161/CIRCULATIONAHA.116.021989
Abstract: Patients successfully resuscitated by paramedics from out-of-hospital cardiac arrest often have severe neurologic injury. Laboratory and observational clinical reports have suggested that induction of therapeutic hypothermia during cardiopulmonary resuscitation (CPR) may improve neurologic outcomes. One technique for induction of mild therapeutic hypothermia during CPR is a rapid infusion of large-volume cold crystalloid fluid. In this multicenter, randomized, controlled trial we assigned adults with out-of-hospital cardiac arrest undergoing CPR to either a rapid intravenous infusion of up to 2 L of cold saline or standard care. The primary outcome measure was survival at hospital discharge secondary end points included return of a spontaneous circulation. The trial was closed early (at 48% recruitment target) due to changes in temperature management at major receiving hospitals. A total of 1198 patients were assigned to either therapeutic hypothermia during CPR (618 patients) or standard prehospital care (580 patients). Patients allocated to therapeutic hypothermia received a mean (SD) of 1193 (647) mL cold saline. For patients with an initial shockable cardiac rhythm, there was a decrease in the rate of return of a spontaneous circulation in patients who received cold saline compared with standard care (41.2% compared with 50.6%, P =0.03). Overall 10.2% of patients allocated to therapeutic hypothermia during CPR were alive at hospital discharge compared with 11.4% who received standard care ( P =0.71). In adults with out-of-hospital cardiac arrest, induction of mild therapeutic hypothermia using a rapid infusion of large-volume, intravenous cold saline during CPR may decrease the rate of return of a spontaneous circulation in patients with an initial shockable rhythm and produced no trend toward improved outcomes at hospital discharge. URL: www.clinicaltrials.gov . Unique identifier: NCT01173393.
Publisher: Elsevier BV
Date: 2001
DOI: 10.1016/S0736-4679(00)00290-0
Abstract: The aim of this study was to determine whether dipstick urinalysis (DU) augmented the accuracy of clinical assessment in the diagnosis of urinary tract infection (UTI). The study was performed in 627 consecutive patients attending an adult emergency department (ED) in whom the clinical diagnosis of UTI was considered. We excluded 227 patients. Treating clinicians gave the probability of a UTI on an ordinal and continuous scale, before and after DU. The assigned clinical probabilities were then compared to the results of formal urine culture. The areas under receiver-operating characteristic curves (AUC) were calculated. We found that clinical assessment alone was effective in detecting those patients with a UTI from those without (AUC 0.75 p < 0.0001). There was, however, a statistically significant difference in the accuracy of diagnosing UTI after DU (AUC 0.87 p < 0.0001). Proportionately more patients with a moderate pre-test probability of UTI were re-assigned to a different probability rating following DU, compared to the low or high pre-test probability groups (p < 0.001). We conclude that DU in combination with clinical assessment is a superior method for diagnosing UTI than clinical assessment alone.
Publisher: Wiley
Date: 11-2014
DOI: 10.5694/MJA13.00235
Abstract: To examine the effect of the "after-hours" (18:00-07:00) model of trauma care on a high-risk subgroup - patients presenting with acute traumatic coagulopathy (ATC). Retrospective analysis of data from the Alfred Trauma Registry for patients with ATC presenting between 1 January 2006 and 31 December 2011. Mortality at hospital discharge, adjusted for potential confounders, describing the association between after-hours presentation and mortality. There were 398 patients with ATC identified during the study period, of whom 197 (49.5%) presented after hours. Mortality among patients presenting after hours was 43.1%, significantly higher than among those presenting in hours (33.1% P = 0.04). Following adjustment for possible confounding variables of age, presenting Glasgow Coma Scale score, urgent surgery or angiography and initial base deficit, after-hours presentation was significantly associated with higher mortality at hospital discharge (adjusted odds ratio, 1.77 95% CI, 1.10-2.87). The after-hours model of care was associated with worse outcomes among some of the most critically ill trauma patients. Standardising patient reception at major trauma centres to ensure a consistent level of care across all hours of the day may improve outcomes among patients who have had a severe injury.
Publisher: Elsevier BV
Date: 11-2016
DOI: 10.1016/J.AAP.2016.08.012
Abstract: The aim of this study was to describe the crash characteristics and patient outcomes of a s le of patients admitted to hospital following bicycle crashes. Injured cyclists were recruited from the two major trauma services for the state of Victoria, Australia. Enrolled cyclists completed a structured interview, and injury details and patient outcomes were extracted from the Victorian State Trauma Registry (VSTR) and the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). 186 cyclists consented to participate in the study. Crashes commonly occurred during daylight hours and in clear weather conditions. Two-thirds of crashes occurred on-road (69%) and were a combination of single cyclist-only events (56%) and multi-vehicle crashes (44%). Of the multi-vehicle crashes, a motor vehicle was the most common impact partner (72%) and distinct pre-crash directional interactions were observed between the cyclist and motor vehicle. Nearly a quarter of on-road crashes occurred when the cyclist was in a marked bicycle lane. Of the 31% of crashes that were not on-road, 28 (15%) occurred on bicycle paths and 29 (16%) occurred in other locations. Crashes on bicycle paths commonly occurred on shared bicycle and pedestrian paths (83%) and did not involve another person or vehicle. Other crash locations included mountain bike trails (39%), BMX parks (21%) and footpaths (18%). While differences in impact partners and crash characteristics were observed between crashes occurring on-road, on bicycle paths and in other locations, injury patterns and severity were similar. Most cyclists had returned to work at 6 months post-injury, however only a third of participants reported a complete functional recovery. Further research is required to develop targeted countermeasures to address the risk factors identified in this study.
Publisher: Wiley
Date: 2005
DOI: 10.1197/J.AEM.2004.08.039
Abstract: The authors aimed to compare propofol and midazolam/fentanyl for reduction of anterior shoulder dislocations using the modified Kocher's maneuver. This was a multicenter, randomized, clinical trial of patients with anterior shoulder dislocation. Patients were randomized to either propofol or midazolam/fentanyl. The randomized drug was titrated to a clinical sedation end point (spontaneous eye closure). One physician sedated the patient. Another, blinded to the drug administered, reduced the shoulder and recorded details of muscle tone and ease of reduction. Eighty-six patients were randomized to treatment with propofol (n = 48) or midazolam/fentanyl (n = 38). Patients in the propofol group had shorter mean times to first wakening (difference in means, 4.6 minutes 95% confidence interval [CI] = 0.7 to 8.6 p = 0.097) and full consciousness (difference in means, 21.7 minutes 95% CI = 14.7 to 28.7 p <0.001), had easier shoulder reduction (difference in mean rating, 0.5 95% CI = 0.0 to 0.9 p = 0.047), and needed fewer reduction attempts (difference in means, 0.5 95% CI = 0.1 to 1.0 p = 0.02). Patients in the propofol group also had less mean muscle tone at the first reduction attempt (p = 0.08) and needed fewer reduction maneuvers (p = 0.40) but had more respiratory depression (11 vs. six patients difference in proportions, 7.1% 95% CI = -11.8 to 26.1 p = 0.58) and had one patient who vomited. Propofol appears to be as effective as midazolam/fentanyl for reduction of anterior shoulder dislocation using the modified Kocher's maneuver. However, the advantage of shorter wakening times associated with propofol should be weighed against the possibility of adverse events, particularly respiratory depression and vomiting.
Publisher: Wiley
Date: 09-09-2013
Abstract: The Australasian Resuscitation In Sepsis Evaluation (ARISE) study is an international, multicentre, randomised, controlled trial designed to evaluate the effectiveness of early goal-directed therapy compared with standard care for patients presenting to the ED with severe sepsis. In keeping with current practice, and taking into considerations aspects of trial design and reporting specific to non-pharmacologic interventions, this document outlines the principles and methods for analysing and reporting the trial results. The document is prepared prior to completion of recruitment into the ARISE study, without knowledge of the results of the interim analysis conducted by the data safety and monitoring committee and prior to completion of the two related international studies. The statistical analysis plan was designed by the ARISE chief investigators, and reviewed and approved by the ARISE steering committee. The data collected by the research team as specified in the study protocol, and detailed in the study case report form were reviewed. Information related to baseline characteristics, characteristics of delivery of the trial interventions, details of resuscitation and other related therapies, and other relevant data are described with appropriate comparisons between groups. The primary, secondary and tertiary outcomes for the study are defined, with description of the planned statistical analyses. A statistical analysis plan was developed, along with a trial profile, mock-up tables and figures. A plan for presenting baseline characteristics, microbiological and antibiotic therapy, details of the interventions, processes of care and concomitant therapies, along with adverse events are described. The primary, secondary and tertiary outcomes are described along with identification of subgroups to be analysed. A statistical analysis plan for the ARISE study has been developed, and is available in the public domain, prior to the completion of recruitment into the study. This will minimise analytic bias and conforms to current best practice in conducting clinical trials.
Publisher: Wiley
Date: 11-06-2019
Abstract: 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). 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). 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. 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.
Publisher: Springer Science and Business Media LLC
Date: 07-2009
DOI: 10.1017/S1481803500011404
Abstract: There is a critical and growing need for emergency physicians and emergency medicine resources worldwide. To meet this need, physicians must be trained to deliver time-sensitive interventions and life-saving emergency care. Currently, there is no internationally recognized standard curriculum that defines the basic minimum standards for emergency medicine education. To address this deficiency, the International Federation for Emergency Medicine convened a committee of international physicians, health professionals and other experts in emergency medicine and international emergency medicine development, to outline a curriculum for foundation training of medical students in emergency medicine. This curriculum document represents the consensus of recommendations by this committee. The curriculum is designed with a focus on the basic minimum emergency medicine educational content that any medical school should be delivering to its students during undergraduate training. It is designed not to be prescriptive, but to assist educators and emergency medicine leadership in advancing physician education in basic emergency medicine content. The content would be relevant not just for communities with mature emergency medicine systems, but also for developing nations or for nations seeking to expand emergency medicine within current educational structures. We anticipate that there will be wide variability in how this curriculum is implemented and taught, reflecting the existing educational milieu, the resources available and the goals of the institutions' educational leadership.
Publisher: Springer Science and Business Media LLC
Date: 2008
DOI: 10.1186/CC6849
Publisher: Wiley
Date: 03-1993
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2008
Publisher: Wiley
Date: 05-2006
DOI: 10.1111/J.1445-2197.2006.03723.X
Abstract: The aim was to study the epidemiology of significant adolescent head injury in a statewide population. A retrospective review of all significant adolescent (12-19 years old) head injuries over a period of 3 years was undertaken and compared with those of children (0-11 years old) and young adults (20-29 years old). The incidence of significant adolescent head injury was 19.2 per 100,000 adolescents per year. This compared to the incidence in children of 12.9 per 100,000 and in young adult of 14.7 per 100,000. Of all significant adolescent head injuries, 63.9% are managed at adult trauma centres. Demographics, pathology, neurosurgical management, length of intensive care unit stay, ventilated hours and length of hospital stay were similar to those of young adults and significantly different from those of children. Prehospital predictors of mortality were similar across all groups. Adolescent discharge destinations were similar to those of young adults and significantly different from those of children. The study emphasizes the incidence of and mortality from adolescent head injury. The pattern of adolescent head injury is different from that of children and supports current practice of treatment of a majority of adolescents in adult trauma centres. These differences have implications on planning for injury prevention and trauma management.
Publisher: Wiley
Date: 10-2003
Publisher: Elsevier BV
Date: 05-2005
DOI: 10.1016/J.JEMERMED.2004.11.028
Abstract: We describe the epidemiology, clinical features and management of anaphylaxis in a population in Hong Kong, including the features associated with progression to biphasic reactions and the nature of these reactions. A retrospective review was undertaken of patients of all age groups, presenting consecutively to the resuscitation room of a large Hong Kong emergency department with the diagnosis of anaphylaxis, from March 1999 to February 2003. There were 282 patients included. Median age was 28 years, with 59% male. A precipitant was identified in 89%, with 19% of patients claiming a known allergy to the precipitant. Seafood was responsible for 71% of all food-related reactions. More patients reacted to nonsteroidal anti-inflammatory drugs rather than antibiotics. Cutaneous features were present in 79%, and 12% presented with hypotension. Ninety-five percent received H1 antagonist, and 67% received epinephrine. Biphasic reactions were reported in 15 (5.3%) cases with 20% of these patients having unstable vital signs. The mean time from treatment to onset of biphasic reaction was 8 h (range 1-23). Patients with respiratory features on initial presentation were less likely to develop biphasic reactions. It is concluded that prolonged observation of patients with anaphylaxis is important, because of the risk of biphasic reactions. Better education could prevent recurrent anaphylaxis.
Publisher: American College of Physicians
Date: 20-04-2004
DOI: 10.7326/0003-4819-140-8-200404200-00008
Abstract: Whether subclinical or atypical presentations of severe acute respiratory syndrome (SARS) occur and whether clinical judgment is accurate in detecting SARS are unknown. To describe the spectrum of SARS coronavirus infection in a large outbreak and to compare diagnoses based on clinical judgment with the SARS coronavirus test. Secondary analysis of prospectively collected clinical data and archived serum. A SARS screening clinic of a university hospital in the New Territories of Hong Kong. 1221 patients attending the clinic between 12 March 2003 and 12 May 2003. SARS coronavirus serology. 145 of 553 (26%) patients had serologic evidence of SARS coronavirus infection. Of 910 patients who were managed without hospitalization, only 6 had serologic evidence of SARS. Five of the six patients had normal chest radiographs, and four had symptoms such as myalgia, chills, coughing, and feeling feverish. With the SARS coronavirus serologic test as the gold standard, the clinical diagnosis of probable SARS at hospitalization had a sensitivity of 0.96 (95% CI, 0.91 to 0.98) and a specificity of 0.96 (CI, 0.92 to 0.97). Follow-up serologic s les were not obtained from almost half of the patients because they declined further testing. Some people living in the community who were infected but who had minor or no symptoms might not have visited the clinic. There is little evidence of widespread subclinical or mild forms of SARS coronavirus infection. Clinical diagnoses during the outbreak were reasonable and resulted in appropriate triaging.
Publisher: Elsevier BV
Date: 03-2012
DOI: 10.1016/J.AHJ.2011.11.011
Abstract: The role of routine supplemental oxygen for patients with uncomplicated acute myocardial infarction (AMI) has recently been questioned. There is conflicting data on the possible effects of hyperoxia on ischemic myocardium. The few clinical trials examining the role of oxygen in AMI were performed prior to the modern approach of emergent reperfusion and advanced medical management. Air Verses Oxygen In myocarDial infarction study (AVOID Study) is a prospective, multi-centre, randomized, controlled trial conducted by Ambulance Victoria and participating metropolitan Melbourne hospitals with primary percutaneous coronary intervention capabilities. The purpose of the study is to determine whether withholding routine supplemental oxygen therapy in patients with acute ST-elevation myocardial infarction but without hypoxia prior to reperfusion decreases myocardial infarct size. AVOID will enroll 490 patients, >18 years of age with acute ST-elevation myocardial infarction of less than 12 hours duration. There is an urgent need for clinical trials examining the role of oxygen in AMI. AVOID will seek to clarify this important issue. Results from this study may have widespread implications on the treatment of AMI and the use of oxygen in both the pre-hospital and hospital settings.
Publisher: Wiley
Date: 28-10-2020
DOI: 10.1111/ACEM.14144
Publisher: Wiley
Date: 10-2013
Publisher: Wiley
Date: 06-2000
Publisher: Wiley
Date: 12-1992
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2007
Publisher: Wiley
Date: 17-08-2020
Publisher: Radiological Society of North America (RSNA)
Date: 09-2003
Publisher: Wiley
Date: 07-07-2020
Abstract: To determine the population of patients where patient transfer may be prevented by assessment of a senior ED registrar at the referring hospital. 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. 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. 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.
Publisher: Springer Science and Business Media LLC
Date: 12-2014
Publisher: Wiley
Date: 24-03-2005
Publisher: BMJ
Date: 05-2010
Abstract: The epidemiology of aortic transection is changing with improvements in road safety and the use of endovascular stents. This research investigates the profile of cases and outcomes of traumatic thoracic aortic transection in Victoria, Australia. Data were extracted from the Victorian State Trauma Registry for the period July 2001 to December 2007. Data pertaining to patient demographics, mechanism of injury, method of treatment and mortality were collected. Prehospital mortality for the first year was assessed using National Coroners Information System data. Figures from the Australian Bureau of Statistics were used to establish population incidence rates. 69 patients reaching hospital were identified with transection over the study period. A total of 85 cases of transection were identified through coroners' records. Overall mortality (including prehospital and hospital) was approximately 94.4%. Prehospital mortality was approximately 88.0%. Overall hospital mortality was 33.3%. Patients were predominately men (73.9%) and had a median age of 38 years. Motor vehicle collisions were the most common mechanism (56.5%), with 85.5% of injuries being traffic related. Repair was performed in 46 patients, with 22 receiving initial endovascular repair and 24 receiving initial open repair. Mortality rates following surgery were 9.1% and 16.7%, respectively. Aortic transection was generally secondary to traffic-related injury affecting young men, with a mortality rate of over 90%. There has been a trend towards endovascular treatment over open repair in Victorian trauma centres.
Publisher: AMPCo
Date: 09-2017
DOI: 10.5694/MJA17.00015
Abstract: To investigate temporal trends in the incidence, mortality, disability-adjusted life-years (DALYs), and costs of health loss caused by serious road traffic injury. A retrospective review of data from the population-based Victorian State Trauma Registry and the National Coronial Information System on road traffic-related deaths (pre- and in-hospital) and major trauma (Injury Severity Score > 12) during 2007-2015.Main outcomes and measures: Temporal trends in the incidence of road traffic-related major trauma, mortality, DALYs, and costs of health loss, by road user type. There were 8066 hospitalised road traffic major trauma cases and 2588 road traffic fatalities in Victoria over the 9-year study period. There was no change in the incidence of hospitalised major trauma for motor vehicle occupants (incidence rate ratio [IRR] per year, 1.00 95% CI, 0.99-1.01 P = 0.70), motorcyclists (IRR, 0.99 95% CI, 0.97-1.01 P = 0.45) or pedestrians (IRR, 1.00 95% CI, 0.97-1.02 P = 0.73), but the incidence for pedal cyclists increased 8% per year (IRR, 1.08 95% CI 1.05-1.10 P < 0.001). While DALYs declined for motor vehicle occupants (by 13% between 2007 and 2015), motorcyclists (32%), and pedestrians (5%), there was a 56% increase in DALYs for pedal cyclists. The estimated costs of health loss associated with road traffic injuries exceeded $14 billion during 2007-2015, although the cost per patient declined for all road user groups. As serious injury rates have not declined, current road safety targets will be difficult to meet. Greater attention to preventing serious injury is needed, as is further investment in road safety, particularly for pedal cyclists.
Publisher: Elsevier BV
Date: 09-2012
DOI: 10.1016/J.INJURY.2011.01.033
Abstract: The use of recombinant factor VIIa (rFVIIa) in trauma patients is usually part of rescue therapy when haemorrhage and coagulopathy have not responded to conventional treatment. In this scenario, trauma patients are likely to have one or more components of the 'triad of death' (coagulopathy, acidosis and hypothermia). The aim of this study was to report on the outcome of trauma patients with the 'triad of death' immediately prior to receiving rFVIIa. Trauma patients receiving rFVIIa with the 'triad of death' were identified from the Australia and New Zealand Haemostasis Registry (ANZHR) and included in the study. The 'triad of death' was defined as an INR of >1.5, serum pH of <7.2 and a core temperature of <35 °C. Pre-dose clinical signs, investigations, adverse events and outcomes were analysed. There were 2792 patients in the ANZHR, of which 386 were trauma patients and 45 patients had the 'triad of death'. Patients with the 'triad of death' were significantly older and had higher injury severity scores than other trauma patients, with a mortality of 68.9%. Survivors were significantly less acidaemic (p<0.001) and had significantly less packed red blood cell (PRBC) transfusion prior to rFVIIa administration (p=0.041) than non-survivors with the triad of death. In the face of refractory bleeding, coagulopathy, acidosis and hypothermia following conventional resuscitation, the use of rFVIIa in trauma patients was associated with survival in 31% of patients and may be considered as a management option. Administration of rFVIIa in patients with a pH of <6.91 appears futile.
Publisher: Wiley
Date: 19-12-2020
Abstract: 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. 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. 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. 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.
Publisher: Wiley
Date: 16-07-2020
Publisher: Elsevier BV
Date: 09-2012
DOI: 10.1016/J.INJURY.2011.01.031
Abstract: The purpose of this study was to describe patterns and rates of sport and active recreation injuries that result in major trauma or death and to examine trends in these rates for all sport and active recreation activities and key sporting groups, for the period July 2001-June 2007, in Victoria, Australia. All sport and active recreation related major trauma cases and deaths were extracted from the Victorian State Trauma Registry (VSTR) and the National Coroners Information System, for the period July 2001-June 2007. Participation data from the Exercise Recreation and Sports Survey (ERASS) was used to establish incidence rates for the group as a whole and for key sporting groups. Poisson regression analysis was used to examine trends in major trauma and death due to participation in sport and active recreation across the six year study period. There were 1019 non-fatal major trauma cases and 218 deaths. The rate of major trauma or death from sport and active recreation injuries was 6.3 per 100,000 participants per year. There was an average annual increase of 10% per year in the major trauma rate (including deaths) across the study period, for the group as a whole (IRR 1.10, 95% CI, 1.06-1.14). There was no increase in the death rate (IRR=0.94, 95% CI, 0.87-1.02 p=0.12). Significant increases were also found for cycling (IRR 1.16, 95% CI, 1.09-1.24) off-road motor sports (IRR 1.10, 95% CI, 1.03-1.19), Australian football (IRR 1.21, 95% CI, 1.03-1.42) and swimming (IRR 1.16, 95% CI, 1.004-1.33). The rate of major trauma inclusive of deaths, due to participation in sport and active recreation has increased over recent years, in Victoria, Australia. Much of this increase can be attributed to cycling, off-road motor sports, Australian football and to a lesser extent swimming, highlighting the need for co-ordinated injury prevention in these areas.
Publisher: CSIRO Publishing
Date: 2008
DOI: 10.1071/AH080246
Abstract: The aim of this study was to pilot a program to encourage shift breaks for emergency department doctors and analyse the effects of breaks on tiredness and fatigue as well as possible effects on overall departmental performance. During Phase 1, medical staff were asked to fill out a survey regarding their working day at the end of every shift. A 30-minute uninterrupted break was promoted during Phase 2 by provision of a cover doctor on the roster as well as educational sessions and posters. There were 233 completed surveys received over the 4-week period. Only 33% of shifts worked included an uninterrupted break in Phase 1, which improved significantly to 60% during Phase 2. Subjective tiredness was significantly lower at the end of a shift when a break was taken (P 0.001), while fatigue levels were also lower, but not significant (P = 0.060). There were significant improvements in some key performance indicators.
Publisher: Wiley
Date: 12-2008
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2005
DOI: 10.1097/01.TA.0000198350.15936.A1
Abstract: Trauma registries have been developed to describe the pattern of trauma and trauma workload, provide data for research, and to demonstrate changes in patient outcomes. Quality improvement using trauma registries at a system-wide level has been difficult to achieve. In Victoria, Australia, a statewide trauma system and trauma registry has been established to monitor and feedback the process of management and outcomes of major trauma patients across all healthcare providers. The development and implementation of the Victorian State Trauma Registry (VSTR), including its role as a quality monitoring tool and results from the first 2 years of operation, are provided. More than 80% of major trauma patients are being managed at major trauma services and standardized death rates are comparable with international standards. Quality indicators identify some areas for improvement. VSTR data indicate that the statewide trauma system is working well and provides a method for ongoing monitoring and trauma care feedback.
Publisher: Wiley
Date: 04-02-2015
Publisher: Wiley
Date: 10-2010
DOI: 10.1111/J.1742-6723.2010.01337.X
Abstract: To describe and compare the incidence and profile of on- and off-road motorcycle-related major trauma (including death) cases across a statewide population. A review of prospectively collected data on adult, motorcycle-related major trauma cases from 2001 to 2008 was conducted. Major trauma survivors were identified from the population-based Victorian State Trauma Registry, and deaths were extracted from the National Coroners Information System. Poisson regression was used to test for increasing incidence using two measures of exposure: population of Victoria aged ≥ 16 years, and registered motorcycles. There were 1157 major trauma survivors and 344 deaths with motorcycle-related injuries over the study period. There was no change in the incidence of motorcycle-related major trauma (both survivors plus deaths) (Incident Rate ratio [IRR]= 1.14, 95% confidence interval [CI] 0.94-1.37) over the study period. Similarly, there was no change over time in the incidence of on-road motorcycle-related injury (survivors plus deaths) per 100,000 population (IRR = 1.03, 95% CI 0.84-1.27). However, the incidence of off-road motorcycle-related injury (survivors plus deaths) increased over the study period (IRR = 1.69, 95% CI 1.10-2.60). Among survivors and deaths, 882 (76%) and 301 (87.5%) cases, respectively, occurred on road. Off-road motorcycle-related major trauma has increased and this has not been targeted in injury prevention c aigns in Australia. The incidence of on-road motorcycle-related death in adults has decreased. Preventive strategies to address on-road injuries have been enforced and these are expected to lead to further reduction of on-road motorcycle crashes in the future.
Publisher: Elsevier BV
Date: 05-2017
Publisher: Wiley
Date: 06-2012
Publisher: Elsevier BV
Date: 02-2017
DOI: 10.1016/J.RESUSCITATION.2016.11.011
Abstract: This study aimed to understand factors associated with paramedics' decision to attempt resuscitation in traumatic out-of-hospital cardiac arrest (OHCA) and to characterise resuscitation attempts ≤10min in patients who die at the scene. The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify all cases of traumatic OHCA between July 2008 and June 2014. We excluded cases <16 years of age or with a mechanism of hanging or drowning. Of the 2334 cases of traumatic OHCA, resuscitation was attempted in 28% of cases and this rate remained steady over time (p=0.10). Multivariable logistic regression revealed that the arresting rhythm [shockable (adjusted odds ratio (AOR)=18.52, 95% confidence interval (CI):6.68-51.36) or pulseless electrical activity (AOR=12.58, 95%CI:9.06-17.45) relative to asystole] and mechanism of injury [motorcycle collision (AOR=2.49, 95%CI:1.60-3.86), fall (AOR=1.91, 95%CI:1.17-3.11) and shooting/stabbing (AOR=2.25, 95%CI:1.17-4.31) relative to a motor vehicle collision] were positively associated with attempted resuscitation. Arrests occurring in rural regions had a significantly lower odds of attempted resuscitation relative to those in urban regions (AOR=0.64, 95%CI:0.46-0.90). Resuscitation attempts ≤10min represented 34% of cases in which resuscitation was attempted but the patient died at the scene. When these resuscitation attempts were selectively excluded from the overall EMS treated population, survival to hospital discharge non-significantly increased from 3.8% to 5.0% (p=0.314). Survival in our study was consistent with existing literature, however the large proportion of cases with resuscitation attempts ≤10min may under-represent survival in those patients that receive full resuscitation attempts.
Publisher: Elsevier BV
Date: 09-2015
DOI: 10.1016/J.JOCN.2015.02.030
Abstract: The aim of this systematic review was to determine whether ethanol is neuroprotective or associated with adverse effects in the context of traumatic brain injury (TBI). Approximately 30-60% of TBI patients are intoxicated with ethanol at the time of injury. We performed a systematic review of the literature using a combination of keywords for ethanol and TBI. Manuscripts were included if the population studied was human subjects with isolated moderate to severe TBI, acute ethanol intoxication was studied as an exposure variable and mortality reported as an outcome. The included studies were assessed for heterogeneity. A meta-analysis was performed and the pooled odds ratio (OR) for the association between ethanol and in-hospital mortality reported. There were seven studies eligible for analysis. A statistically significant association favouring reduced mortality with ethanol intoxication was found (OR 0.78 95% confidence interval 0.73-0.83). Heterogeneity among selected studies was not statistically significant (p=0.25). Following isolated moderate-severe TBI, ethanol intoxication was associated with reduced in-hospital mortality. The retrospective nature of the studies, varying definitions of brain injury, degree of intoxication and presence of potential confounders limits our confidence in this conclusion. Further research is recommended to explore the potential use of ethanol as a therapeutic strategy following TBI.
Publisher: Wiley
Date: 25-07-2003
DOI: 10.1046/J.1442-2026.2003.00474.X
Abstract: The Glasgow Coma Scale (GCS) was first introduced in the 1970s to provide a simple and reliable method of recording and monitoring change in the level of consciousness of head injured patients. Since its introduction, the GCS has been widely utilized in the trauma community and its use expanded beyond the original intentions of the score. In the context of traumatic injury, this paper discusses the use of the GCS as a predictor of outcome, the limitations of the GCS, the reliability of the GCS and potential alternatives through a critical review of the literature. The relevance to Australian trauma populations is also addressed.
Publisher: Wiley
Date: 11-2012
DOI: 10.1111/J.1445-5994.2012.02866.X
Abstract: The mortality rate post admission to hospital after successful resuscitation from out-of-hospital cardiac arrest is high, with significant variation between regions and in idual institutions. While prehospital factors such as age, bystander cardiopulmonary resuscitation and total cardiac arrest time are known to influence outcome, several aspects of post-resuscitative care including therapeutic hypothermia, coronary intervention and goal-directed therapy may also influence patient survival. Regional systems of care have improved provider experience and patient outcomes for those with ST elevation myocardial infarction and life-threatening traumatic injury. In particular, hospital factors such as hospital size and interventional cardiac care capabilities have been found to influence patient mortality. This paper reviews the evidence supporting the possible development and implementation of Australian cardiac arrest centres.
Publisher: Elsevier BV
Date: 09-2016
Publisher: Springer Science and Business Media LLC
Date: 05-03-2014
DOI: 10.1007/S10140-014-1203-7
Abstract: Current literature suggests that a large proportion of chest X-rays (CXRs) performed in emergency department (ED) patients with chest pain and suspected acute coronary syndrome (ACS) are unnecessary. The Canadian ACS Guidelines aim to guide clinicians in the appropriate use of CXR within this patient population. This study determined the prevalence of clinically significant CXR abnormalities and assessed the utility of the guidelines in a population of ED patients with chest pain and suspected ACS. Included in the study were participants over the age of 18 who presented to an Australian metropolitan ED, over a 1-year period, with a primary complaint of chest pain and who had a CXR and troponin level ordered in the ED (N = 760). We retrospectively compared their radiographic findings with their recommendations for CXR according to the ACS Guidelines. We found that 12 % of the participants had a clinically significant chest X-ray. The guidelines had a sensitivity of 80 % (95 % CI 0.70-0.87) and specificity of 50 % (95 % CI 0.47-0.54). The positive predictive value was 18 % (95 % CI 0.15-0.22) with a 95 % negative predictive value (95 % CI 0.92-0.97). Had the ACS guidelines been applied to our patient population, the number of CXR performed would have been reduced by 47 %. This study suggests that the ACS Guidelines has the potential to reduce the numbers of unnecessary CXR performed in ED patients. However, this would come at the expense of missing a minority of significant CXR abnormalities.
Publisher: Oxford University Press (OUP)
Date: 07-08-2012
Abstract: The objective of this review was to critically appraise the literature relating to associations between high-level structural and operational hospital characteristics and improved performance. The Cochrane Library, MEDLINE (Ovid), CINAHL, proQuest and PsychINFO were searched for articles published between January 1996 and May 2010. Reference lists of included articles were reviewed and key journals were hand searched for relevant articles. and data extraction Studies were included if they were systematic reviews or meta-analyses, randomized controlled trials, controlled before and after studies or observational studies (cohort and cross-sectional) that were multicentre, comparative performance studies. Two reviewers independently extracted data, assigned grades of evidence according to the Australian National Health and Medical Research Council guidelines and critically appraised the included articles. Data synthesis Fifty-seven studies were reported within 12 systematic reviews and 47 observational articles. There was heterogeneity in use and definition of performance outcomes. Hospital characteristics investigated were environment (incentives, market characteristics), structure (network membership, ownership, teaching status, geographical setting, service size) and operational design (innovativeness, leadership, organizational culture, public reporting and patient safety practices, information technology systems and decision support, service activity and planning, workforce design, staff training and education). The strongest evidence for an association with overall performance was identified for computerized physician order entry systems. Some evidence supported the associations with workforce design, use of financial incentives, nursing leadership and hospital volume. There is limited, mainly low-quality evidence, supporting the associations between hospital characteristics and healthcare performance. Further characteristic-specific systematic reviews are indicated.
Publisher: Wiley
Date: 02-2003
Publisher: AMPCo
Date: 06-2016
DOI: 10.5694/MJA15.01369
Abstract: To describe the incidence and causes of hospitalisation for severe traumatic brain injury (TBI) in Victoria over a 9-year period. A retrospective review of data from the population-based Victorian State Trauma Registry for hospitalised cases of severe TBI, 2006-2014. Temporal trends in the incidence of severe TBI and in causes of injury. There were 2062 patients hospitalised with severe TBI in Victoria during the 9-year study period. The incidence of severe TBI declined significantly over this period, from 5.0 to 3.2 cases per 100000 population per year, mainly because of reductions in severe TBI resulting from motor vehicle crashes (incidence rate ratio [IRR], 0.89 95% CI, 0.86-0.92 P < 0.001), which largely involved people in the 15-34-year-old age group (64.7%). A decline was also observed in severe TBI in motorcyclists, but this was not statistically significant (IRR, 0.94 95% CI, 0.89-1.00 P = 0.06). The incidence of severe TBI resulting from low falls, which occurred mostly in people aged 65 years or more (68.1%), increased (IRR, 1.04 95% CI, 1.00-1.08 P = 0.03). The overall incidence of severe TBI resulting from intentional events was 0.60 cases per 100000 population, and declined over the study period (IRR, 0.95 95% CI, 0.91-1.00 P = 0.03). The decline in the incidence of motor vehicle-related severe TBI suggests that road injury prevention measures have been effective. Additional targeted measures for reducing the incidence of major head injuries from falls should be explored.
Publisher: Elsevier BV
Date: 07-2013
Publisher: Wiley
Date: 04-2014
Abstract: Following findings of the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2) trial, tranexamic acid (TxA) use post trauma is becoming widespread. However, issues of generalisability, applicability and predictability beyond the context of study sites remain unresolved. Internal and external validity of the CRASH-2 trial are currently lacking and therefore incorporation of TxA into routine trauma resuscitation guidelines appears premature. The Pre-hospital Antifibrinolytics for Traumatic Coagulopathy and Haemorrhage (PATCH)-Trauma study is a National Health and Medical Research Council-funded randomised controlled trial of early administration of TxA in severely injured patients likely to have acute traumatic coagulopathy. The study population chosen has high mortality and morbidity and is potentially most likely to benefit from TxA's known mechanisms of action. This and further trials involving appropriate s le populations are required before evidence based guidelines on TxA use during trauma resuscitation can be developed.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2013
Publisher: Wiley
Date: 10-11-2011
DOI: 10.1111/J.1445-2197.2010.05535.X
Abstract: The epidemiology of patients with acute scrotal pain presenting to the emergency department (ED) is largely unknown. Urgent surgical referral is recommended for patients presenting with suspected testicular torsion. However, we have noted an increasing use of Doppler ultrasound (US) as an adjunctive tool in the evaluation of patients with acute scrotal pain. This study aimed to retrospectively review the presentation of patients with acute scrotal pain to a tertiary ED and the use of ultrasound in the assessment of acute scrotal pain. An explicit chart review was performed including all patients presenting to an adult tertiary ED between 2003 and 2008 with acute scrotal pain. The timing of presentation, initial assessment, review by the Urology team and the use of US were recorded. The diagnosis recorded at hospital discharge was the primary end point, while follow-up at outpatient clinic or private urologist rooms was used as a secondary end point. There were 329 patients with acute scrotal pain during the study period, with 294 patients included in the study. Of these, 173 (58.8%) had a US scan performed in the ED. There were 44 (15.0%) patients who underwent scrotal exploration, with 19 having a prior US. There was a significant increase in the use of US over the study period. Colour-flow duplex Doppler ultrasonography appeared to play an increasing role in the assessment for patients presenting with acute testicular pain. Rapid and more reliable assessments of these patients may be possible through greater education of emergency personnel in ultrasonography techniques.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2005
DOI: 10.1097/01.TA.0000174840.35406.71
Abstract: The success of a trauma system relies on transfer of patients from the field to the most appropriate hospital for definitive care. However, no consensus has been reached regarding the best criteria or triage tool for identifying patients injured seriously enough to warrant transfer to a trauma center. Predictors of mortality and intensive care unit stay were identified and prediction models developed in a design data set. The performance of these models was evaluated in a test data set and compared with current trauma triage guidelines, derived from the American College of Surgeons model. The newly developed prediction models performed comparably with the current trauma triage guidelines. Although the performance of newly developed triage models was promising, their performance did not exceed that of the current trauma triage guidelines. In particular, the anatomic injury criteria appeared to be the key component of the current trauma triage guidelines.
Publisher: Wiley
Date: 04-2007
DOI: 10.1111/J.1742-6723.2007.00948.X
Abstract: To identify potentially preventable prehospital deaths following traumatic cardiac arrest. Deaths following prehospital traumatic cardiac arrest during 2003 were reviewed in the state of Victoria, Australia. Possible survival with optimal bystander first-aid and shorter ambulance response times were identified. Injury Severity Scores (ISS) were calculated. Victims with an ISS <50 and signs of life were reviewed for potentially preventable factors contributing to death including signs of airway obstruction, excessive bleeding and/or delayed ambulance response times. We reviewed 112 cases that had full ambulance care records, hospital records and autopsy details in Victoria 2003. Most deaths involved road trauma and 55 victims had an ISS 10 min might have contributed to five deaths with an ISS <25. Five (4.5%) potentially preventable prehospital trauma deaths were identified. Three deaths potentially involved airway obstruction and two involved excessive bleeding. There is a case for increased awareness of the need for bystander first-aid at scene following major trauma.
Publisher: Wiley
Date: 24-11-2009
Publisher: Elsevier BV
Date: 05-2016
Publisher: Elsevier BV
Date: 07-2009
Publisher: Elsevier BV
Date: 1998
DOI: 10.1111/J.1467-842X.1998.TB01155.X
Abstract: Self-inflicted harm, whether by trauma or drug overdose, is not uncommon, and has important social consequences. This study was a retrospective record analysis of patients who presented to an emergency department after deliberate self-inflicted harm. Over the two-year study period, there were 175 self-inflicted trauma and 441 overdose presentations. The self-inflicted trauma patients were a heterogeneous group and included patients who displayed suicide-related behaviour and behaviour not related to suicide. The self-inflicted traumatic injuries tended to be either relatively minor or potentially very serious. Lacerations to the upper limb were seen most frequently. The trauma and overdose groups were almost mutually exclusive populations and showed some significant differences. The trauma group was smaller, contained a significantly greater proportion of younger patients and males, presented more commonly in the late evening and early morning hours and ultimately received less psychiatric counselling. Research of this type has problems of underreporting and data bias. Prospective studies of self-inflicted trauma would improve the identification of patients after self-harm and improve the understanding of the relationship between the patterns of injury psychiatric diagnosis and the long-term risk of future self-harm.
Publisher: Wiley
Date: 05-2013
DOI: 10.1111/IMJ.12061
Abstract: Population ageing is projected to impact on health services utilisation including Emergency Departments (ED), with older patients reportedly having a high rate of return visits. We describe and compare patterns in ED utilisation between older and younger adults, and quantify the proportion and rate of return visits. Population-based retrospective analysis of metropolitan Melbourne public hospital ED data, 1999/2000 to 2008/2009. Numbers of patients, presentations, re-presentations and rates per 1000 population were calculated, with comparison of older (aged ≥ 70 years) and younger (15-69 years) attendances. Population growth in each age group was similar over the study period, yet ED presentations rose by 72% for older adults compared with a 59% increase for younger adults. Rates per 1000 population rose with increasing age. Of the population aged ≥ 70 years, 39% presented to ED compared with 17% of the population aged 15-69 years in 2008/2009. Twenty-seven per cent of the increase in older adult presentations was driven by a cohort who attended ≥ 4 times in 2008/2009. The number of older patients presenting ≥ 4 times doubled over the decade, contributing to 23% of all older presentations in 2008/2009. ED length of stay rose with increasing age 69% of older adults remained in ED for ≥ 4 h compared with 39% of younger adults in 2008/2009. The number of older adult ED hospital admissions doubled over the decade. Older patients are disproportionately represented among ED attendances. They also have an increasing propensity to re-present to ED, indicating a need to identify the clinical, social and health system-related risk factors for re-attendance by specific patients.
Publisher: Springer Science and Business Media LLC
Date: 05-05-2017
DOI: 10.1007/S10926-016-9642-5
Abstract: Purpose Traumatic injury is a leading cause of work disability. Receiving compensation post-injury has been consistently found to be associated with poorer return to work. This study investigated whether the relationship between receiving compensation and return to work was associated with elevated symptoms of psychological distress (i.e., anxiety, depression, and posttraumatic stress disorder) and perceived injustice. Methods Injured persons, who were employed at the time of injury (n = 364), were recruited from the Victorian State Trauma Registry, and Victorian Orthopaedic Trauma Outcomes Registry. Participants completed the Hospital Anxiety and Depression Scale, Posttraumatic Stress Disorder Checklist, Injustice Experience Questionnaire, and appraisals of pain and work status 12-months following traumatic injury. Results Greater financial worry and indicators of actual erceived injustice (e.g., consulting a lawyer, attributing fault to another, perceived injustice, sustaining compensable injury), trauma severity (e.g., days in hospital and intensive care, discharge to rehabilitation), and distress symptoms (i.e., anxiety, depression, PTSD) led to a twofold to sevenfold increase in the risk of failing to return to work. Anxiety, post-traumatic stress and perceived injustice were elevated following compensable injury compared with non-compensable injury. Perceived injustice uniquely mediated the association between compensation and return to work after adjusting for age at injury, trauma severity (length of hospital, admission to intensive, and discharge location) and pain severity. Conclusions Given that perceived injustice is associated with poor return to work after compensable injury, we recommend greater attention be given to appropriately addressing psychological distress and perceived injustice in injured workers to facilitate a smoother transition of return to work.
Publisher: Elsevier BV
Date: 12-2021
Publisher: Wiley
Date: 02-2014
Publisher: Wiley
Date: 27-06-2017
DOI: 10.1111/BJH.14804
Abstract: We aimed to compare hypofibrinogenaemia prevalence in major bleeding patients across all clinical contexts, fibrinogen supplementation practice, and explore the relationship between fibrinogen concentrations and mortality. This cohort study included all adult patients from 20 hospitals across Australia and New Zealand who received massive transfusion between April 2011 and October 2015. Of 3566 patients, 2829 (79%) had fibrinogen concentration recorded, with a median first and lowest concentration of 2·0 g/l (interquartile range [IQR] 1·5-2·7) and 1·8 g/l (IQR 1·3-2·4), respectively. Liver transplant (1·7 g/l, IQR 1·2-2·1), trauma (1·8, IQR 1·3-2·5) and vascular surgery (1·9 g/l, IQR 1·4-2·5) had lower concentrations. Total median fibrinogen dose administered from all products was 7·3 g (IQR 3·3-13·0). Overall, 1732 (61%) received cryoprecipitate and 9 (<1%) fibrinogen concentrate. Time to cryoprecipitate issue in those with initial fibrinogen concentration <1 g/l was 2·5 h (IQR 1·2-4·3 h). After adjustment, initial fibrinogen concentration had a U-shaped association with in-hospital mortality [adjusted odds ratios: fibrinogen 4 g/l, 2·03 (95% CI 1·35-3·04), 2-4 g/l reference category]. The findings indicate areas for practice improvement including timely administration of cryoprecipitate, which is the most common source of concentrated fibrinogen in Australia and New Zealand.
Publisher: Elsevier BV
Date: 12-2010
DOI: 10.1016/J.ARTH.2009.08.011
Abstract: Although deep surgical site infection (SSI) is a major complication of primary total hip arthroplasty (THA), there are conflicting data regarding the incidence of deep SSI, and no comprehensive evaluation of the associated risk factors has been undertaken. We performed a systematic review of the literature undertaking computer-aided searches of electronic databases, assessment of methodological quality, and a best-evidence synthesis. The incidence of SSI ranged from 0.2% before discharge to 1.1% for the period up to and including 5 years post surgery. Greater severity of a pre-existing illness and a longer duration of surgery were found to be independent risk factors for deep SSI. There is a need for high-quality, prospective studies to further identify modifiable risk factors for deep SSI after THA.
Publisher: Elsevier BV
Date: 04-2012
DOI: 10.1016/J.RESUSCITATION.2011.11.009
Abstract: Many consider attempted resuscitation for traumatic out-of-hospital cardiac arrest (OHCA) futile. This study aims to describe the characteristics and profile of paediatric traumatic OHCA. The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify all trauma related cases of OHCA in patients aged less than 16 years of age. Cases were linked with their coronial findings. Between 2000 and 2009, EMS attended 33,722 OHCAs including 2187 adult traumatic OHCAs. There were 538 (1.6%) OHCAs in children less than 16 years of age of which n=64 were due to trauma. The median age (IQR) of paediatric traumatic OHCA was 7 (4.5-13) years and 44 were male (69%). Bystander CPR was performed in 22 cases (34.4%). The first recorded rhythm by EMS was asystole seen in 42 (66%), PEA in 14 (22%) cases and VF in 2 cases (3%). Cardiac output was present in 7 (11%) cases who subsequently had an EMS witnessed OHCA. EMS attempted resuscitation in 35 (55%) patients of whom 7 (20%) achieved ROSC and were transported, and 1 (3%) survived to hospital discharge with severe neurological sequelae 14(40%) were transported with CPR of whom none survived. Coronial cause of death was multiple injuries in 35%, head injury in 33%, head and neck injury in 10%, chest injuries in 10% and other causes (12%). Traumatic aetiology of OHCA when compared to the incidence of adult traumatic OHCAs is uncommon. Resuscitation efforts are seldom effective and associated with poor neurological outcome.
Publisher: Wiley
Date: 10-2011
DOI: 10.1111/J.1742-6723.2011.01489.X
Abstract: To meet a critical and growing need for emergency physicians and emergency medicine resources worldwide, physicians must be trained to deliver time-sensitive interventions and lifesaving emergency care. Currently, there is no globally recognized, standard curriculum that defines the basic minimum standards for specialist trainees in emergency medicine. To address this deficit, the International Federation for Emergency Medicine convened a committee of international physicians, health professionals and other experts in emergency medicine and international emergency medicine development to outline a curriculum for training of specialists in emergency medicine. This curriculum document represents the consensus of recommendations by this committee. The curriculum is designed to provide a framework for educational programmes in emergency medicine. The focus is on the basic minimum emergency medicine educational content that any emergency medicine physician specialist should be prepared to deliver on completion of a training programme. It is designed not to be prescriptive but to assist educators and emergency medicine leadership to advance physician education in basic emergency medicine no matter the training venue. The content of this curriculum is relevant not just for communities with mature emergency medicine systems, but in particular for developing nations or for nations seeking to expand emergency medicine within the current educational structure. We anticipate that there will be wide variability in how this curriculum is implemented and taught. This variability will reflect the existing educational milieu, the resources available, and the goals of the institutions' educational leadership with regard to the training of emergency medicine specialists.
Publisher: Elsevier BV
Date: 04-2018
DOI: 10.1016/J.EURURO.2017.11.001
Abstract: Renal colic is a common, acute presentation of urolithiasis that requires immediate pain relief. European Association of Urology guidelines recommend nonsteroidal anti-inflammatory drugs (NSAIDs) as the preferred analgesia. However, the fear of NSAID adverse effects and the uncertainty about superior analgesic effect have maintained the practice of advocating intravenous opioids as the initial analgesia. The objective of this systematic review and meta-analysis was to compare the safety and efficacy of NSAIDs with opioids and paracetamol (acetaminophen) for the management of acute renal colic. Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, World Health Organization International Clinical Trials Registry Platform, Google Scholar, and the reference list of retrieved articles were searched up to December 2016 without language restrictions. Two reviewers independently assessed eligible studies using the Cochrane Collaboration tool for assessing and reporting the risk of bias and abstracted data using predefined data fields. From 468 potentially relevant studies, 36 randomized controlled trials (RCTs) including 4887 patients, published between 1982 and 2016, were included in this systematic review. The treatment effect observed indicated marginal benefit of NSAIDs over opioids in initial pain reduction at 30min (11 RCTs, n=1985, mean difference [MD] -5.58, 95% confidence interval [CI] -10.22 to -0.95 heterogeneity I NSAIDs were equivalent to opioids or paracetamol in the relief of acute renal colic pain at 30min. There was less vomiting and fewer requirements for rescue analgesia with NSAIDs compared with opioids. Patients treated with NSAIDs required less rescue analgesia compared with paracetamol. Despite observed heterogeneity among the included studies and the overall quality of evidence, the findings of a lower need for rescue analgesia and fewer adverse events, in conjunction with the practical advantages of ease of delivery, suggest that NSAIDs should be the preferred analgesic option for patients presenting to the emergency department with renal colic. In kidney stone-related acute pain episodes in patients with adequate renal function, treatment with nonsteroidal anti-inflammatory drugs offers effective and most sustained pain relief, with fewer side effects, when compared with opioids or paracetamol.
Publisher: SAGE Publications
Date: 07-2004
DOI: 10.1177/102490790401100303
Abstract: In April 2003, rumours spread that smoking protected patients from developing SARS (Severe Acute Respiratory Syndrome). In a case-control study of 447 patients who attended a SARS screening clinic, 63 patients were admitted with SARS. Although a higher proportion of SARS cases were non-smokers than smokers, the adjusted odds of non-smokers with SARS was 1.7 (p=0.54). There is no evidence that smoking protects patients from developing SARS.
Publisher: Wiley
Date: 09-1993
Publisher: Springer Science and Business Media LLC
Date: 2007
DOI: 10.2165/00007256-200737060-00001
Abstract: The sport of boxing has been the source of much debate, with concerns about the neurological risks of participating having led to many calls to ban the sport. This review seeks to establish an evidence base for the development of boxing-related chronic traumatic encephalopathy (CTE) and to determine the relevance of this information to the modern day sport.The clinical features of CTE include various symptoms affecting the pyramidal and extrapyramidal systems, which manifest most often as disturbed gait and coordination, slurred speech and tremors, as well as cerebral dysfunction causing cognitive impairments and neurobehavioural disturbances. Both amateur and professional boxers are potentially at risk of developing CTE. No current epidemiological evidence exists to determine the prevalence of this condition in modern day boxing, despite 17% of professional boxers in Britain with careers in the 1930-50s having clinical evidence of CTE. As medical presence within the sport increases and with modern boxers likely to have shorter careers, a reduced exposure to repetitive head trauma, and improved treatment and understanding of the development of CTE will occur. This should lead to the incidence of CTE diminishing in boxing populations.
Publisher: Mary Ann Liebert Inc
Date: 15-06-2016
Abstract: Early decompression may improve neurological outcome after spinal cord injury (SCI), but is often difficult to achieve because of logistical issues. The aims of this study were to 1) determine the time to decompression in cases of isolated cervical SCI in Australia and New Zealand and 2) determine where substantial delays occur as patients move from the accident scene to surgery. Data were extracted from medical records of patients aged 15-70 years with C3-T1 traumatic SCI between 2010 and 2013. A total of 192 patients were included. The median time from accident scene to decompression was 21 h, with the fastest times associated with closed reduction (6 h). A significant decrease in the time to decompression occurred from 2010 (31 h) to 2013 (19 h, p = 0.008). Patients undergoing direct surgical hospital admission had a significantly lower time to decompression, compared with patients undergoing pre-surgical hospital admission (12 h vs. 26 h, p < 0.0001). Medical stabilization and radiological investigation appeared not to influence the timing of surgery. The time taken to organize the operating theater following surgical hospital admission was a further factor delaying decompression (12.5 h). There was a relationship between the timing of decompression and the proportion of patients demonstrating substantial recovery (2-3 American Spinal Injury Association Impairment Scale grades). In conclusion, the time of cervical spine decompression markedly improved over the study period. Neurological recovery appeared to be promoted by rapid decompression. Direct surgical hospital admission, rapid organization of theater, and where possible, use of closed reduction, are likely to be effective strategies to reduce the time to decompression.
Publisher: Wiley
Date: 2013
DOI: 10.1111/J.1445-5994.2012.02842.X
Abstract: To examine non-clinical factors associated with emergency department (ED) attendance by lower urgency older patients. An exploratory descriptive study comprising structured interviews with lower urgency community-dwelling patients aged ≥70 years presenting to a tertiary metropolitan Melbourne public hospital ED. Demographical and clinical characteristics, self-reported feelings of social connectedness, perceived accessibility to primary care, reason for attending ED were measured. One hundred patients were interviewed: mean age 82 years, 56% female, 57% lived alone 73% presented during business hours, 58% arrived by ambulance, 80% presented for illness, and 65% were discharged home within 48 h. Fifty-six per cent of patients reported feeling socially disconnected, comprising 49% living alone compared with 65% who lived with their spouse/family. All patients attended a regular general practitioner, 31% reporting regular review appointments. Thirty-five per cent reported waiting times >2-3 days for urgent problems 59% stated accessing care 'after hours' without attending ED as difficult, with 20% having attended ED 3-6 times in the previous 12 months. Reasons for attending ED were referral by a third party, difficulty with accessibility to primary care, patient preferences for timely care and fast-track access to specialist care. Most older patients of lower clinical urgency presented to ED because of perceived access block to primary or specialist services, alongside an expectation of more timely and specialised care. This suggests that EDs should be redesigned and/or integrated community-based models of care developed to meet the specific needs of this age group who have growing demand for acute care.
Publisher: Wiley
Date: 10-2009
DOI: 10.1111/J.1742-6723.2009.01213.X
Abstract: There is a critical and growing need for emergency physicians and emergency medicine resources worldwide. To meet this need, physicians must be trained to deliver time-sensitive interventions and life-saving emergency care. Currently, there is no internationally recognized, standard curriculum that defines the basic minimum standards for emergency medicine education. To address this lack, the International Federation for Emergency Medicine (IFEM) convened a committee of international physicians, health professionals and other experts in emergency medicine and international emergency medicine development, to outline a curriculum for foundation training of medical students in emergency medicine. This curriculum document represents the consensus of recommendations by this committee. The curriculum is designed with a focus on the basic minimum emergency medicine educational content that any medical school should be delivering to its students during their undergraduate years of training. It is designed, not to be prescriptive, but to assist educators and emergency medicine leadership in advancing physician education in basic emergency medicine content. The content would be relevant, not just for communities with mature emergency medicine systems, but also for developing nations or for nations seeking to expand emergency medicine within current educational structures. We anticipate that there will be wide variability in how this curriculum is implemented and taught, reflecting the existing educational milieu, the resources available, and the goals of the institutions' educational leadership.
Publisher: Wiley
Date: 10-2003
DOI: 10.1046/J.1442-2026.2003.00496.X
Abstract: Objective: To assess whether prehospital triage guidelines, based on mechanistic criteria alone, accurately identify victims of motor vehicle accidents (MVA) with major injury. Methods: Retrospective analysis of the Royal Melbourne Hospital trauma database. Mechanisms analysed were those outlined by the American College of Surgeons Committee on Trauma and Advanced Trauma Life Support/Early Management of Severe Trauma prehospital triage guidelines. Results: There were 621 MVA analysed, 253 with major injury (40.7%). Multivariate logistic regression indicated prolonged extrication time ( P 0.0001), cabin intrusion ( P = 0.047), high speed ( P = 0.003) and ejection from vehicle ( P = 0.04) were statistically associated with major injury. Vehicle rollover and fatality in the same vehicle were not statistically associated with major injury. Conclusions: These data suggest that existing guidelines for the prehospital triage of MVA victims, based on mechanistic criteria alone may need revision.
Publisher: Elsevier BV
Date: 2015
DOI: 10.1016/J.INJURY.2014.08.050
Abstract: Red blood cell (RBC) transfusion is often essential during trauma resuscitation but is associated with high cost and potential adverse outcomes. This study aimed to determine the incidence of potentially avoidable RBC transfusions (PAT) among adult major trauma patients. A retrospective review of data collected by Registry on patients presenting between Jan 2006 and Dec 2011 was conducted. Eligible patients received at least 1 unit of RBC in the first 24h following presentation to the Emergency Department (ED). Episodes of PAT were determined according to haemodynamic stability and post-transfusion haemoglobin levels. There were 621 patients included, of whom 224 (36.1% 95% CI: 32.3-40.0) received PAT. Of them, 132 (58.9%) were haemodynamically stable on arrival and did not require a surgical procedure. Patients with PAT had significantly lower injury severity scores (30 vs 34, p<0.01), higher presenting systolic blood pressure (129 vs 112mm Hg, p<0.01) and a lower frequency of a shock index ≥1 (24.1 vs 65.0%, p<0.01), compared to those without PAT. They also had a significantly lower mortality (13.4 vs 21.7%, p<0.01). PAT after trauma was common and often delivered to haemodynamically stable patients who did not require surgical procedures. Clinical decision pathways for trauma resuscitation should aim to limit PAT.
Publisher: BMJ
Date: 08-2013
DOI: 10.1136/EMERMED-2013-203000
Abstract: All emergency departments (EDs) have an obligation to deliver care that is demonstrably safe and of the highest possible quality. Emergency medicine is a unique and rapidly developing specialty, which forms the hub of the emergency care system and strives to provide a consistent and effective service 24 h a day, 7 days a week. The International Federation of Emergency Medicine, representing more than 70 countries, has prepared a document to define a framework for quality and safety in the ED. Following a consensus conference and with subsequent development, a series of quality indicators have been proposed. These are tabulated in the form of measures designed to answer nine quality questions presented according to the domains of structure, process and outcome. There is an urgent need to improve the evidence base to determine which quality indicators have the potential to successfully improve clinical outcomes, staff and patient experience in a cost-efficient manner--with lessons for implementation.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2011
Publisher: Elsevier BV
Date: 08-2017
DOI: 10.1016/J.RESUSCITATION.2017.06.002
Abstract: Clear and efficient communication between emergency caller and call-taker is crucial to timely ambulance dispatch. We aimed to explore the impact of linguistic variation in the delivery of the prompt "okay, tell me exactly what happened" on the way callers describe the emergency in the Medical Priority Dispatch System We analysed 188 emergency calls for cases of paramedic-confirmed out-of-hospital cardiac arrest. We investigated the linguistic features of the prompt "okay, tell me exactly what happened" in relation to the format (report vs. narrative) of the caller's response. In addition, we compared calls with report vs. narrative responses in the length of response and time to dispatch. Callers were more likely to respond with a report format when call-takers used the present perfect ("what's happened") rather than the simple past ("what happened") (Adjusted Odds Ratio [AOR] 4.07 95% Confidence Interval [95%CI] 2.05-8.28, p<0.001). Reports were significantly shorter than narrative responses (9s vs. 18s, p<0.001), and were associated with less time to dispatch (50s vs. 58s, p=0.002). These results suggest that linguistic variations in the way the scripted sentences of a protocol are delivered can have an impact on the efficiency with which call-takers process emergency calls. A better understanding of interactional dynamics between caller and call-taker may translate into improvements of dispatch performance.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2015
Publisher: Medical Journals Sweden AB
Date: 2015
Abstract: To estimate the potential improvement in acute and rehabilitation hospital length of stay for rehabilitation patients from hypothetical scenarios that address barriers to patient flow. Data about the duration of key processes for patients (n = 360) admitted to acute hospitals and subsequently transferred to inpatient rehabilitation in 2 wards in Melbourne, Australia were used to develop a computer simulation model. Simulated patients. A computer model of length of stay was developed, validation checks performed and alternate care pathways simulated. Almost all scenarios resulted in significant changes in the length of stay compared with baseline. The effect size for the changes was typically small to medium. The duration of the rehabilitation discharge barriers showed significant changes in all hypothetical scenarios. The effect size was smaller when changes were made to a single barrier, but larger when multiple barriers were changed simultaneously. Health system modelling can provide information regarding potential improvements in length of stay from addressing barriers to patient flow affecting rehabilitation patients. This can inform reforms to models of care and assist with cost benefit analyses.
Publisher: Elsevier BV
Date: 04-2013
Publisher: Wiley
Date: 04-10-2013
DOI: 10.1111/J.1445-2197.2012.06285.X
Abstract: The Australian and New Zealand Haemostasis Registry (ANZHR) included patients who received off-licence recombinant activated factor VII (rFVIIa) for critical bleeding from 2000 to 2009. Approximately 1.3% of the ANZHR patients were Jehovah's Witnesses (JWs). We compared them with the non-JW patients in the registry. Patient characteristics (e.g. gender, context of bleeding), factors influencing rFVIIa use (e.g. body temperature and pH) and outcomes (e.g. bleeding response (stopped/attenuated or unchanged) to rFVIIa, mortality) were compared between JW and non-JW patients using Fisher's exact chi-square tests and Kruskal-Wallis tests. A total of 42 JW and 3134 non-JW patients were included in the analysis. Approximately 99% (n = 3098) of non-JWs received blood products compared with only 30% (n = 13) of JWs (P < 0.01). The distribution of gender and contexts of critical bleeding in the two groups was significantly different. Approximately 17% of the non-JW patients were hypothermic (T < 35°C) and about 19% were acidotic (pH < 7.2) at the time of initial rFVIIa administration. Conversely, none of the JWs were hypothermic and only one was acidotic. The proportion of positive responders to rFVIIa (stopped/attenuated bleeding following rFVIIa use) was similar in both groups (75% non-JWs, 74% JWs P = 1.0). Approximately 28% of non-JW and 17% of JW patients were deceased by day 28 following rFVIIa use (P = 0.16). Several factors were observed to be significantly different between JW and non-JW patients, yet the proportions of responders to rFVIIa were similar in both groups. The actual factors influencing response to rFVIIa are yet to be determined.
Publisher: AMPCo
Date: 2017
DOI: 10.5694/MJA16.00341
Abstract: To evaluate the impact of comprehensive public awareness c aigns by the National Heart Foundation of Australia on emergency medical service (EMS) use by people with chest pain. A retrospective analysis of 253428 emergency ambulance attendances for non-traumatic chest pain in Melbourne, January 2008 - December 2013. Time series analyses, adjusted for underlying trend and seasonal effects, assessed the impact of mass media c aigns on EMS use. Monthly ambulance attendances. The median number of monthly ambulance attendances for chest pain was 3609 (IQR, 3011-3891), but was higher in c aign months than in non-c aign months (3880 v 3234, P<0.001). After adjustments, c aign activity was associated with a 10.7% increase (95% CI, 6.5-14.9% P<0.001) in monthly ambulance use for chest pain, and a 15.4% increase (95% CI, 10.1-20.9% P<0.001) when the two-month lag periods were included. Clinical presentations for suspected acute coronary syndromes, as determined by paramedics, increased by 11.3% (95% CI, 6.9-15.9% P<0.001) during c aigns. Although the number of patients transported to hospital by ambulance increased by 10.0% (95% CI, 6.1-14.2% P<0.001) during c aign months, the number of patients not transported to hospital also increased, by 13.9% (95% CI, 8.3-19.8% P<0.001). A public awareness c aign about responding to prodromal acute myocardial infarction symptoms was associated with an increase in EMS use by people with chest pain and suspected acute coronary syndromes. C aign activity may also lead to increased EMS use in low risk populations.
Publisher: Springer Science and Business Media LLC
Date: 02-2010
DOI: 10.2165/11319750-000000000-00000
Abstract: Sport and active recreation injuries are common. Participants are generally young, healthy and physically active in iduals and as a result their injuries can have long-ranging effects for both the in iduals and society. Accurate and appropriate measurement of the outcomes of sport and active recreation injuries is essential for understanding the time frame and quality of recovery, and quantifying the burden of these injuries. The WHO has developed a framework that can be used for studying health-related outcomes called the International Classification of Function (ICF). As such, the ICF is a useful tool for assessing the suitability of outcome measures for general sport and active recreation populations. This article provides a review of outcome measures that are potentially suitable for use in a general sport and active recreation injury population, assessed within the framework of the ICF. An extensive literature search was performed to identify instruments used in sport and active recreation (and general) injury populations that would be suitable for measuring the outcomes and burden of sport and recreation injuries and return to physical activity. The search identified six health status and health-related quality-of-life (HR-QOL) measures and five functional outcome measures. Of the outcome measures reviewed, the Short Form-36 was the most commonly used and covered many of the areas relevant to a sport and active recreation population. The comprehensiveness of the Sickness Impact Profile-36 meant that it contained many relevant items however, its usefulness is limited by its high level of responder burden. The Musculoskeletal Functional Assessment provided a detailed measure of function, appropriate to a sport and active recreation population, and the Glasgow Outcome Scale-Extended can provide a suitable global measure of function. The Short International Physical Activity Questionnaire is a potential means of measuring return to physical activity for this group. There are no outcome measures specifically designed to measure outcomes in a general sport and active recreation population. There are, however, existing measures that when used in combination have the potential to provide a comprehensive assessment of injury outcomes in this group. Future research should focus on validating existing measures suitable for a sport and active recreation population as well as developing an ICF sport and active recreation core set of items. An ICF core set would assist researchers and clinicians in selecting the combination of outcome measures most appropriate to their needs as well forming the basis for the development of a specific sport and active recreation outcome measure.
Publisher: Elsevier BV
Date: 09-2010
DOI: 10.1016/J.RESUSCITATION.2010.04.029
Abstract: Previous studies of paediatric cardiac arrest have reported a low survival rate but there is limited data from Australia. We sought to determine the characteristics and outcomes of paediatric out-of-hospital cardiac arrest in Melbourne, Australia. Between October 1999 and June 2007, all cases of out-of-hospital cardiac arrest attended by emergency medical services in Melbourne, Australia were entered into a database (the Victorian Ambulance Cardiac Arrest Registry). Data on patients aged less than 16 years in cardiac arrest on arrival of ambulance paramedics was analysed. There were 209 children in cardiac arrest on arrival of paramedics during the study period. Of these, resuscitation was not attempted in 16 children due to signs of definite death. Of the 193 children who had attempted resuscitation, 143 (74%) had an initial cardiac rhythm of asystole, 36 (18%) were in pulseless electrical activity and 14 (7%) were in ventricular fibrillation. There were 49 patients (25%) with return of spontaneous circulation at arrival to hospital of whom 14 (7%) survived to hospital discharge. Of 138 patients without return of a circulation, 120 were transported to hospital with continuing resuscitation and one survived (0.9%). Survival was higher in patients with an initial cardiac rhythm of ventricular fibrillation (5/14 35%) compared with other rhythms (10/179 4%), OR 9.38, 95% CI 2.64-33.2. Overall, 7.7% of paediatric patients with out-of-hospital cardiac arrest survive to leave hospital. Increased survival was seen if the initial cardiac rhythm was ventricular fibrillation. Survival was very rare (<1%) unless there was return of spontaneous circulation prior to hospital arrival.
Publisher: Elsevier BV
Date: 09-2010
Publisher: Elsevier BV
Date: 07-2020
Publisher: Springer Science and Business Media LLC
Date: 06-09-2017
Publisher: Wiley
Date: 10-2009
DOI: 10.1111/J.1445-5994.2008.01733.X
Abstract: Measuring healthcare quality has become an increasingly important task for regulating bodies and healthcare institutions. Strategically chosen quality indicators provide a means of understanding the quality and safety of the healthcare system. Current frameworks developed to determine aspects of care to be measured do not provide the level of precision required to ensure that indicators are best selected to enable focused action to improve health. We propose a clearly structured process for selecting indicators at a national and local level based on six steps: (i) identify the problem for which measurement is needed, (ii) identify the perspective from which to measure, (iii) focus measurement on transition points through the health system, (iv) identify the type of probe required, (v) apply evaluation criteria to prioritize indicator selection and action and (vi) test the indicator in the clinical setting to which it will be applied. These steps should form the basis of a framework to drive quality indicator development.
Publisher: Wiley
Date: 06-2009
DOI: 10.1111/J.1445-5994.2009.01961.X
Abstract: Development of indicators to measure health-care quality has progressed rapidly. This development has, however, rarely occurred in a systematic fashion, and some aspects of care have received more attention than others. The aim of this study is to identify and classify indicators currently in use to measure the quality of care provided by hospitals, and to identify gaps in current measurement. A literature search was undertaken to identify indicator sets. Indicators were included if they related to hospital care and were clearly being collected and reported to an external body. A two-person independent review was undertaken to classify indicators according to aspects of care provision (structure, process or outcome), dimensions of quality (safety, effectiveness, efficiency, timeliness, patient-centredness and equity), and domain of application (hospital-wide, surgical and non-surgical clinical specialities). 383 discrete indicators were identified from 22 source organizations or projects. Of these, 27.2% were relevant hospital-wide, 26.1% to surgical patients and 46.7% to non-surgical specialities, departments or diseases. Cardiothoracic surgery, cardiology and mental health were the specialities with greatest coverage, while nine clinical specialities had fewer than three specific indicators. Processes of care were measured by 54.0% of indicators and outcomes by 38.9%. Safety and effectiveness were the domains most frequently represented, with relatively few indicators measuring the other dimensions. Despite the large number of available indicators, significant gaps in measurement still exist. Development of indicators to address these gaps should be a priority. Work is also required to evaluate whether existing indicators measure what they purport to measure.
Publisher: Wiley
Date: 04-2005
DOI: 10.1197/J.AEM.2004.12.002
Abstract: Inclusion of a measure of comorbidity in trauma scoring has been suggested due to the potential for preexisting conditions to impact on patient outcomes, but studies have reported varied results. The Charlson Comorbidity Index (CCI) includes 19 diseases weighted on the basis of their association with mortality, and can be extrapolated from International Classification of Diseases, Ninth Revision (ICD-9) codes for administrative databases. To evaluate the CCI as a predictor of trauma outcome. Major trauma patient data from the Victorian State Trauma Registry (VSTR) were used to evaluate the CCI (n = 2,819). The CCI was scored from ICD-10 codes through modification of a previous method of mapping ICD-9 codes to the CCI. Logistic regression was used to determine the association between the CCI and mortality, the effect of adding the CCI to the Trauma and Injury Severity Score (TRISS) methodology, and the impact of adding the CCI to a modification of the TRISS methodology. Model performance was assessed through discrimination and calibration. The CCI was associated with death (p < 0.001), but adding the CCI to TRISS [area under the receiver-operating characteristic curve (AUC) 0.86 95% CI = 0.84 to 0.88] did not result in improved discrimination over TRISS alone (AUC 0.83 95% CI = 0.81 to 0.86). Modifying TRISS methodology, with age left as a continuous variable, performed better than the original TRISS (AUC 0.91 95% CI = 0.89 to 0.92), but the addition of the CCI did not further improve this model (AUC 0.91 95% CI = 0.89 to 0.92). While the CCI can be extrapolated from ICD codes and provides a measure of comorbid condition severity and was associated with mortality, addition of the CCI to prediction models did not result in a substantial improvement in performance.
Publisher: Informa UK Limited
Date: 20-11-2018
DOI: 10.1080/02699052.2017.1385097
Abstract: This systematic review aimed to determine the prognostic value of neuron-specific enolase (NSE) to predict post-concussion symptoms following mild traumatic brain injury (TBI). Seven databases were searched for studies evaluating the association between NSE levels and post-concussion symptoms assessed ≥ 3 months (persistent) or ≥ 7 days < 3 months (early) after mild TBI. Two researchers independently screened studies for inclusion, extracted data and appraised quality using the Quality in Prognostic Studies (QUIPS) tool. The search strategy yielded a total of 23,298 citations from which 8 cohorts presented in 10 studies were included. Studies included between 45 and 141 patients (total 608 patients). The outcomes most frequently assessed were post-concussion syndrome (PCS, 12 assessments) and neuropsychological performance deficits (10 assessments). No association was found between an elevated NSE serum level and PCS. Only one study reported a statistically significant association between a higher NSE serum level and alteration of at least three cognitive domains at 2 weeks but this association was no longer significant at 6 weeks. Overall, risk of bias of the included studies was considered moderate. Early NSE serum level is not a strong independent predictor of post-concussion symptoms following mild TBI.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 19-01-2016
Publisher: Wiley
Date: 17-11-2012
DOI: 10.1111/J.1423-0410.2011.01564.X
Abstract: Early prediction of massive transfusion (MT) post-trauma may reduce mortality by earlier delivery of blood products. A clinical prediction tool (PWH score) for this purpose was developed at the Prince of Wales Hospital, Hong Kong. The aims of this study were to apply this tool to major trauma patients in Victoria, Australia and compare the score to the Assessment of Blood Consumption (ABC) score and the Trauma-Associated Severe Haemorrhage (TASH) score. A retrospective review of patients entered into the The Alfred Trauma Registry between January 2006 and December 2009 was conducted. The performance of the PWH score to predict MT defined by 5 units of packed red blood cells in 4 h was compared with the ABC and TASH scores. Included patients presented to the Emergency & Trauma Centre from the scene and had had complete datasets with respect to the components of the three scores. There were 1234 patients included in the study with 195 (15·8%) receiving a MT and an overall mortality of 14·0%. The PWH score had an area under the receiver operating characteristics (ROC) curve of 0·842 (95% CI: 0·820-0·862). The area under the ROC curve of the PWH score was significantly less than that of the TASH score (χ(2)=19·8, P<0·001) and significantly greater than that of the ABC score (χ(2)=9·3, P=0·002). The PWH score performs with similar accuracy when applied to an Australian population as in its derivation population. The relative simplicity of the PWH score makes it a viable tool for clinical use, although utility of such tools may be more suited for research in determining inclusion or exclusion criteria for comparative outcome studies.
Publisher: Wiley
Date: 10-10-2022
Abstract: 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. 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. 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 ex le, the negative correlation between high triage acuity and joint pain. 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.
Publisher: BMJ
Date: 04-2016
Publisher: AMPCo
Date: 10-2013
DOI: 10.5694/MJA13.11030
Publisher: Wiley
Date: 20-12-2005
Publisher: Elsevier BV
Date: 2012
DOI: 10.1016/J.RESUSCITATION.2011.06.030
Abstract: CPR in patients in residential aged care facilities (RACF) deserves careful consideration. We examined the characteristics, management and outcomes of out-of-hospital cardiac arrest (OHCA) in RACF patients in Melbourne, Australia. The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for all OHCAs occurring in RACFs in Melbourne. The characteristics and outcomes were compared to non-RACF patients in the VACAR. Between 2000 and 2009 there were 30,006 OHCAs, 2350 (7.8%) occurring in a RACF. A shockable rhythm was present in 179 (7.6%) patients on arrival of paramedics of whom bystander CPR had been performed in 118 (66%) 173 (97%) received an EMS attempted resuscitation. ROSC was achieved in 71 (41%) patients and 15 (8.7%) patients survived to leave hospital. Non shockable rhythm was present in 2171 patients (92%) of whom 804 (37%) had an attempted resuscitation by paramedics. ROSC was achieved in 176 patients (22%) and 10 patients (1.2%) were discharged alive. Survival from OHCA occurring in a RACF was less than survival in those aged >70 years of age who suffered OHCA in their own homes (1.8% vs. 4.7%, p=0.001). On multivariable analysis, witnessed OHCA (OR 3.0, 95% CI 2.4-3.7) and the presence of bystander CPR (OR 4.6, 95% CI 3.7-5.8) was associated with the paramedic decision to resuscitate. Resuscitation of patients in RACF is not futile. However, informed decisions concerning resuscitation status should be made by patients and their families on entry to a RACF. Where it is appropriate to perform resuscitation, outcomes may be improved by the provision of BLS training and possibly AED equipment to RACF staff.
Publisher: Elsevier BV
Date: 09-2009
Publisher: Elsevier BV
Date: 03-2011
DOI: 10.1016/J.RESUSCITATION.2010.10.016
Abstract: Serious sequelae have been associated with injured patients who are hypothermic (<35°C) including coagulopathy, acidosis, decreased myocardial contractility and risk of mortality. Establish the incidence of accidental hypothermia in major trauma patients and identify causative factors. Prospective identification and subsequent review of 732 medical records of major trauma patients presenting to an Adult Major Trauma Centre was undertaken between January and December 2008. Multivariate analysis was performed using logistic regression. Significant and clinically relevant variables from univariate analysis were entered into multivariate models to evaluate determinants for hypothermia and for death. Goodness of fit was determined with the use of the Hosmer-Lemeshow statistic. Overall mortality was 9.15%. The incidence of hypothermia was 13.25%. The mortality of patients with hypothermia was 29.9% with a threefold independent risk of death: OR (CI 95%) 3.44 (1.48-7.99), P = 0.04. Independent determinants for hypothermia were pre-hospital intubation: OR (CI 95%) 5.18 (2.77-9.71), P < 0.001, Injury Severity Score (ISS): 1.04 (1.01-1.06), P = 0.01, Arrival Systolic Blood Pressure (ASBP) 35 °C.
Publisher: Elsevier BV
Date: 03-2016
DOI: 10.1016/J.INJURY.2016.01.007
Abstract: Globally, injury is a major cause of death and disability. Improvements in trauma care have been driven by trauma registries. The capacity of a trauma registry to inform improvements in the quality of trauma care is dependent upon the quality of data. The literature on data quality in disease registries is inconsistent and ambiguous methods used for classifying, measuring, and improving data quality are not standardised. The aim of this study was to review the literature to determine the methods used to classify, measure and improve data quality in trauma registries. A scoping review of the literature was performed. Databases were searched using the term "trauma registry" and its synonyms, combined with multiple terms denoting data quality. There was no restriction on year. Full-length manuscripts were included if the classification, measurement or improvement of data quality in one or more trauma registries was a study objective. Data were abstracted regarding registry demographics, study design, data quality classification, and the reported methods used to measure and improve the pre-defined data quality dimensions of accuracy, completeness and capture. Sixty-nine publications met the inclusion criteria. Four publications classified data quality. The most frequently described methods for measuring data accuracy (n=47) were checks against other datasets (n=18) and checks of injury coding (n=17). The most frequently described methods for measuring data completeness (n=47) were the percentage of included cases, for a given variable or list of variables, for which there was an observation in the registry (n=29). The most frequently described methods for measuring data capture (n=37) were the percentage of cases in a linked reference dataset that were also captured in the primary dataset being evaluated (n=24). Most publications dealing with the measurement of a dimension of data quality did not specify the methods used most publications dealing with the improvement of data quality did not specify the dimension being targeted. The classification, measurement and improvement of data quality in trauma registries is inconsistent. To maintain confidence in the usefulness of trauma registries, the metrics and reporting of data quality need to be standardised.
Publisher: Society for Neuroscience
Date: 25-02-2015
DOI: 10.1523/JNEUROSCI.3388-14.2015
Abstract: Electrical stimulation of vestibular efferent neurons rapidly excites the resting discharge of calyx/dimorphic (CD) afferents. In turtle, this excitation arises when acetylcholine (ACh), released from efferent terminals, directly depolarizes calyceal endings by activating nicotinic ACh receptors (nAChRs). Although molecular biological data from the peripheral vestibular system implicate most of the known nAChR subunits, specific information about those contributing to efferent-mediated excitation of CD afferents is lacking. We sought to identify the nAChR subunits that underlie the rapid excitation of CD afferents and whether they differ from α9α10 nAChRs on type II hair cells that drive efferent-mediated inhibition in adjacent bouton afferents. We recorded from CD and bouton afferents innervating the turtle posterior crista during electrical stimulation of vestibular efferents while applying several subtype-selective nAChR agonists and antagonists. The α9α10 nAChR antagonists, α-bungarotoxin and α-conotoxin RgIA, blocked efferent-mediated inhibition in bouton afferents while leaving efferent-mediated excitation in CD units largely intact. Conversely, 5-iodo-A-85380, sazetidine-A, varenicline, α-conotoxin MII, and bPiDDB ( N , N -dodecane-1,12-diyl- bis -3-picolinium dibromide) blocked efferent-mediated excitation in CD afferents without affecting efferent-mediated inhibition in bouton afferents. This pharmacological profile suggested that calyceal nAChRs contain α6 and β2, but not α9, nAChR subunits. Selective blockade of efferent-mediated excitation in CD afferents distinguished dimorphic from calyx afferents by revealing type II hair cell input. Dimorphic afferents differed in having higher mean discharge rates and a mean efferent-mediated excitation that was smaller in litude yet longer in duration. Molecular biological data demonstrated the expression of α9 in turtle hair cells and α4 and β2 in associated vestibular ganglia.
Publisher: Elsevier BV
Date: 06-2013
DOI: 10.1016/J.INJURY.2013.03.007
Abstract: Head injury is the leading cause of death and long term disability from bicycle injuries and may be prevented by helmet wearing. We compared the pattern of injury in major trauma victims resulting from bicyclist injury admitted to hospitals in the State of Victoria, Australia and South-West Netherlands, with respective high and low prevalence of helmet use among bicyclists. A cohort of bicycle injured patients with serious injury (defined as Injury Severity Score>15) in South-West Netherlands, was compared to a cohort of serious injured bicyclists in the State of Victoria, Australia. Additionally, the cohorts of patients with serious injury admitted to a Dutch level 1 trauma centre in Rotterdam, the Netherlands and an Australian level 1 trauma centre in Melbourne, Australia were compared. Both cohorts included patients admitted between July 2001 and June 2009. Primary outcome was in-hospital mortality and secondary outcome was prevalence of severe injury per body region. Outcome was compared using univariate analysis and mortality outcomes were also calculated using multivariable logistic regression models. A total of 219 cases in South-West Netherlands and 500 cases in Victoria were analyzed. Further analyses comparing the major trauma centres in each region, showed the percentage of bicycle-related death was higher in the Dutch population than in the Australian (n=45 (24%) vs n=13(7%) P<0.001). After adjusting for age, mechanism of injury, GCS and head injury severity in both hospitals, there was no significant difference in mortality (adjusted odds ratio 1.4 95% confidence interval=0.6, 3.5). Patients in Netherlands trauma centre suffered from more serious head injuries (Abbreviated Injury Scale≥3) than patients in the Australian trauma centre (n=165 (88.2%) vs n=121 (62.4%) P<0.001). The other body regions demonstrated significant differences in the AIS scores with significantly more serious injuries (AIS≥3) of the chest, abdominal and extremities regions in the Australian group. Bicycle related major trauma admissions in the Netherlands trauma centre, and in South-West Netherlands had a higher mortality rate associated with a higher percentage of serious head injuries compared with that in the Australian trauma centre and the State of Victoria.
Publisher: Wiley
Date: 08-2005
DOI: 10.1111/J.1445-2197.2005.03484.X
Abstract: The present study explored a range of variables to identify predictors of mortality and morbidity and to develop prediction models based on these variables. Tools for predicting mortality, hospital length of stay and a patient's destination post-hospital discharge were developed using logistic regression in one dataset (design) and evaluated for prediction performance in a separate dataset (validation). The performance of the mortality model was compared to the trauma and injury severity score (TRISS) and a severity characterization of trauma (ASCOT). The profile of variables contributing to the final prediction models developed from the design dataset varied across the different outcomes of interest although age, injury severity score, development of complications and triage category were common predictors of all three outcomes. The performance of the new mortality prediction model was superior to both TRISS and ASCOT in the validation dataset. Overall, the new models did not meet the prespecified performance criteria. The present study identified key predictors of mortality and morbidity (length of hospital stay and discharge destination). The newly developed mortality model out-performed published trauma scoring methods. However, further development and trial of the new prediction models is required before implementation as definitive audit and benchmarking tools could be recommended.
Publisher: Wiley
Date: 05-01-2023
Abstract: 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). 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. 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. 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.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2014
Publisher: Elsevier BV
Date: 09-2007
DOI: 10.1016/J.INJURY.2007.05.003
Abstract: There is increasing use of rFVIIa (eptagog alpha, Novoseven) in injured patients with critical bleeding. The role of rFVIIa is not defined in this group of patients. Registries provide an opportunity to review the patients, reported response and adverse events for rFVIIa. To determine the pattern of use, reported response and adverse events in patients receiving rFVIIa following injury using the Australian and New Zealand Haemostasis Registry (ANZHR). The ANZHR (commenced May 2005) collects data from 53 hospitals on all patients receiving rFVIIa in those hospitals. Of 695 cases in the registry, 108 patients from 19 hospitals were submitted with a primary trauma diagnosis. Most (88) patients received one 90microg/kg dose of rFVIIa. There was a significant reduction in the use of all blood products following rFVIIa (p<0.001) and rFVIIa was thought to have decreased or stopped bleeding in 59% of cases. There was wide variation in the timing of rFVIIa use. There were two adverse events that were considered possibly linked and a total of three thromboembolic events. Following multivariate analysis, pH provided the best model of response to rFVIIa. Patients with a pH<7.05 were significantly less likely to respond (OR=0.3, 95% CI=0.0-0.3). Only two patients would fit the criteria for the present prospective study of rFVIIA in trauma patients. The best approach to managing critical bleeding in trauma patients is not agreed. The role of rFVIIa will only be clarified if there is a standardised approach to fluid management and transfusion of blood products. The registry allows tracking of current practice, outcomes and adverse events and will complement present phase 2 and 3 trials.
Publisher: Springer Science and Business Media LLC
Date: 11-1994
Publisher: Oxford University Press (OUP)
Date: 12-10-2017
DOI: 10.1002/BJS.10638
Abstract: Assessment of functional outcomes in survivors of severe injury is an identified priority for trauma systems. The predictive Functional Capacity Index (pFCI) within the 2008 Abbreviated Injury Scale dictionary (pFCI08) offers a widely available tool for predicting functional outcomes without requiring long-term follow-up. This study aimed to assess the 12-month functional outcome predictions of pFCI08 in a major trauma population, and to test the assumptions made by its developers to ensure population homogeneity. Patients with major trauma from Victoria, Australia, were followed up using routine telephone interviews. Assessment of survivors 12 months after injury included the Glasgow Outcome Scale – Extended (GOS-E). κ scores were used to measure agreement between pFCI08 and assessed GOS-E scores. Of 20 098 patients with severe injury, 12 417 had both pFCI08 and GOS-E scoring available at 12 months. The quadratic weighted κ score across this population was 0·170 this increased to 0·244 in the subgroup of 1939 patients who met all pFCI assumptions. However, expanding the age range used in this group did not significantly affect κ scores until patients over the age of 70 years were included. The pFCI08 has only a slight agreement with outcomes following major trauma. However, the age limits in the pFCI development assumptions are unnecessarily restrictive. The pFCI08 may be able to contribute to future systems predicting functional outcomes following severe injury, but is likely to explain only a small proportion of the variability in patient outcomes.
Publisher: British Editorial Society of Bone & Joint Surgery
Date: 04-2006
DOI: 10.1302/0301-620X.88B4.17223
Abstract: Although the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was designed, and has been validated, as a measure of disability in patients with disorders of the upper limb, the influence of those of the lower limb on disability as measured by the DASH score has not been assessed. The aim of this study was to investigate whether it exclusively measures disability associated with injuries to the upper limb. The Short Musculoskeletal Functional Assessment, a general musculoskeletal assessment instrument, was also completed by participants. Disability was compared in 206 participants, 84 with an injury to the upper limb, 73 with injury to the lower limb and 49 controls. We found that the DASH score also measured disability in patients with injuries to the lower limb. Care must therefore be taken when attributing disability measured by the DASH score to injuries of the upper limb when problems are also present in the lower limb. Its inability to discriminate clearly between disability due to problems at these separate sites must be taken into account when using this instrument in clinical practice or research.
Publisher: AMPCo
Date: 11-2011
DOI: 10.5694/MJA10.11361
Abstract: To determine perceptions of barriers to admission to subacute care from acute hospital care, and barriers to subsequent discharge from subacute care. Web-based survey of key stakeholders using Likert scales and closed questions. Prompts were emailed repeatedly to potential participants in Australia between 15 May and 24 July 2009. Participants were physicians working in inpatient rehabilitation medicine and aged care units, as well as senior hospital managers with responsibility for patient flow. Perceived admission and discharge barriers in subacute care. Half of the 101 respondents reported barriers to admission to subacute hospitals as moderate, severe or extreme, and 81% reported a similar grading of severity for barriers to discharge. There was no relationship between these perceptions and whether respondents worked only in the public hospital system (barriers to access: χ² = 0.02 [df = 1 P = 1.0] and barriers to discharge: χ² = 0.0 [df = 1 P = 1.0]). The most commonly reported barriers to admission were: availability of beds (61% of respondents) physical, environmental and equipment inadequacies (62% of respondents) and allied health or nursing staff issues (55% of respondents). The most commonly reported barriers to discharge included: waiting for a more appropriate setting of care (76% of respondents) and funding for home modifications, equipment or carers (55% of respondents). There was no relationship between respondents' position and their reporting of various admission (χ² = 6.2 df = 8 P = 0.6) or discharge barriers (χ² = 13.8 df = 12 P = 0.3). There is a strong perception among key stakeholders in subacute care that there are major barriers to patient admission and discharge. Redistributing proposed funding for inpatient subacute beds to measures for overcoming these barriers is likely to improve patient flow though the whole hospital system.
Publisher: Elsevier BV
Date: 07-2000
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 16-06-2015
DOI: 10.1161/CIRCULATIONAHA.114.014494
Abstract: Oxygen is commonly administered to patients with ST-elevation–myocardial infarction despite previous studies suggesting a possible increase in myocardial injury as a result of coronary vasoconstriction and heightened oxidative stress. We conducted a multicenter, prospective, randomized, controlled trial comparing oxygen (8 L/min) with no supplemental oxygen in patients with ST-elevation–myocardial infarction diagnosed on paramedic 12-lead ECG. Of 638 patients randomized, 441 patients had confirmed ST-elevation–myocardial infarction and underwent primary end-point analysis. The primary end point was myocardial infarct size as assessed by cardiac enzymes, troponin I, and creatine kinase. Secondary end points included recurrent myocardial infarction, cardiac arrhythmia, and myocardial infarct size assessed by cardiac magnetic resonance imaging at 6 months. Mean peak troponin was similar in the oxygen and no oxygen groups (57.4 versus 48.0 μg/L ratio, 1.20 95% confidence interval, 0.92–1.56 P =0.18). There was a significant increase in mean peak creatine kinase in the oxygen group compared with the no oxygen group (1948 versus 1543 U/L means ratio, 1.27 95% confidence interval, 1.04–1.52 P =0.01). There was an increase in the rate of recurrent myocardial infarction in the oxygen group compared with the no oxygen group (5.5% versus 0.9% P =0.006) and an increase in frequency of cardiac arrhythmia (40.4% versus 31.4% P =0.05). At 6 months, the oxygen group had an increase in myocardial infarct size on cardiac magnetic resonance (n=139 20.3 versus 13.1 g P =0.04). Supplemental oxygen therapy in patients with ST-elevation–myocardial infarction but without hypoxia may increase early myocardial injury and was associated with larger myocardial infarct size assessed at 6 months. URL: www.clinicaltrials.gov . Unique identifier: NCT01272713.
Publisher: CSIRO Publishing
Date: 2014
DOI: 10.1071/AH13217
Abstract: Objective To assess the time taken to complete a Synthesised Geriatric Assessment (SGA) in an Emergency Department (ED) and to determine what secondary patient characteristics affect results. Methods A convenience s le of 25 patients aged over 65 from an Australian single-centre ED was used for this pilot study. Primary outcome measures included the overall time taken as well as the times for in idual screening instruments. Data regarding patient characteristics were taken as secondary outcome measures to assess impact on times. For each of the screening instruments, the mean, median, interquartile range and the 90th percentile for the test duration was calculated. Linear regression was used to evaluate univariate associations between times and patient characteristics. P-values 0.05 were considered as statistically significant. Results Time required for completion of the SGA by 90% of the study population was 20 min and 40 s. This represents approximately 8.6% of new 4-h ED targets. Secondary characteristics that affected the time taken for screening included patients from non-English-speaking backgrounds (P 0.05). Conclusions Use of the SGA for intra-ED geriatric risk stratification is feasible and practical in the time-critical National Emergency Access Target (NEAT) environment. The relatively short amount of time used for screening this vulnerable demographic has implications for interdisciplinary management and potentially represents an efficient intervention to reduce future re-presentations and overcrowding in Australian EDs. Future high-quality trials are required to assess the clinical benefit of the SGA. What is known about the topic? The newly introduced ED NEAT encourages patient discharge from ED within 4 h of arrival, placing increased pressure on ED protocols to be time efficient, while still maintaining safe quality care. The Comprehensive Geriatric Assessment in inpatient and ED settings has demonstrated improved outcomes in populations aged 65, including parameters of ED re-presentations, functional independence and short-term mortality. Geriatric emergency patient guidelines have been recently adopted in the US and UK which incorporate intra-ED geriatric screening processes. Studies focusing on the feasibility of geriatric screening in Australian EDs are scarce. What does this paper add? Our pilot study focuses on the timing requirements of geriatric screening in time-critical ED environments. We analysed the time taken to conduct a SGA that was developed for a large research project, and the secondary patient characteristics that affected these times. Our paper provides valuable information for Australian EDs when considering the introduction of geriatric screening into EDs to optimise the care and outcomes of this patient group. Analysis of secondary patient characteristics and data patterns will further help EDs and future research into design of new protocols. What are the implications for practitioners? The results of our pilot study suggest that use of the SGA in Australian ED settings is feasible and practical. By using the results of our pilot study, EDs and clinician researchers can make informed decisions about implementation of new protocol to manage older patients. We suggest that implementation of intra-ED geriatric screening assessments will result in improved patient outcomes, including long-term functional independence and decreased rates of ED re-presentation. This in turn would help to unclog our currently overloaded EDs.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2012
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2004
DOI: 10.1097/01.TA.0000053398.40463.51
Abstract: This study was undertaken to describe the epidemiology of motor vehicle mortality in Hong Kong, and to assess its impact on trauma service delivery. Hong Kong has an area of 1,072 km2 and a population of 6,800,000. There were 500,000 registered vehicles in 2001. All motor vehicle deaths must be reported to the coroner in Hong Kong. A manual retrospective review of all coroner case notes involving motor vehicles for 2001 was performed. The review identified 165 cases involving 111 male and 54 female patients. Elderly cases were predominant, with 37% of the cases involving in iduals older than 60 years. Most of the cases involved pedestrians (59%), and half of these pedestrians had experienced collisions with public light buses and trucks. Alcohol was not commonly involved, and when it was, it was isolated to the group 20 to 40 years of age. Most in iduals died of major head injury alone or multiple injuries. There were very few major vessel injuries, and these included 13 aortic transections. Hong Kong has a very low motor vehicle death rate relative to its population (2.4 per 100,000), but the rate is less impressive when it is related to motor vehicle registrations (33 per 100,000 vehicles). The low incidence of motor vehicle trauma has implications for trauma service delivery in terms of trauma expertise and specialization. Despite the low incidence of trauma, there still are opportunities for prevention, especially in relation to elderly pedestrians and public light buses.
Publisher: Springer Science and Business Media LLC
Date: 28-10-2016
Publisher: Elsevier BV
Date: 2010
DOI: 10.1016/J.INJURY.2009.09.029
Abstract: Recent retrospective studies have found high fresh frozen plasma (FFP) to packed red blood cell (PRBC) ratios during trauma resuscitation to be associated with improved mortality. Whilst this association may be related to a mortality bias present in these studies, there has been an overall tendency towards a 1:1 FFP:PRBC ratio in massive transfusion guidelines worldwide. The aim of this study was to retrospectively review the administration of FFP in patients undergoing massive transfusion during trauma resuscitation, to add to the evidence base for massive transfusion guidelines. Multi-trauma patients who were administered blood transfusions of 5units or more of packed red blood cells (PRBCs) in the first 4h were included in this study. Mortality was the primary endpoint with length of hospital stay, ICU hours and mechanically ventilated hours secondary endpoints. There were 331 patients included in this study with a median Injury Severity Score (ISS) of 36 (25-50) and a mortality of 29.9%. There was little change in the ratio of FFP:PRBC transfused per patient from 2005 to 2008. A low FFP:PRBC ratio in the first 4h of resuscitation, older age, low initial GCS and coagulopathy on presentation were significant independent factors associated with mortality. When deaths in the first 24h were excluded, the FFP:PRBC ratio had no association with mortality. This study has shown increased initial survival in association with higher FFP:PRBC ratios during massive transfusion in a population with a high proportion of blunt injuries. The association is difficult to interpret because of an inherent survival bias. The optimal ratio of FFP:PRBC during massive transfusion may be different to 1:1 and further prospective research is required. There is now an increasing need for well designed randomised controlled trials to determine the best FFP:PRBC ratio for the resuscitation of blunt multi-trauma patients.
Publisher: Springer Science and Business Media LLC
Date: 28-08-2012
Publisher: Springer Science and Business Media LLC
Date: 13-10-2011
Publisher: Wiley
Date: 29-10-2003
DOI: 10.1046/J.1445-1433.2003.02833.X
Abstract: The revised trauma score (RTS) has been embraced by the trauma community worldwide. Although originally developed as a triage tool, the use of the RTS has since been expanded to include the prediction of outcome following traumatic injury. Through a critical review of the literature, evidence for use of the RTS is discussed along with the limitations of this commonly used tool. In summary, the RTS is a well-established predictor of mortality in trauma populations, but there is a lack of definitive evidence supporting its use as a primary triage tool and as a predictor of outcomes other than mortality. Difficulty in collecting the components of the RTS creates issues for data validity and the use of the RTS as a research tool. Although the weighted RTS has been developed to improve the prediction capacity of the RTS, studies reporting its use are few and there is debate regarding the applicability of the published coefficients for broad use. Overall, further studies are warranted to clearly establish the usefulness of the RTS as a triage tool in the field, to further evaluate the weighted version of the RTS, and to determine the ability of the RTS to predict functional outcome and quality of life. In particular, future research is needed to address these issues in Australian trauma populations.
Publisher: Wiley
Date: 10-2010
DOI: 10.1111/J.1742-6723.2010.01334.X
Abstract: In 2009 emergency medicine had not been officially established as a specialty in Vietnam. As a result of a non-government organization identifying the need to improve the delivery of emergency care, the Vietnam2010 Symposium in Emergency Medicine was held in Hue in March 2010. This involved 1 week of activity including: an Emergency Medicine Conference, providing lectures and practical workshops in topics of emergency medicine a Deans' Conference, dedicated to the development of emergency medicine as a specialty a Disaster and EMS Conference and an Emergency Nursing Conference. Vietnam2010 was a high impact event and was successful in raising the profile of emergency medicine. It formalized key international linkages, showcased the role of the knowledge and skills relevant to emergency care and provided the impetus for emergency medicine specialization in Vietnam. A consensus document committing to the development of emergency medicine as a specialty in Vietnam was signed by multiple national and international governmental, university and emergency medicine representatives. Challenges included a tendency for international flagbearers from mature systems to promote the specialty according to local expectations, with a consequent emphasis on vertical specialty topics and on technology, and the running of medical and nursing conferences separately. Vietnam now needs a medium-term plan to develop the specialty to ensure these initial steps are translated into a sustainable capacity to provide emergency care nationally.
Publisher: Wiley
Date: 07-2010
DOI: 10.1111/J.1445-5994.2009.02044.X
Abstract: Recombinant activated factor VII (rFVIIa) is being increasingly used as a treatment option in settings of uncontrolled bleeding. Despite this, national practice guidelines are lacking, resulting in widespread practice variation between providers. This investigation aimed to describe the differences in use of rFVIIa across Australian and New Zealand hospitals. Data were extracted from the Haemostasis Registry that collects both contemporaneous and retrospective cases of off-licence (i.e. in non-haemophilia patients) rFVIIa use in participating institutions. Hospitals were classified according to geographical location and service provision. 2075 cases from 87 hospitals were recorded on the Haemostasis Registry. Across all hospital categories, over 41% of cases received rFVIIa in relation to cardiac surgery. Case complexity varied between providers, with large urban centres treating more severely ill patients. This was reflected in significant differences in the use of blood components and products before rFVIIa administration. Despite differences in patient complexity and use of blood products between hospital categories, response to treatment and patient outcomes remained similar across providers, with survival rates ranging from 68.29% to 70.41%. This is the largest study of off-licence use of rFVIIa. There is significant regional variation in the administration of rFVIIa in Australian and New Zealand hospitals, with little documentation of adherence to guidelines. National consensus guidelines based on available evidence should be developed and promulgated to ensure optimal outcomes.
Publisher: BMJ
Date: 11-2015
Publisher: Wiley
Date: 05-1999
DOI: 10.1046/J.1365-2222.1999.00567.X
Abstract: Grass pollen allergens are the most important cause of hay fever and allergic asthma during summer in cool temperate climates. Pollen counts provide a guide to hay fever sufferers. However, grass pollen, because of its size, has a low probability of entering the lower airways to trigger asthma. Yet, grass pollen allergens are known to be associated with atmospheric respirable particles. We aimed (1) to determine the concentration of group 5 major allergens in (a) pollen grains of clinically important grass species and (b) atmospheric particles (respirable and nonrespirable) and (2) to compare the atmospheric allergen load with clinical data to assess different risk factors for asthma and hay fever. We have performed a continuous 24 h s ling of atmospheric particles greater and lower than 7.2 microm in diameter during the grass pollen season of 1996 and 1997 (17 October 1996-16 January 1997) by means of a high volume cascade impactor at a height of about 15 m above ground in Melbourne. Using Western analysis, we assessed the reactivity of major timothy grass allergen Phl p 5 specific monoclonal antibody (MoAb) against selected pollen extracts. A MoAb-based ELISA was then employed to quantify Phl p 5 and cross-reactive allergens in pollen extracts and atmospheric particles larger and smaller than 7.2 microm. Phl p 5-specific MoAb detected group 5 allergens in tested grass pollen extracts, indicating that the ELISA employed here determines total group 5 allergen concentrations. On average, 0.05 ng of group 5 allergens were detectable per grass pollen grain. Atmospheric group 5 allergen concentrations in particles > 7.2 microm were significantly correlated with grass pollen counts (rs = 0.842, P < 0. 001). On dry days, 37% of the total group 5 allergen load, whereas upon rainfall, 57% of the total load was detected in respirable particles. After rainfall, the number of starch granule equivalents increased up to 10-fold starch granule equivalent is defined as a hypothetical potential number of airborne starch granules based on known pollen count data. This indicates that rainfall tended to wash out large particles and contributed to an increase in respirable particles containing group 5 allergens by bursting of pollen grains. Four day running means of group 5 allergens in respirable particles and of asthma attendances (delayed by 2 days) were shown to be significantly correlated (P < 0.001). Here we present, for the first time, an estimation of the total group 5 allergen content in respirable and nonrespirable particles in the atmosphere of Melbourne. These results highlight the different environmental risk factors for hay fever and allergic asthma in patients, as on days of rainfall following high grass pollen count, the risk for asthma sufferers is far greater than on days of high pollen count with no associated rainfall. Moreover, rainfall may also contribute to the release of allergens from fungal spores and, along with the release of free allergen molecules from pollen grains, may be able to interact with other particles such as pollutants (i.e. diesel exhaust carbon particles) to trigger allergic asthma.
Publisher: SAGE Publications
Date: 2004
DOI: 10.1177/102490790401100103
Abstract: Severe acute respiratory syndrome (SARS) is associated with a lymphopenia, thrombocytopenia and neutrophilia and suspected cases may be admitted to hospital on the basis of such abnormalities. Laboratories may report changes as percentages or absolute counts. To investigate whether absolute or percentage differential counts were more predictive of patients with SARS pneumonia. Prospective observational study. SARS clinic of an emergency department in Hong Kong. Whole blood and differential counts were performed on 506 patients presenting to a SARS screening clinic. Ninety-six patients subsequently developed SARS pneumonia. Sixty-nine patients had abnormal lymphocyte absolute counts on first attendance at clinic of which 37 (54%) developed SARS pneumonia. This compared with 142 subjects with abnormal percentage lymphocyte values of which 50 (35%) developed SARS pneumonia. The area under the ROC curve for absolute lymphocyte counts is 0.851 (95%CI 0.816 to 0.881) and for percentage lymphocytes is 0.736 (95%CI 0.694 to 0.775). The area under the ROC curve for absolute monocyte counts is 0.535 (95%CI 0.489 to 0.580) and for percentage monocytes is 0.635 (95%CI 0.591 to 0.678). The area under the ROC curve for absolute neutrophil counts is 0.591 (95%CI 0.546 to 0.636) and for percentage neutrophils is 0.703 (95%CI 0.660 to 0.744). Reporting absolute rather than percentage values for differential leucocyte counts are more accurate predictors of SARS pneumonia.
Publisher: Wiley
Date: 10-2009
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 17-08-2010
DOI: 10.1161/CIRCULATIONAHA.109.906859
Abstract: Background— Therapeutic hypothermia is recommended for the treatment of neurological injury after resuscitation from out-of-hospital cardiac arrest. Laboratory studies have suggested that earlier cooling may be associated with improved neurological outcomes. We hypothesized that induction of therapeutic hypothermia by paramedics before hospital arrival would improve outcome. Methods and Results— In a prospective, randomized controlled trial, we assigned adults who had been resuscitated from out-of-hospital cardiac arrest with an initial cardiac rhythm of ventricular fibrillation to either prehospital cooling with a rapid infusion of 2 L of ice-cold lactated Ringer’s solution or cooling after hospital admission. The primary outcome measure was functional status at hospital discharge, with a favorable outcome defined as discharge either to home or to a rehabilitation facility. A total of 234 patients were randomly assigned to either paramedic cooling (118 patients) or hospital cooling (116 patients). Patients allocated to paramedic cooling received a median of 1900 mL (first quartile 1000 mL, third quartile 2000 mL) of ice-cold fluid. This resulted in a mean decrease in core temperature of 0.8°C ( P =0.01). In the paramedic-cooled group, 47.5% patients had a favorable outcome at hospital discharge compared with 52.6% in the hospital-cooled group (risk ratio 0.90, 95% confidence interval 0.70 to 1.17, P =0.43). Conclusions— In adults who have been resuscitated from out-of-hospital cardiac arrest with an initial cardiac rhythm of ventricular fibrillation, paramedic cooling with a rapid infusion of large-volume, ice-cold intravenous fluid decreased core temperature at hospital arrival but was not shown to improve outcome at hospital discharge compared with cooling commenced in the hospital. Clinical Trial Registration— URL: www.anzctr.org.au. Unique identifier: ACTRN12605000179639.
Publisher: Elsevier BV
Date: 2014
DOI: 10.1016/J.RESUSCITATION.2013.08.258
Abstract: Preventable bystander delays following out-of-hospital cardiac arrest (OHCA) are common, and include bystanders inappropriately directing their calls for help. We retrospectively extracted Utstein-style data from the Victorian Ambulance Cardiac Arrest Registry (VACAR) for adult OHCA occurring in Victoria, Australia, between July 2002 and June 2012. Emergency medical service (EMS) witnessed events were excluded. Cases were assigned into two groups on the basis of the first bystander call for help being directed to EMS. Study outcomes were: likelihood of receiving EMS treatment survival to hospital, and survival to hospital discharge. A total of 44499 adult OHCA cases attended by EMS were identified, of which first bystander calls for help were not directed to EMS in 2842 (6.4%) cases. Calls to a relative, friend or neighbour accounted for almost 60% of the total emergency call delays. Patient characteristics and survival outcomes were consistently less favourable when calls were directed to others. First bystander call to others was independently associated with older age, male gender, arrest in private location, and arrest in a rural region. The risk-adjusted odds of treatment by EMS (OR 1.33, 95% CI 1.20-1.48), survival to hospital (OR 1.64, 95% CI 1.37-1.96) and survival to hospital discharge (OR 1.64, 95% CI 1.13-2.36) were significantly improved if bystanders called EMS first. The frequency of inappropriate bystander calls following OHCA was low, but associated with a reduced likelihood of treatment by EMS and poorer survival outcomes.
Publisher: Wiley
Date: 22-07-2007
DOI: 10.1111/J.1742-6723.2007.00958.X
Abstract: To determine the drug use in injured Victorian drivers involved in motor vehicle collisions and subsequently transported to a major adult trauma centre in Victoria. A blood s le was obtained from patients who had been taken to The Alfred Emergency & Trauma Centre (Prahran, Vic., Australia) following a motor vehicle collision. This was performed at the same time and under the same law as compulsory blood screening in Victoria (Section 56 of the Road Safety Act). Four hundred and thirty-six specimens were analysed. Blood stored in vacutainer tubes containing preservative were screened for drugs using enzyme-linked immunosorbent assay and gas chromatography-mass spectometry analysis. Medically administered drugs were excluded from the results. Four hundred and thirty-six specimens were analysed. Metabolites of cannabis were the most commonly found drug (46.7%), the active form of cannabis (Delta9-tetrahydrocannabinol) was found in 33 specimens (7.6%). The next most prevalent drugs were benzodiazepines (15.6%), opiates (11%), hetamines (4.1%) and methadone (3%). Cocaine was detected in 1.4% of cases. Of the motor vehicle collisions 66% involved males and females of 15-44 years old and Delta9-tetrahydrocannabinol was almost exclusively found in this age group. In motor vehicle collisions involving older drivers there was an increasing use of benzodiazepines. In women >65 years old 30% were positive for benzodiazepines. Drug usage found in this group of injured drivers was disturbingly high. The introduction of further initiatives to decrease the prevalence of drug use in motor vehicle drivers is required.
Publisher: Informa UK Limited
Date: 03-2006
Publisher: Elsevier BV
Date: 02-2012
DOI: 10.1016/J.JCLINEPI.2011.06.017
Abstract: At the time of licensing by regulatory agencies, the full range of risks and possible adverse drug reactions associated with a medication is rarely fully realized. This commentary aims to describe the role of registries as useful components of postmarketing pharmacovigilance systems for monitoring highly specialized medications associated with significant financial costs. We consider the limitations of traditional pharmacovigilance programs and discuss the strengths, limitations, and uses of registries in postmarketing pharmacovigilance systems. Registries have become increasingly appealing in postmarketing surveillance of medications however, their exact role continues to evolve. Key registry projects, including the Prospective Immunogenicity Surveillance Registry, British Society for Rheumatology Biologics Register, Australian Rheumatology Association Database, the Haemostasis Registry, and the Bosentan Patient Registry highlight the value of registries for monitoring the incidence of rare adverse events. Although often limited by lack of a control group and the need for complete case ascertainment to maintain data integrity, registries are a useful component of postmarketing pharmacovigilance systems for monitoring highly specialized medications associated with significant financial costs.
Publisher: Elsevier BV
Date: 2016
DOI: 10.1016/J.INJURY.2015.07.003
Abstract: The Injury Severity Score (ISS) is the most ubiquitous summary score derived from Abbreviated Injury Scale (AIS) data. It is frequently used to classify patients as 'major trauma' using a threshold of ISS >15. However, it is not known whether this is still appropriate, given the changes which have been made to the AIS codeset since this threshold was first used. This study aimed to identify appropriate ISS and New Injury Severity Score (NISS) thresholds for use with the 2008 AIS (AIS08) which predict mortality and in-hospital resource use comparably to ISS >15 using AIS98. Data from 37,760 patients in a state trauma registry were retrieved and reviewed. AIS data coded using the 1998 AIS (AIS98) were mapped to AIS08. ISS and NISS were calculated, and their effects on patient classification compared. The ability of selected ISS and NISS thresholds to predict mortality or high-level in-hospital resource use (the need for ICU or urgent surgery) was assessed. An ISS >12 using AIS08 was similar to an ISS >15 using AIS98 in terms of both the number of patients classified major trauma, and overall major trauma mortality. A 10% mortality level was only seen for ISS 25 or greater. A NISS >15 performed similarly to both of these ISS thresholds. However, the AIS08-based ISS >12 threshold correctly classified significantly more patients than a NISS >15 threshold for all three severity measures assessed. When coding injuries using AIS08, an ISS >12 appears to function similarly to an ISS >15 in AIS98 for the purposes of identifying a population with an elevated risk of death after injury. Where mortality is a primary outcome of trauma monitoring, an ISS >12 threshold could be adopted to identify major trauma patients. Level II evidence--diagnostic tests and criteria.
Publisher: Wiley
Date: 09-2000
Publisher: Hamad bin Khalifa University Press (HBKU Press)
Date: 2015
DOI: 10.5339/QMJ.2014.16
Abstract: Background: The use of emergency department (ED) services for non-urgent conditions is well-studied in many Western countries but much less so in the Middle East and Gulf region. While the consequences are universal—a drain on ED resources and poor patient outcomes—the causes and solutions are likely to be region and country specific. Unique social and economic circumstances also create gender-specific motivations for patient attendance. Alleviating demand on ED services requires understanding these circumstances, as past studies have shown. We undertook this study to understand why female patients with low-acuity conditions choose the emergency department in Qatar over other healthcare options. Setting and design: Prospective study at Hamad General Hospital's (HGH) emergency department female “see-and-treat” unit that treats low-acuity cases. One hundred female patients were purposively recruited to participate in the study. Three trained physicians conducted semi-structured interviews with patients over a three-month period after they had been treated and given informed consent. Results: The study found that motivations for ED attendance were systematically influenced by employment status as an expatriate worker. Forty percent of the s le had been directed to the ED by their employers, and the vast majority (89%) of this group cited employer preference as the primary reason for choosing the ED. The interviews revealed that a major obstacle to workers using alternative facilities was the lack of a government-issued health card, which is available to all citizens and residents at a nominal rate. Conclusion: Reducing the number of low-acuity cases in the emergency department at HGH will require interventions aimed at encouraging patients with non-urgent conditions to use alternative healthcare facilities. Potential interventions include policy changes that require employers to either provide workers with a health card or compel employees to acquire one for themselves.
Publisher: Oxford University Press (OUP)
Date: 12-01-2016
Abstract: an emergency department (ED) visit is a sentinel event for an older person, with increased likelihood of adverse outcomes post-discharge including early re-presentation. to determine factors associated with early re-presentation. prospective cohort study conducted in the ED of a large acute Melbourne tertiary hospital. Community-dwelling patients ≥65 years were interviewed including comprehensive assessment of cognitive and functional status, and mood. Logistic regression was used to identify risk factors for return within 30 days. nine hundred and fifty-nine patients, median age 77 years, were recruited. One hundred and forty patients (14.6%) re-presented within 30 days, including 22 patients (2.3%) on ≥2 occasions and 75 patients (7.8%) within 7 days. Risk factors for re-presentation included depressive symptoms, cognitive impairment, co-morbidity, triaged as less urgent (ATS 4) and attendance in the previous 12 months, with a decline in risk after 85 years of age. Logistic regression identified chronic obstructive pulmonary disease (OR 1.78, 95% CI 1.02-3.11), moderate cognitive impairment (OR 2.07, 95% CI 1.09-3.90), previous ED visit (OR 2.11, 95% CI 1.43-3.12) and ATS 4 (OR 2.34, 95% CI 1.10-4.99) as independent risk factors for re-presentation. Age ≥85 years was associated with reduced risk (OR 0.81, 95% CI 0.70-0.93). older discharged patients had a high rate of early re-presentation. Previously identified risk factors-increased age, living alone, functional dependence and polypharmacy-were not associated with early return in this study. It is not clear whether these inconsistencies represent a change in patient case-mix or strategies implemented to reduce re-attendance. This remains an important area for future research.
Publisher: Elsevier BV
Date: 02-2012
DOI: 10.1016/J.BURNS.2011.03.005
Abstract: Prior to 2004, Australia and New Zealand lacked a systematic method to measure burn incidence, aetiology and quality of care or outcomes for burn patients. The Australian and New Zealand Burn Association (ANZBA) commenced the Bi-National Burns Registry (Bi-NBR) at that time. As a result of the limitations identified with the registry, ANZBA collaborated with Monash University to develop the registry as a clinical quality registry [1]. A Steering Committee was formed to oversee the conduct and development of the registry. A Reference Committee revised the minimum dataset and working parties developed clinical quality indicators, and an outcome pilot project. Institutional ethics approval has been obtained for 16 out of 17 sites and a formalised governance process developed. The minimum dataset was improved and includes clinical quality indicators. The Bi-NBR clinical quality registry was launched on July 1st 2009. A long-term outcome pilot project has been developed with five burn units participating (recruitment commenced October 2009). Through a rigorous development process, a clinical quality registry for burns has been established which allows benchmarking of processes and outcomes between units. The intention is that all burns units across Australia and New Zealand will contribute to the registry.
Publisher: Elsevier BV
Date: 2015
DOI: 10.1016/J.RESUSCITATION.2014.09.010
Abstract: Many patients who suffer cardiac arrest do not respond to standard cardiopulmonary resuscitation. There is growing interest in utilizing veno-arterial extracorporeal membrane oxygenation assisted cardiopulmonary resuscitation (E-CPR) in the management of refractory cardiac arrest. We describe our preliminary experiences in establishing an E-CPR program for refractory cardiac arrest in Melbourne, Australia. The CHEER trial (mechanical CPR, Hypothermia, ECMO and Early Reperfusion) is a single center, prospective, observational study conducted at The Alfred Hospital. The CHEER protocol was developed for selected patients with refractory in-hospital and out-of-hospital cardiac arrest and involves mechanical CPR, rapid intravenous administration of 30 mL/kg of ice-cold saline to induce intra-arrest therapeutic hypothermia, percutaneous cannulation of the femoral artery and vein by two critical care physicians and commencement of veno-arterial ECMO. Subsequently, patients with suspected coronary artery occlusion are transferred to the cardiac catheterization laboratory for coronary angiography. Therapeutic hypothermia (33 °C) is maintained for 24h in the intensive care unit. There were 26 patients eligible for the CHEER protocol (11 with OHCA, 15 with IHCA). The median age was 52 (IQR 38-60) years. ECMO was established in 24 (92%), with a median time from collapse until initiation of ECMO of 56 (IQR 40-85) min. Percutaneous coronary intervention was performed on 11 (42%) and pulmonary embolectomy on 1 patient. Return of spontaneous circulation was achieved in 25 (96%) patients. Median duration of ECMO support was 2 (IQR 1-5) days, with 13/24 (54%) of patients successfully weaned from ECMO support. Survival to hospital discharge with full neurological recovery (CPC score 1) occurred in 14/26 (54%) patients. A protocol including E-CPR instituted by critical care physicians for refractory cardiac arrest which includes mechanical CPR, peri-arrest therapeutic hypothermia and ECMO is feasible and associated with a relatively high survival rate.
Publisher: Wiley
Date: 24-06-2022
Abstract: 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. 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. 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. 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.
Publisher: BMJ
Date: 18-02-2011
Abstract: Hanging is a rare but devastating cause of out of hospital cardiac arrest (OHCA). The characteristics and outcomes of hanging associated OHCA in the paediatric age group are described. The Victorian Ambulance Cardiac Arrest Registry was searched for patients aged less than 18 years where the precipitant cause of OHCA was hanging. Results were cross checked with the coronial database. During the years 2000-2009, there were 680 paediatric cardiac arrests of which 53 (7.8%) were precipitated by hanging with an incidence of 4.4 per million paediatric patients (<18 years) per year. Median age was 16 (IQR 14-17) years and 58.5% were males. Five were unintentional hangings median age 3 (IQR 2-4) years. The youngest deliberate hanging associated OHCA was aged 10 years. Most hangings occurred in a house (85%) and bystander cardiopulmonary resuscitation (CPR) was performed in 30%. Asystole was the most common initial cardiac arrest rhythm seen in 50 cases (94%) while three patients had pulseless electrical activity. The emergency medical services (EMS) attempted resuscitation in 18 patients (34%), inserting an endotracheal tube in 13 patients. The majority (n=41) were not transported seven patients were transported with return of spontaneous circulation (ROSC) and five patients were transported with ongoing CPR. Victims who had bystander CPR were more likely to have EMS attempted resuscitation (p<0.001). Only patients who had received bystander CPR achieved ROSC (p<0.001). Three patients survived to hospital discharge two survivors suffered severe neurological injury (Cerebral Performance Category Scale 3-4). Non-intentional hanging is rare but deliberate hanging with suicidal intent represents a significant proportion of OHCAs in patients under 18&emsp14 years of age. A focus on prevention is key, as outcomes are poor, with survivors likely to suffer a severe neurological insult.
Publisher: Wiley
Date: 16-06-2023
Abstract: 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. 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. 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). 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.
Publisher: Wiley
Date: 08-2006
DOI: 10.1111/J.1445-2197.2006.03841.X
Abstract: The hospital reception phase of major trauma management requires a great number of expedient decisions. However, despite widely taught programmes advocating a standardized, algorithmic approach to decision-making, there is an ongoing rate of human errors contributing to adverse outcomes. It is now time for a fundamental change in our approach to trauma resuscitation. Point-of-care computer technology linked to real-time decision-making and trauma team coordination may achieve error reduction through standardized decision-making and a corresponding reduction in preventable mortality and morbidity.
Publisher: Elsevier BV
Date: 06-2012
DOI: 10.1016/J.ANNEMERGMED.2011.11.012
Abstract: We assess the efficacy of intravenous ketamine compared with intravenous morphine in reducing pain in adults with significant out-of-hospital traumatic pain. This study was an out-of-hospital, prospective, randomized, controlled, open-label study. Patients with trauma and a verbal pain score of greater than 5 after 5 mg intravenous morphine were eligible for enrollment. Patients allocated to the ketamine group received a bolus of 10 or 20 mg, followed by 10 mg every 3 minutes thereafter. Patients allocated to the morphine alone group received 5 mg intravenously every 5 minutes until pain free. Pain scores were measured at baseline and at hospital arrival. A total of 135 patients were enrolled between December 2007 and July 2010. There were no differences between the groups at baseline. After the initial 5-mg dose of intravenous morphine, patients allocated to ketamine received a mean of 40.6 mg (SD 25 mg) of ketamine. Patients allocated to morphine alone received a mean of 14.4 mg (SD 9.4 mg) of morphine. The mean pain score change was -5.6 (95% confidence interval [CI] -6.2 to -5.0) in the ketamine group compared with -3.2 (95% CI -3.7 to -2.7) in the morphine group. The difference in mean pain score change was -2.4 (95% CI -3.2 to -1.6) points. The intravenous morphine group had 9 of 65 (14% 95% CI 6% to 25%) adverse effects reported (most commonly nausea [6/65 9%]) compared with 27 of 70 (39% 95% CI 27% to 51%) in the ketamine group (most commonly disorientation [8/70 11%]). Intravenous morphine plus ketamine for out-of-hospital adult trauma patients provides analgesia superior to that of intravenous morphine alone but was associated with an increase in the rate of minor adverse effects.
Publisher: AMPCo
Date: 06-2013
DOI: 10.5694/MJA12.11754
Abstract: To accurately estimate the proportion of patients presenting to the emergency department (ED) who may have been suitable to be seen in general practice. Using data sourced from the Emergency Department Information Systems for the calendar 2013s 2009 to 2011 at three major tertiary hospitals in Perth, Western Australia, we compared four methods for calculating general practice-type patients. These were the validated Sprivulis method, the widely used Australasian College for Emergency Medicine method, a discharge diagnosis method developed by the Tasmanian Department of Human and Health Services, and the Australian Institute of Health and Welfare (AIHW) method. General practice-type patient attendances to EDs, estimated using the four methods. All methods except the AIHW method showed that 10%-12% of patients attending tertiary EDs in Perth may have been suitable for general practice. These attendances comprised 3%-5% of total ED length of stay. The AIHW method produced different results (general practice-type patients accounted for about 25% of attendances, comprising 10%-11% of total ED length of stay). General practice-type patient attendances were not evenly distributed across the week, with proportionally more patients presenting during weekday daytime (08:00-17:00) and proportionally fewer overnight (00:00-08:00). This suggests that it is not a lack of general practitioners that drives patients to the ED, as weekday working hours are the time of greatest GP availability. The estimated proportion of general practice-type patients attending the EDs of Perth's major hospitals is 10%-12%, and this accounts for < 5% of the total ED length of stay. The AIHW methodology overestimates the actual proportion of general practice-type patient attendances.
Publisher: Wiley
Date: 04-2012
DOI: 10.1111/J.1553-2712.2012.01327.X
Abstract: The objective was to identify predictive factors and outcomes associated with patients who leave emergency departments (EDs) without being seen in Victoria, Australia. This was a retrospective observational study of Victorian ED patient visits between July 1, 2000, and June 30, 2005, using linked hospital, ED, and death registration data. Index ED visits were identified for patients who left without being seen (LWBS) and for those who completed ED treatment and were discharged home. Statistical analyses included a general description and univariate analysis of patient, ED visit, temporal, and hospital-level factors. Logistic regression models were developed to assess risk factors associated with LWBS status compared to patients who completed treatment, to assess 48 hour re-presentations to ED 48-hour hospital admissions and 2-,7-, and 30-day mortality among those who LWBS compared to those who completed treatment. Adjusted odds ratios (ORs) and 99% confidence intervals (CIs) are presented. There were 239,305 LWBS episodes, for 205,500 patients over the 5-year period. Independent factors associated with LWBS patients in comparison to those who completed treatment include patients who are younger (15 to 24 years, OR = 2.46, 99% CI = 2.37 to 2.56), male (OR = 1.07, 99% CI = 1.05 to 1.08), of Australian indigenous background (OR = 1.63, 99% CI = 1.53 to 1.73), of non-English-speaking background (OR = 1.08, 99% CI = 1.06 to 1.10), noncompensable status (OR = 1.73, 99% CI = 1.68 to 1.79), self-referring (OR = 1.46, 99% CI = 1.43 to 1.49), nonassisted arrival mode (OR = 1.35, 99% CI = 1.30 to 1.40), and those with a hospital admission in the 12 months before the ED presentation (OR = 1.53, 99% CI = 1.51 to 1.55). Patients who LWBS had triage categories of lower urgency (nonurgent, OR = 8.21, 99% CI = 8.00 to 8.43), attended during the evening (OR = 1.10, 99% CI = 1.08 to 1.12), on either Sunday (OR = 1.20, 99% CI = 1.18 to 1.23) or Monday (OR = 1.20, 99% CI = 1.17 to 1.23), in winter (OR = 1.14, 99% CI = 1.12 to 1.16), with higher rates occurring in higher volume EDs (OR = 2.20, 99% CI = 2.15 to 2.26). There was no greater risk of mortality for LWBS patients compared to patients who completed treatment. The risk of hospital admission within 48 hours of discharge was lower for LWBS patients (OR = 0.60, 99% CI = 0.58 to 0.62) however, ED re-presentation risk was higher (OR = 1.63, 99% CI = 1.60 to 1.67). Patients who leave EDs in Victoria, Australia, without being seen are at lower risk of hospital admission and at no greater risk of mortality, but are at higher risk of re-presenting to an ED compared to patients who complete treatment and are discharged home.
Publisher: Wiley
Date: 04-2011
Publisher: Springer Science and Business Media LLC
Date: 15-11-2011
Abstract: Pain is the most common reason that patients present to an emergency department (ED) and is often inadequately managed. Evidence suggests that acupuncture is effective for pain relief, yet it is rarely practiced in the ED. The current study aims to assess the efficacy of acupuncture for providing effective analgesia to patients presenting with acute low back pain, migraine and ankle sprain at the EDs of four hospitals in Melbourne, Australia. The study is a multi-site, randomized, assessor-blinded, controlled trial of acupuncture analgesia in patients who present to an ED with low back pain, migraine or ankle sprain. Patients will be block randomized to receive either acupuncture alone, acupuncture as an adjunct to pharmacotherapy or pharmacotherapy alone. Acupuncture will be applied according to Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA). Pain after one hour, measured using a visual analogue scale (VAS), is the primary outcome. Secondary outcomes measures include the following instruments the Oswestry low back pain disability questionnaire, 24-hour Migraine Quality of Life questionnaire and Patient's Global Assessment of Ankle Injury Scale. These measures will be recorded at baseline, 1 hour after intervention, each hour until discharge and 48 ± 12 hours of ED discharge. Data will also be collected on the safety and acceptability of acupuncture and health resource utilization. The results of this study will determine if acupuncture, alone or as an adjunct to pharmacotherapy provides effective, safe and acceptable pain relief for patients presenting to EDs with acute back pain, migraine or ankle sprain. The results will also identify the impact that acupuncture treatment may have upon health resource utilisation in the ED setting. Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000989246
Publisher: Elsevier BV
Date: 09-2011
DOI: 10.1016/J.RESUSCITATION.2011.04.007
Abstract: The inability to accurately predict acute traumatic coagulopathy (ATC) has been a key factor in the low level of evidence guiding its management. The aim of this study was to develop a tool to accurately identify patients with ATC using pre-hospital variables without the use of pathology or radiological testing. Retrospective data from the trauma registry on major trauma patients were used to identify variables independently associated with coagulopathy. These variables were clinically evaluated to develop a scoring system to predict ATC, which was prospectively validated in the same setting. There were 1680 major trauma patients in the derivation dataset, with 151 patients being coagulopathic. Pre-hospital variables independently associated with ATC were entrapment (OR 1.85 95% CI: 1.12-3.06), temperature (OR 0.60 95% CI: 0.60-0.72), systolic blood pressure (OR 0.99 95% CI: 0.98-0.99), abdominal or pelvic content injury (OR 2.0 95% CI: 1.27-3.12) and pre-hospital chest decompression (OR 4.99 2.77-8.99). The COAST score was developed, scoring points for entrapment, temperature <35°C, systolic blood pressure < 100 mm Hg, abdominal or pelvic content injury and chest decompression. Prospectively validated using 1225 major trauma patients, a COAST score of ≥ 3 had a specificity of 96.4% with a sensitivity of 60.0%, with an area under the receiver operating characteristic curve of 0.83 (0.78-0.88). The COAST score accurately identified a group of patients with ATC using pre-hospital observations. This predictive tool can be used to select patients for inclusion into prospective studies examining management options for ATC. Mortality in these patients is high, potentially improving feasibility of outcome studies.
Publisher: Radiological Society of North America (RSNA)
Date: 08-2003
Publisher: Elsevier BV
Date: 08-2011
DOI: 10.1016/J.RESUSCITATION.2011.04.005
Abstract: Previous studies have reported improvements in out-of-hospital cardiac arrest (OHCA) outcomes with the introduction of the 2005 cardiopulmonary resuscitation guidelines however they have not adjusted for underlying trends in OHCA survival. We compare outcomes before and after the 2005 guideline changes adjusting for underlying trends in OHCA survival. The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for adult (≥16 years) OHCA of presumed cardiac aetiology, unwitnessed by paramedics with attempted resuscitation. Outcomes for OHCA occurring between 2003 and 2005 were compared with 2007-2009. Segmented regression analysis of interrupted time series data was performed, adjusting for known predictors, to examine changes in survival to hospital and survival to hospital discharge. For the pre- and post- guideline periods there were 3115 and 3248 OHCAs, respectively. Asystole increased as presenting rhythm (33-43%, p<0.001) as did median EMS response times (7.1-7.8 min, p<0.001) over the two periods. VF/VT arrests decreased (40-35.5%, p=0.001) as did bystander witnessed arrests (63-59%, p=0.002). On univariate analysis survival to hospital discharge improved between the two periods (9.4-11.8%, p=0.002) due to improved outcomes in VF/VT (19-28%, p<0.001). Segmented regression analysis of interrupted time series data showed improvement in the rate of survival to get to hospital for shockable and non-shockable rhythms [OR (95% CI)=1.54 (1.10-2.15, p=0.01) and 1.45 (1.10-2.00, p=0.02), respectively] following implementation of the guidelines however survival to hospital discharge did not improve [OR=1.07 (0.70-1.62, p=0.70) and 1.40 (0.69-2.85, p=0.40), respectively]. OHCA outcomes have improved since introduction of the 2005 CPR guidelines, but multivariable segmented regression analysis adjusting for pre-existing trends in survival suggests that this improvement may not be due to implementation of the 2005 resuscitation guidelines.
Publisher: Wiley
Date: 04-2012
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2006
Publisher: Elsevier BV
Date: 10-2011
DOI: 10.1016/J.RESUSCITATION.2011.05.031
Abstract: We aim to describe the coronial findings of young adults where the out-of-hospital cardiac arrest (OHCA) aetiology was 'presumed cardiac'. Presumed cardiac aetiology OHCAs occurring in young adults aged 16-39 years were identified using the Victorian Ambulance Cardiac Arrest Registry (VACAR) and available coronial findings reviewed. We identified 841 young adult OHCAs where the Utstein aetiology was 'presumed cardiac'. Of these 740 died and 572 (77%) OHCAs were matched to coroner's findings. On review of the coroner's cause of death, 230 (40.2%) had a 'confirmed cardiac' aetiology, 221 (38.6%) were proven 'non-cardiac', 97 (17%) were inconclusive and 24 (4.2%) cases remained 'open'. 'Confirmed cardiac' causes of OHCA were ischemic heart disease (n=126, 55%), cardiomegaly (n=26, 11.3%), cardiomyopathy (n=25, 11%), congenital heart disease (n=15, 6.5%), cardiac t onade due to dissecting thoracic aorta aneurysm (n=10, 4.3%), myocarditis (n=8, 3.5%), arrhythmia (n=7, 3%), others (n=13, 5.7%). 'Non-cardiac' causes of OHCA were epilepsy/sudden unexplained death in epilepsy (SUDEP) (n=56, 25%), pulmonary embolism (n=29, 13%), subarachnoid haemorrhage (n=17, 7.7%), other intracranial bleed (n=7, 3.2%), pneumonia (n=17, 7.7%), DKA (n=16, 7.2%), other complications of diabetes mellitus (n=8, 3.6%), complications of obesity (n=9, 4%), haemorrhage (n=12, 5.4%), sepsis (n=8, 3.6%), peritonitis (n=6, 2.7%), aspiration (n=6, 2.7%), renal failure (n=5, 2.3%), asthma (n=5, 2.3%), complications of anorexia (n=3) and alcohol abuse (n=2), thyrotoxicosis (n=2), meningitis (n=1) and others (n=12). Compared with coroner's diagnosed 'non-cardiac' OHCAs, 'confirmed cardiac' were more likely to be witnessed (41% vs 23%, p≤0.01), receive bystander CPR (35% vs 20%, p≤0.001), have a shockable rhythm (27% vs 6.3%, p<0.001) and have EMS attempted resuscitation (62% vs 44%, p<0.001). Linking OHCA registries with coronial databases for aetiology of the arrest will improve the quality of the data and should be considered by all OHCA registries, particularly for young adult OHCA.
Publisher: Elsevier BV
Date: 12-2012
DOI: 10.1016/J.INJURY.2011.08.032
Abstract: The aim of this study was to establish the profile and outcomes of paediatric major trauma care (PTMC) within an integrated inclusive regionalised trauma system. Prospectively collected data from July 2001 to June 2009 from the Victorian State Trauma Registry of patients aged 2) was the most frequent injury (n=950, 58%). Surgery was required in 39% (n=637) of all cases 437 patients in the 10-17 year old group and 200 patients in the 0-9 year old group the mortality was 6.6%. There were 530 patients (32.4%) ventilated in ICU these had a median ISS (IQR) of 25 (17-34) and mortality of 7.4%. Improvements in risk-adjusted mortality have occurred as the years have progressed [adjusted OR 95% CI: 0.87 (0.76, 0.99)] and being treated at a Level 1 trauma centre was associated with lower adjusted odds of mortality [adjusted OR 95% CI: 0.27 (0.11, 0.68)]. The establishment of this integrated inclusive regionalised trauma system has been associated with progressively improving risk-adjusted mortality. The relatively low volume of major trauma requiring surgery in the 0-9 year old age group is notable, creating a challenging environment for maintaining skills and institutional preparedness.
Publisher: BMJ
Date: 12-04-2006
Publisher: Oxford University Press (OUP)
Date: 07-11-2016
Abstract: Increased public awareness of the warning signs of a heart attack and the importance of early medical intervention may help to prevent premature deaths from out-of-hospital cardiac arrest (OHCA). We sought to investigate the impact of the Heart Foundation's public awareness c aigns on the monthly incidence of, and deaths from, OHCA in Melbourne, Australia. Between July 2005 and June 2015, we included registry data for 25 060 OHCA of presumed cardiac aetiology. Time series models with distributed lags were used to explore the effect of c aign activity on OHCA outcomes. A sensitivity analysis involving segmented regression of the pre-intervention, intervention, and post-intervention time segments was also performed. The mean monthly incidence of, and deaths from, OHCA was 207 and 189 events respectively. After adjustment for temporal trends, c aign activity was associated with a 6.0% [95% confidence interval (CI): 2.8-9.0% P < 0.001] reduction in the monthly incidence of OHCA, or 11.7% (95% CI: 7.7-15.5%, P < 0.001) with the addition of residual effects in two additional lag months. Similarly, the rate of deaths from OHCA reduced by 6.4% (95% CI: 2.8-10.0% P = 0.001) during months with c aign activity. C aign activity had a greater effect in males and patients aged ≥65 years, and reduced the incidence of OHCA in unwitnessed and initial non-shockable arrests. In the segmented regression analysis, the intervention period was associated with a 15.2% (95% CI: 9.2-20.9% P < 0.001) reduction in the mean monthly incidence and a 16.6% (95% CI: 9.9-22.7% P < 0.001) reduction in deaths from OHCA. A comprehensive mass media c aign targeting the community's awareness of heart attack symptoms was associated with a substantial reduction in the incidence of OHCA and associated deaths.
Publisher: AMPCo
Date: 05-2012
DOI: 10.5694/MJA12.10315
Publisher: BMJ
Date: 13-07-2013
DOI: 10.1136/EMERMED-2013-202862
Abstract: Improved early pain control may affect the longer-term prevalence of persistent pain. In a previous randomised, controlled trial, we found that the administration of ketamine on hospital arrival decreased pain scores to a greater extent than morphine alone in patients with prehospital traumatic pain. In this follow-up study, we sought to determine the prevalence of persistent pain and whether there were differences in patients who received ketamine or morphine. This study was a long-term follow-up study of the prehospital, prospective, randomised, controlled, open-label study comparing ketamine with morphine in patients with trauma and a verbal pain score of >5 after 5 mg intravenous morphine. Patients were followed-up by telephone 6-12 months after enrollment, and a questionnaire including the SF-36 (V.2) health-related quality of life survey and the Verbal Numerical Rating Scale for pain was administered. A total of 97/135 (72%) patients were able to be followed-up 6-12 months after enrollment between July 2008 and July 2010. Overall, 44/97 (45%) participants reported persistent pain related to their injury, with 3/97 (3%) reporting persistent severe pain. The prevalence of persistent pain was the same between study groups (22/50 (44%) for the ketamine group vs 22/47 (46%) for the morphine group). There was no difference in the SF-36 scores between study arms. There is a high incidence of persistent pain after traumatic injury, even in patients with relatively minor severity of injury. Although decreased pain scores at hospital arrival are achieved with ketamine compared with morphine, this difference does not affect the prevalence of persistent pain or health-related quality of life 6 months after injury. Further larger studies are required to confirm this finding. Australian and New Zealand Clinical Trials Registry (ACTRN12607000441415).
Publisher: Wiley
Date: 12-1999
Publisher: Wiley
Date: 16-01-2023
Publisher: Informa UK Limited
Date: 02-02-2016
DOI: 10.3109/10903127.2015.1128028
Abstract: Outcomes of patients who are discharged at the scene by paramedics are not fully understood. We aimed to describe the risk of re-presentation and/or death in prehospital patients discharged at the scene. We conducted a retrospective cohort study using linked ambulance, emergency department (ED), and death data. We compared outcomes in patients who were discharged at the scene by paramedics with those who were transported to ED by paramedics and then discharged from ED between January 1 and December 31, 2013 in metropolitan Perth, Western Australia. Occurrences of subsequent ambulance requests, ED attendance, hospital admission and death were compared between those discharged at the scene and those discharged from ED. There were 47,330 patients during the study period, of whom 19,732 and 27,598 patients were discharged at the scene and from ED, respectively. Compared to those discharged from ED, those discharged at the scene were more likely to subsequently: request an ambulance (6.1% vs. 1.8%, adjusted odds ratio [adj OR] 3.4 95% confidence interval [CI] 3.0-3.9), attend ED (4.6% vs. 1.4%, adj OR 3.3 95% CI 2.8-3.8), be admitted to hospital (3.3% vs. 0.8%, adj OR 4.2 95% CI 3.4-5.1). Those discharged at the scene tended towards an increased likelihood of death (0.2% vs. 0.1%, adj OR 1.8 95% CI 0.99-3.2) within 24 hours of discharge compared to those discharged from ED. Patients attended by paramedics who were discharged at the scene had more subsequent events than those who were transported to and discharged from ED. Further consideration needs to be given to who is suitable to be discharged at the scene by paramedics.
Publisher: AMPCo
Date: 02-2012
DOI: 10.5694/MJA11.10955
Abstract: To measure the increase in volume and age-specific rates of presentations to public hospital emergency departments (EDs), as well as any changes in ED length of stay (LOS) and to describe trends in ED utilisation. Population-based retrospective analysis of Department of Health public hospital ED data for metropolitan Melbourne for 1999-00 to 2008-09. Presentation numbers presentation rates per 1000 person-years ED LOS. ED presentations increased from 550,662 in 1999-00 to 853,940 in 2008-09. This corresponded to a 32% rise in rate of presentation (95% CI, 29%-35%), an average annual increase of 3.6% (95% CI, 3.4%-3.8%) after adjustment for population changes. Almost 40% of all patients remained in the ED for ≥4 hours in 2008-09, with LOS increasing over time for patients who were more acutely unwell. The likelihood of presentation rose with increasing age, with people aged≥85 years being 3.9 times as likely to present as those aged 35-59 years (95% CI, 3.8-4.0). The volume of older people presenting more than doubled over the decade. They were more likely to arrive by emergency ambulance and were more acutely unwell than 35-59 year olds, with 75% having an LOS≥4 hours and 61% requiring admission in 2008-09. The rise in presentation numbers and presentation rates per 1000 person-years over 10 years was beyond that expected from demographic changes. Current models of emergency and primary care are failing to meet community needs at times of acute illness. Given these trends, the proposed 4-hour targets in 2012 may be unachievable unless there is significant redesign of the whole system.
Publisher: BMJ
Date: 08-2009
Abstract: Understanding and applying human factors in healthcare provides significant opportunities for improving patient safety. A key human factors concept is "resilience," which investigates how in iduals, teams and organisations monitor, adapt to and act on failures in high-risk situations. Although it is a new concept to healthcare, it is well accepted in other high-risk industries. Resilience moves the focus away from "What went wrong?" to "Why does it go right?", that is, it moves from simplistic reactions to error making toward valuing a proactive focus on error recovery. Resilience is a better match for healthcare settings than the principles for high reliability because it more effectively addresses the unique complexities of healthcare. This article introduces the concept of resilience and how it applies to healthcare using clinical handover as an exemplar. Clinical handover and the risks it presents to patient safety are used to illustrate the key principles of resilience to healthcare professionals. The overall aim of this paper is to motivate research which focuses on understanding how frontline staff "fix" mistakes. Researching resilience in healthcare needs to focus on developing measurement, improvement and prediction tools. Resilience can benefit patient safety efforts because it represents a change in emphasis from a traditional, reactive focus on errors to seeing humans as a defence against failure. Translating this concept into practice requires identifying and testing mechanisms for measuring and building resilience within complex healthcare processes.
Publisher: Springer Science and Business Media LLC
Date: 27-04-2018
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2008
Publisher: Wiley
Date: 09-2006
DOI: 10.1111/J.1834-7819.2006.TB00433.X
Abstract: Trauma has been identified as a major public health problem in Australia. Maxillofacial trauma constitutes a significant proportion of trauma, although epidemiological studies in Australia are few. The purpose of this study was to assess the prevalence and the epidemiological pattern of maxillofacial trauma occurring in major trauma patients. Data were obtained from the Victorian State Trauma Registry, which included all major trauma patients in Victoria. All data relating to maxillofacial trauma defined according to Abbreviated Injury Scale and International Classification of Diseases codes from 1 July 2001 to 30 June 2004 were selected. Data collected included demographic and injury details, and operative procedures carried out. Sixteen per cent of major trauma patients sustained maxillofacial trauma. The highest frequency of injuries occurred in the 15-24 years age group. More males were affected than females (3:1). The majority of injuries were due to transportrelated causes (69 per cent) and occurred mostly on roads, streets or highways (70 per cent). Falls were the cause of 15 per cent of injuries, 10.5 per cent of these injuries were fatal while 20.7 per cent needed rehabilitation. The most common type of bony injury was a fractured maxilla. The need for preventive strategies to be reinforced has been highlighted as transport-related injuries remain high especially in the younger age groups.
Publisher: BMJ
Date: 02-08-2010
Abstract: This retrospective, electronic patient care record review examined a consecutive s le of patients presenting with pain to the metropolitan region of Ambulance Victoria over a period of 12&emsp14 months in 2008. The majority of patients did not achieve clinically significant pain reduction, but did achieve some pain relief while in ambulance care. Those with the most severe pain had pain reduction that was clinically significant. Further research is needed to provide optimal pain relief in the prehospital setting.
Publisher: Cambridge University Press (CUP)
Date: 10-12-2017
DOI: 10.1017/S1049023X17007014
Abstract: Historically, the quality and performance of prehospital emergency care (PEC) has been assessed largely based on surrogate, non-clinical endpoints such as response time intervals or other crude measures of care (eg, stakeholder satisfaction). However, advances in Emergency Medical Services (EMS) systems and services world-wide have seen their scope and reach continue to expand. This has dictated that novel measures of performance be implemented to compliment this growth. Significant progress has been made in this area, largely in the form of the development of evidence-informed quality indicators (QIs) of PEC. Quality indicators represent an increasingly popular component of health care quality and performance measurement. However, little is known about the development of QIs in the PEC environment. The purpose of this study was to assess the development and characteristics of PEC-specific QIs in the literature. A scoping review was conducted through a search of PubMed (National Center for Biotechnology Information, National Institutes of Health Bethesda, Maryland USA) EMBase (Elsevier Amsterdam, Netherlands) CINAHL (EBSCO Information Services Ipswich, Massachusetts USA) Web of Science (Thomson Reuters New York, New York USA) and the Cochrane Library (The Cochrane Collaboration Oxford, United Kingdom). To increase the sensitivity of the literature, a search of the grey literature and review of select websites was additionally conducted. Articles were selected that proposed at least one PEC QI and whose aim was to discuss, analyze, or promote quality measurement in the PEC environment. The majority of research (n=25 articles) was published within the last decade (68.0%) and largely originated within the USA (68.0%). Delphi and observational methodologies were the most commonly employed for QI development (28.0%). A total of 331 QIs were identified via the article review, with an additional 15 QIs identified via the website review. Of all, 42.8% were categorized as primarily Clinical, with Out-of-Hospital Cardiac Arrest contributing the highest number within this domain (30.4%). Of the QIs categorized as Non-Clinical (57.2%), Time-Based Intervals contributed the greatest number (28.8%). Population on Whom the Data Collection was Constructed made up the most commonly reported QI component (79.8%), followed by a Descriptive Statement (63.6%). Least reported were Timing of Data Collection (12.1%) and Timing of Reporting (12.1%). Pilot testing of the QIs was reported on 34.7% of QIs identified in the review. Overall, there is considerable interest in the understanding and development of PEC quality measurement. However, closer attention to the details and reporting of QIs is required for research of this type to be more easily extrapolated and generalized. Howard I , Cameron P , Wallis L , Castren M , Lindstrom V . Quality indicators for evaluating prehospital emergency care: a scoping review . Prehosp Disaster Med . 2018 33 ( 1 ): 43 – 52 .
Publisher: AMPCo
Date: 12-2012
DOI: 10.5694/MJA12.11571
Publisher: Wiley
Date: 08-2004
Publisher: Mary Ann Liebert Inc
Date: 06-2011
Abstract: The question as to whether mild traumatic brain injury (mTBI) results in persisting sequelae over and above those experienced by in iduals sustaining general trauma remains controversial. This prospective study aimed to document outcomes 1 week and 3 months post-injury following mTBI assessed in the emergency department (ED) of a major adult trauma center. One hundred and twenty-three patients presenting with uncomplicated mTBI and 100 matched trauma controls completed measures of post-concussive symptoms and cognitive performance (Immediate Post-Concussion Assessment and Cognitive Testing battery ImPACT) and pre-injury health-related quality of life (SF-36) in the ED. These measures together with measures of psychiatric status (the Mini-International Neuropsychiatric Interview [MINI]) pre- and post-injury, the Hospital Anxiety and Depression Scale, Visual Analogue Scale for Pain, Functional Assessment Questionnaire, and PTSD Checklist-Specific, were re-administered at follow-up. Participants with mTBI showed significantly more severe post-concussive symptoms in the ED and at 1 week post-injury. They performed more poorly than controls on the Visual Memory subtest of the ImPACT at 1 week and 3 months post-injury. Both the mTBI and control groups recovered well physically, and most were employed 3 months post-injury. There were no significant group differences in psychiatric function. However, the group with mild TBI was more likely to report ongoing memory and concentration problems in daily activities. Further investigation of factors associated with these ongoing problems is warranted.
Publisher: BMJ
Date: 22-08-2013
Publisher: American Medical Association (AMA)
Date: 02-2011
DOI: 10.1001/ARCHSURG.2010.333
Abstract: This project tested the hypothesis that computer-aided decision support during the first 30 minutes of trauma resuscitation reduces management errors. Ours was a prospective, open, randomized, controlled interventional study that evaluated the effect of real-time, computer-prompted, evidence-based decision and action algorithms on error occurrence during initial resuscitation between January 24, 2006, and February 25, 2008. A level I adult trauma center. Severely injured adults. The primary outcome variable was the error rate per patient treated as demonstrated by deviation from trauma care algorithms. Computer-assisted video audit was used to assess adherence to the algorithms. A total of 1171 patients were recruited into 3 groups: 300 into a baseline control group, 436 into a concurrent control group, and 435 into the study group. There was a reduction in error rate per patient from the baseline control group to the study group (2.53 to 2.13, P = .004) and from the control group to the study group (2.30 to 2.13, P = .04). The difference in error rate per patient from the baseline control group to the concurrent control group was not statistically different (2.53 to 2.30, P = .21). A critical decision was required every 72 seconds, and error-free resuscitations were increased from 16.0% to 21.8% (P = .049) during the first 30 minutes of resuscitation. Morbidity from shock management (P = .03), blood use (P < .001), and aspiration pneumonia (P = .046) were decreased. Computer-aided, real-time decision support resulted in improved protocol compliance and reduced errors and morbidity. Trial Registration clinicaltrials.gov Identifier: NCT00164034.
Publisher: Medknow
Date: 2011
Publisher: Elsevier BV
Date: 2016
DOI: 10.1016/J.INJURY.2015.06.032
Abstract: The international burden of injury is an increasing concern in global healthcare. Developed trauma care systems have reduced death and disability following injury. The ideal platform for surveillance and clinical governance in trauma care quality improvement is the trauma registry. There is a great disparity in the prevalence of active trauma registries between developed and developing countries. More detailed information on lessons learnt would guide those settings, hospitals and regions looking to establish a sustainable trauma registry. The aim of this study was to explore the experiences and perceptions of trauma registry custodians regarding the development of successful and sustainable trauma registries. This was a qualitative study using semi-structured interviews of trauma registry custodians. Trauma registries were selected from a wide range of jurisdictions, including single hospital and multi-hospital registries, based in developed and developing countries. Interview transcripts were analysed using thematic analysis recurrent themes were identified, and a coding frame developed. Quotes were identified to illustrate the themes in the participants' own words. Twenty-seven interviews, representing 29 registries, were completed. Fourteen of the source registries were based in developed countries (6 single hospital, 8 multi-hospital) and 15 were based in developing countries (9 single hospital, 6 multi-hospital). The analysis generated 15 themes covering resources, data and strategies. The themes dealing with resources were: funding, staffing, information technology and tools for guidance. The themes dealing with data were: data quality, simplicity, injury coding and data utilisation. The themes dealing with strategies were: having a local ch ion and a clear purpose, stakeholder buy-in, governance, integration, getting started and persistence. For developing countries, the need for a local ch ion, dealing with data quality through prospective data collection, integration into local resources and keeping it simple were considered particularly important. The general consensus was that, for a trauma registry to be successful, in addition to adequate funding and trained staff, it needs to be led by a local ch ion with engagement of key local stakeholders. It should have a clear purpose, pay close attention to data quality and ensure that the data is well used.
Publisher: Wiley
Date: 06-1995
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2009
Publisher: Wiley
Date: 03-1999
DOI: 10.1046/J.1440-1622.1999.01519.X
Abstract: Team leader performance in trauma resuscitations was assessed using a published system to assess the utility of video recording and to assess the current early management of trauma at The Royal Melbourne Hospital, Melbourne, Australia. Fifty trauma resuscitations were videotaped over a 21-month period. Each videotape was assessed by an emergency physician. The team leader was an emergency physician in 37 resuscitations, an emergency medicine registrar in eight and a surgical registrar in five. The mean team leader score was 68.5 +/- 8.5 (range 45-78, maximum possible 80). The average time to primary survey completion was 3.3 +/- 1.7 min, second phase of resuscitation up to and including chest radiography 14.1 +/- 8.5 min, to completion of secondary survey and announcement of overall plan 30 +/- 20 min. Frequent deficiencies are documented. Problems with videotaping included forgetting/lack of motivation to start taping, forgetting to turn on the sound, difficulty discerning size of cannulae and logistical problems with only one cubicle outfitted for videotaping. Advantages included lack of intrusion into the resuscitation, increased vigilance by team members aware of the possibility of taping, ability to assess tapes at leisure and team leader performance in after-hours resuscitations. Video recording is a useful method for the assessment of team member performance in trauma resuscitations. Deficiencies in resuscitation technique can be identified and fed back to those involved. Medico-legal issues have not proved to be a barrier to the use of the technique. A reliable method of starting taping is needed.
Publisher: Oxford University Press (OUP)
Date: 27-05-2014
Abstract: The Alfred Emergency Short Stay Unit initiated a chest pain protocol for patients presenting with chest pain to risk stratify for acute coronary syndrome (ACS). A 30-day follow-up of patients discharged with low-or-intermediate risk of ACS demonstrated no deaths or ACS. The purpose of this study was to evaluate the long-term safety of the chest pain protocol, a one year follow-up was undertaken. A questionnaire was designed for the one-year follow-up and it was administered via a telephone interview by emergency nurses to document adverse cardiac events and health care utilisation. From 297 patients, 224 (75%) were contacted 12 months following discharge. There was one death from stroke (0.4% 95% confidence interval (CI): 0.01-2.5%) and another from an unknown cause. Five patients had been diagnosed with atrial fibrillation (2.2% 95% CI: 0.7-5.1%), two patients had an acute myocardial infarction (0.9% 95% CI: 0.03-2.1%) and four were diagnosed with angina (1.8% 95% CI: 0.9-3.2%). Nearly half (n=103, 46% 95% CI: 39.5-52.5%) had returned to the emergency department (ED) for various conditions including 42 patients with further chest pain. Ninety-six patients (43% 95% CI: 39.3-52.7%) had specialist referrals and 124 investigations were performed. Thirty-four patients had cardiology referrals (15% 95% CI: 10.7-20.5%) and 25 patients had gastroenterology referrals (11% 95% CI: 7.3-16.0%). Diagnostic cardiac tests were performed on 38 patients: coronary angiography (n=10), 24-hour Holter monitoring (n=17), 24-hour blood pressure (BP) monitoring (n=4), thallium scans (n=5), exercise stress test (n=1) and CT scan (n=1). Patients had a low risk of adverse events 12 months after discharge but substantial continuing health care utilization was observed. Complete assessment by health care professionals prior to discharge may help mitigate representations.
Publisher: CSIRO Publishing
Date: 2002
DOI: 10.1071/AH020059
Abstract: There is pessimism regarding the ability of the Acute Health Sector to manage access block for emergency and elective patients. Melbourne Health suffered an acute bed crisis in 2001 resulting in record ambulance ersions and emergency department (ED) delays. We conducted an observational study to reduce access block for emergency patients whilst maintaining elective throughput at Melbourne Health. This involved a clinician-led taskforce using previously proven principles for organisational change to implement 51 actions to improve patient access over a three-month period. The primary outcome measures were ambulance ersion, emergency patients waiting more than 12 hours for an inpatient bed, elective throughput and theatre cancellations. Despite a reduction in multi-day bed numbers all primary objectives were met, ambulance ersion decreased to minimal levels, 12-hour waits decreased by 40%and elective throughput was maintained. Theatre cancellations were also minimised. We conclude that access block can be improved by clinician-led implementation of proven process improvements over a short time frame. The ability to sustain change over the longer term requires further study.
Publisher: Wiley
Date: 11-2012
Publisher: BMJ
Date: 08-07-2010
Abstract: Currently, there is no internationally recognised, standard curriculum that defines the basic minimum standards for emergency medicine education. To address this, the International Federation for Emergency Medicine convened a committee of international experts in emergency medicine and international emergency medicine development to outline a global curriculum for medical students in emergency medicine. This curriculum document represents the consensus of recommendations by this committee. The curriculum is designed with a focus on the basic minimum emergency medicine educational content that any medical school should be delivering to its students during their undergraduate years of training. The content is relevant not just for communities with mature emergency medicine systems, but also for developing nations or for nations seeking to expand emergency medicine within current educational structures. It is anticipated that there will be wide variability in how this curriculum is implemented and taught, reflecting the existing educational milieu, the resources available and the goals of the institutions' educational leadership.
Publisher: Springer Science and Business Media LLC
Date: 25-10-2017
DOI: 10.1007/S00268-017-4292-0
Abstract: The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes. We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria. We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [-0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization. This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2013
Publisher: Wiley
Date: 20-09-2022
Abstract: 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.
Publisher: Elsevier BV
Date: 06-2013
DOI: 10.1016/J.INJURY.2013.02.003
Abstract: The burden of injury is greatest in developing countries. Trauma systems have reduced mortality in developed countries and trauma registries are known to be integral to monitoring and improving trauma care. There are relatively few trauma registries in developing countries and no reviews describing the experience of each registry. The aim of this study was to examine the collective published experience of trauma registries in developing countries. A structured review of the literature was performed. Relevant abstracts were identified by searching databases for all articles regarding a trauma registry in a developing country. A tool was used to abstract trauma registry details, including processes of data collection and analysis. There were 84 articles, 76 of which were sourced from 47 registries. The remaining eight articles were perspectives. Most were from Iran, followed by China, Jamaica, South Africa and Uganda. Only two registries used the Injury Severity Score (ISS) to define inclusion criteria. Most registries collected data on variables from all five variable groups (demographics, injury event, process of care, injury severity and outcome). Several registries collected data for less than a total of 20 variables. Only three registries measured disability using a score. The most commonly used scores of injury severity were the ISS, followed by Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS) and the K ala Trauma Score (KTS). Amongst the small number of trauma registries in developing countries, there is a large variation in processes. The implementation of trauma systems with trauma registries is feasible in under-resourced environments where they are desperately needed.
Publisher: Wiley
Date: 12-2013
DOI: 10.1111/ACEM.12272
Abstract: At the 2013 Academic Emergency Medicine global health consensus conference, a breakout session to develop a research agenda for resuscitation was held. Two articles are the result of that discussion. This second article addresses data collection, management, and analysis and regionalization of postresuscitation care, resuscitation programs, and research ex les around the world and proposes a strategy to strengthen resuscitation research globally. There is a need for reliable global statistics on resuscitation, international standardization of data, and development of an electronic standard for reporting data. Regionalization of postresuscitation care is a priority area for future research. Large resuscitation clinical research networks are feasible and can give valuable data for improvement of service and outcomes. Low-cost models of population-based research, and emphasis on interventional and implementation studies that assess the clinical effects of programs and interventions, are needed to determine the most cost-effective strategies to improve outcomes. The global challenge is how to adapt research findings to a developing world situation to have an effect internationally.
Publisher: BMJ
Date: 09-2002
Abstract: The impact of mild head injury is variable and determinants of outcome remain poorly understood. Results of previous intervention studies have been mixed. To evaluate the impact on outcome of the provision of information, measured in terms of reported symptoms, cognitive performance, and psychological adjustment three months postinjury. 202 adults with mild head injury were studied: 79 were assigned to an intervention group and were assessed one week and three months after injury 123 were assigned to a non-intervention control group and were seen at three months only. Participants completed measures of preinjury psychological adjustment, concurrent life stresses, post-concussion symptoms, and tests of attention, speed of information processing, and memory. Subjects seen at one week were given an information booklet outlining the symptoms associated with mild head injury and suggested coping strategies. Those seen only at three months after injury did not receive this booklet. Patients in the intervention group who were seen at one week and given the information booklet reported fewer symptoms overall and were significantly less stressed at three months after the injury. The provision of an information booklet reduces anxiety and reporting of ongoing problems.
Publisher: Elsevier BV
Date: 1996
DOI: 10.1016/S0196-0644(96)70293-7
Abstract: To determine the extent of interobserver agreement in the ECG diagnosis of ventricular tachycardia (VT) by using a four-step algorithm and three observers. Simulated emergency department setting from records of an urban university teaching hospital. All ECGs taken in the ED during a 2-year period that showed a QRS duration of more than 120 msec and a heart rate faster than 110 beats per minute were reviewed. ECGs were categorized as demonstrating sinus rhythm (SR), irregular broad-complex tachycardia (I-BCT), or regular broad-complex tachycardia (BCT). Copies of the BCT ECGs and short clinical histories were given to each of three emergency physicians, who used a published, four-step algorithm (the Brugada algorithm) to categorize the BCT ECGs as indicating VT, indicating supraventricular tachycardia with aberrancy (SVT-A), or indeterminate. Interobserver agreement was assessed with the K-statistic. The records contained 178 ECGs, 88 of which were SR, 63 I-BCT, and 27 BCT. The 27 BCT ECGs were selected for review. The emergency physicians disagreed with each other 22% of the time in differentiating VT from SVT-A (K = .58). Application of the algorithm to actual clinical practice in the ED would probably result in the misdiagnosis of a substantial minority of patients having BCT, with potentially serious adverse consequences.
Publisher: Wiley
Date: 09-2002
DOI: 10.1046/J.1445-5994.2002.00268.X
Abstract: As the population of Australia ages, the issue of advance care planning (ACP) to improve medical management towards life's end becomes more important. However, ACP appears poorly developed in Australia. This article discusses ACP and advance directives in the context of the Australian experience and compares this with the experience overseas. It highlights the need for an improvement in ACP and recommends specific areas for discussion and research.
Publisher: Wiley
Date: 12-2013
DOI: 10.1111/ACEM.12270
Abstract: At the 2013 Academic Emergency Medicine global health consensus conference, a breakout session on a resuscitation research agenda was held. Two articles focusing on cardiac arrest and trauma resuscitation are the result of that discussion. This article describes the burden of disease and outcomes, issues in resuscitation research, and global trends in resuscitation research funding priorities. Globally, cardiovascular disease and trauma cause a high burden of disease that receives a disproportionately smaller research investment. International resuscitation research faces unique ethical challenges. It needs reliable baseline statistics regarding quality of care and outcomes data linkages between providers reliable and comparable national databases and an effective, efficient, and sustainable resuscitation research infrastructure to advance the field. Research in resuscitation in low- and middle-income countries is needed to understand the epidemiology, infrastructure and systems context, level of training needed, and potential for cost-effective care to improve outcomes. Research is needed on low-cost models of population-based research, ways to disseminate information to the developing world, and finding the most cost-effective strategies to improve outcomes.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2011
Publisher: AMPCo
Date: 02-2013
DOI: 10.5694/MJA12.10340
Abstract: To assess the prevalence of and reasons for barriers to discharge from inpatient rehabilitation, to measure the resulting additional days in hospital, and to determine if these were predicted by key demographic or clinical variables. Prospective open cohort study of 360 patients admitted into two inpatient rehabilitation units in Melbourne over an 8-02 and a 10-02 period in 2008. Occurrence of discharge barriers, their causes and the duration of unnecessary hospitalisation. There were 360 patients in the study s le, 186 were female (51.7%), and mean age was 58.4 years. Fifty-nine (16.4%) patients had a discharge barrier. The most frequent causes of discharge barriers were patients being non-weight bearing after lower limb fracture, family deliberations about discharge planning, waiting for home modifications and waiting for accommodation. Patients with acquired brain damage and lower limb fracture were the impairment groups most likely to experience a discharge barrier. Over the study period, 21.0% (3152/14 976) of all bed-days were occupied by patients deemed to have a discharge barrier. Regression analysis showed that age, sex, impairment group and dependency level on admission all influenced the occurrence of a discharge barrier. Although regression analysis showed that dependency on admission and age group were significant predictors of additional days in hospital resulting from discharge barriers (P = 0.006), these variables explained only 11% of the additional bed-days. Barriers to discharge from inpatient rehabilitation are common and substantial, and they represent an important opportunity for improvement.
Publisher: Elsevier BV
Date: 04-2005
DOI: 10.1016/J.INJURY.2004.06.014
Abstract: Orthopaedic injuries are common among trauma patients and can result in long-term problems. Considerable data are available regarding functional outcomes following lower extremity trauma. There is, however, a paucity of data available for upper extremity trauma patients. Whilst currently available instruments appear to assess outcomes of relevance in trauma populations, the reliability, validity and responsiveness of these instruments have not been evaluated in the upper extremity trauma population. This paper reviews instruments designed for patient self-evaluation of musculoskeletal disorders of the upper extremity, and instruments used in an orthopaedic trauma population to assess functional recovery following injury. The Musculoskeletal Functional Assessment (MFA), Short Musculoskeletal Functional Assessment (SMFA), Disabilities of the Arm, Shoulder, and Hand (DASH), American Shoulder and Elbow Surgeons Shoulder Scale (ASES-s), American Shoulder and Elbow Surgeons Elbow Scale (ASES-e), Patient Rated Elbow Evaluation (PREE), and the Patient Rated Wrist Evaluation (PRWE) were reviewed. Until research is published outlining the evaluation of assessment instruments in upper extremity orthopaedic populations, authors will need to conduct their own validation studies before investigating outcomes in specific trauma populations.
Publisher: BMJ
Date: 04-07-2012
DOI: 10.1136/EMERMED-2012-201267
Abstract: Evaluating the quality of life of young adult survivors of out-of-hospital cardiac arrest (OHCA) is important as they are likely to have a longer life expectancy than older patients. The aim of this study was to assess their functional and quality of life outcomes. The Victorian Ambulance Cardiac Arrest Registry records were used to identify survivors of OHCA that occurred between 2003 and 2008 in the 18-39 year-old age group. Survivors were administered a telephone questionnaire using Short Form (SF-12), EQ-5D and Glasgow Outcome Scale-Extended. Cerebral Performance Category (CPC) ascertained at hospital discharge from the medical record was recorded for the uncontactable survivors. Of the 106 young adult survivors, five died in the intervening years and 45 were not contactable or refused. CPC scores were obtained for 37 (74%) of those who did not take part in telephone follow-up, and 7 (19%) of these had a CPC ≥ 3 indicating severe cerebral disability. The median follow-up time was 5 years (range 2.7- 8.6 years) for the 56 (53%) patients included. Of these, 84% were living at home independently, 68% had returned to work, and only 11% reported marked or severe disability. The majority of patients had no problems with mobility (75%), personal care (75%), usual activities (66%) or pain/discomfort (71%). However, 61% of respondents reported either moderate (48%) or severe (13%) anxiety. The majority of survivors have good functional and quality of life outcomes. Telephone follow-up is feasible in the young adult survivors of cardiac arrest loss to follow-up is common.
Publisher: Wiley
Date: 09-1992
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2010
Publisher: Wiley
Date: 08-1993
DOI: 10.1111/J.1445-5994.1993.TB01434.X
Abstract: The role of intravenous aminophylline in acute asthma is unclear despite meta-analysis of many studies comparing aminophylline with other bronchodilator therapies. The aim of this study is to determine whether continuous aminophylline infusion confers any benefit in acute severe asthmatics treated with intravenous steroids and inhaled bronchodilators. The study was randomised, double-blind and placebo-controlled. All patients received nebulised salbutamol (1 mL of 0.5%) and ipratropium bromide (1 mL of 0.025%) with glycol diluent (1 mL) at 0, two, four, six, eight and 12 hours, and six-hourly thereafter. In addition all patients were given intravenous hydrocortisone 250 mg six-hourly and oxygen to maintain normoxia. Aminophylline infusions were adjusted to maintain therapeutic levels. Peak expiratory flow rate (PEFR) was measured before and after nebulised bronchodilator on a two-hourly basis in the Emergency Department (ED) and six-hourly on the inpatient wards. Thirty-one patients were clinically sufficiently improved within 12 hours to be discharged home from the ED. The remaining 28 patients were admitted to the inpatient ward for a total trial duration of 48 hours. No significant difference was found between the placebo and treatment groups for measurements of PEFR, or for the duration of stay of the patients in hospital. The power of the study was 80% for a 25% to 33% difference at a 5% level of significance. Presentation values of PEFR and arterial blood gases did not predict which patients would require inpatient admission and which could be safely discharged home from the ED.
Publisher: Wiley
Date: 09-01-2023
Abstract: To report the frequency of electric scooter‐related trauma and association with alcohol and other drug (AOD) use. A retrospective cohort study was conducted, including presentations from 1 January 2017 to 31 May 2022 to a metropolitan health service. 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. Urgent preventive measures with a focus on reducing AOD exposure and promoting of helmet use is indicated.
Publisher: Elsevier BV
Date: 09-2017
DOI: 10.1016/J.AAP.2017.06.019
Abstract: As cycling-related injury rates are on the rise, there is a need to understand the long term outcomes of these patients in order to quantify the burden of injury and to inform injury prevention strategies. This study aimed to investigate predictors of return to work and functional recovery in a cohort of cyclists hospitalised for orthopaedic trauma from crashes occurring on-road. A retrospective analysis of data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) was conducted for patients who were hospitalised for orthopaedic trauma following a cycling crash that occurred on-road between July 2007 and June 2015. There were 1787 injured cyclists admitted at the participating hospitals. Most cyclists were male (79%), resided in major cities (89%) and were in the highest socioeconomic quintile (52%). The majority of crashes were either non-collisions (41%) or collisions with a motor vehicle (35%). A smaller proportion of cyclists who collided with motor vehicles had returned to work and had returned to pre-injury functional levels at 12 months post-injury, when compared to collisions with other impact counterparts and non-collisions. Mixed effects logistic regression models revealed that compensable patients demonstrated lower odds of complete functional recovery and return to work when compared with non-compensable patients. Cyclists who collided with motor vehicles had worse outcomes compared to crashes with other impact counterparts and non-collision events. These findings provide support for reducing the potential for interaction between cyclists and motor vehicles.
Publisher: Wiley
Date: 14-07-2022
Publisher: Elsevier BV
Date: 07-2016
DOI: 10.1016/J.JOCN.2015.11.024
Abstract: Acute traumatic coagulopathy (ATC) has been reported in the setting of isolated traumatic brain injury (iTBI) and is associated with poor outcomes. We aimed to evaluate the effectiveness of procoagulant agents administered to patients with ATC and iTBI during resuscitation, hypothesizing that timely normalization of coagulopathy may be associated with a decrease in mortality. A retrospective review of the Alfred Hospital trauma registry, Australia, was conducted and patients with iTBI (head Abbreviated Injury Score [AIS] ⩾3 and all other body AIS <3) and coagulopathy (international normalized ratio ⩾1.3) were selected for analysis. Data on procoagulant agents used (fresh frozen plasma, platelets, cryoprecipitate, prothrombin complex concentrates, tranexamic acid, vitamin K) were extracted. Among patients who had achieved normalization of INR or survived beyond 24hours and were not taking oral anticoagulants, the association of normalization of INR and death at hospital discharge was analyzed using multivariable logistic regression analysis. There were 157 patients with ATC of whom 68 (43.3%) received procoagulant products within 24hours of presentation. The median time to delivery of first products was 182.5 (interquartile range [IQR] 115-375) minutes, and following administration of coagulants, time to normalization of INR was 605 (IQR 274-1146) minutes. Normalization of INR was independently associated with significantly lower mortality (adjusted odds ratio 0.10 95% confidence interval 0.03-0.38). Normalization of INR was associated with improved mortality in patients with ATC in the setting of iTBI. As there was a substantial time lag between delivery of products and eventual normalization of coagulation, specific management of coagulopathy should be implemented as early as possible.
Publisher: Elsevier BV
Date: 07-2003
DOI: 10.1067/MEM.2003.318
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2009
Publisher: Elsevier BV
Date: 05-2018
DOI: 10.1016/J.RESUSCITATION.2018.02.029
Abstract: The aim of this study was to investigate regional variation in the characteristics, incidence and outcomes of out-of-hospital cardiac arrest (OHCA) in Australia and New Zealand. This was a population-based cohort study of OHCA using data from the Aus-ROC Australian and New Zealand OHCA Epistry over the period of 01 January 2015-31 December 2015. Seven ambulance services contributed data to the Epistry with a capture population of 19.8 million people. All OHCA attended by ambulance, regardless of aetiology or patient age, were included. In 2015, there were 19,722 OHCA cases recorded in the Aus-ROC Epistry with an overall crude incidence of 102.5 cases per 100,000 population (range: 51.0-107.7 per 100,000 population). Of all OHCA cases attended by EMS (excluding EMS-witnessed cases), bystander CPR was performed in 41% of cases (range: 36%-50%). Resuscitation was attempted (by EMS) in 48% of cases (range: 40%-68%). The crude incidence for attempted resuscitation cases was 47.6 per 100,000 population (range: 34.7-54.1 per 100,000 population). Of cases with attempted resuscitation, 28% survived the event (range: 21%-36%) and 12% survived to hospital discharge or 30 days (range: 9%-17% data provided by five ambulance services). In the first results of the Aus-ROC Australian and New Zealand OHCA Epistry, significant regional variation in the incidence, characteristics and outcomes was observed. Understanding the system-level and public health drivers of this variation will assist in optimisation of the chain of survival provided to OHCA patients with the aim of improving outcomes.
Publisher: Springer Science and Business Media LLC
Date: 03-01-2018
Publisher: Elsevier BV
Date: 06-2006
Publisher: BMJ
Date: 16-02-2018
DOI: 10.1136/INJURYPREV-2016-042206
Abstract: Accurate coding of injury event information is critical in developing targeted injury prevention strategies. However, little is known about the validity of the most universally used coding system, the International Classification of Diseases (ICD-10), in characterising crash counterparts in pedal cycling events. This study aimed to determine the agreement between hospital-coded ICD-10-AM (Australian modification) external cause codes with self-reported crash characteristics in a s le of pedal cyclists admitted to hospital following bicycle crashes. Interview responses from 141 injured cyclists were mapped to a single ICD-10-AM external cause code for comparison with ICD-10-AM external cause codes from hospital administrative data. The percentage of agreement was 77.3% with a κ value of 0.68 (95% CI 0.61 to 0.77), indicating substantial agreement. Nevertheless, studies reliant on ICD-10 codes from administrative data should consider the 23% level of disagreement when characterising crash counterparts in cycling crashes.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2016
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2008
Publisher: Elsevier BV
Date: 07-2011
DOI: 10.1016/J.RESUSCITATION.2011.03.008
Abstract: Characteristics and outcomes of out-of-hospital cardiac arrest (OHCA) in young adults are not well described in Australia. A 10-year retrospective case review of all OHCA in young adults (aged 16-39) and not witnessed by EMS, was performed using data from the Victorian Ambulance Cardiac Arrest Registry (VACAR). Between 2000 and 2009 there were 30,006 adult cardiac arrests of which 3912 (13%) were in this age group. The median (IQR) age was 30 (25-35) years for both sexes with a 3:1 male to female ratio. Overdose was the most common precipitant (33.5%) followed by presumed cardiac (20%). Bystander CPR occurred in 21.2%, EMS median response time was 7 min and resuscitation was attempted in 36% of OHCAs. The presenting rhythm was asystole in 84.6%, PEA in 8.8% and VF/VT in 6.6%. Survival to hospital discharge, for all cause OHCA where resuscitation was attempted, was similar for young adult and older adults (8.8% vs 8.4%, p=0.2). However, for presumed cardiac aetiology OHCA, young adults had a greater proportion of survivors (14.8% vs 9.0%, p<0.001). Cardiac arrest with shockable rhythm (VF ulseless VT) had a survival rate of 31.2% for young adults compared to 18.5% for older adults (p<0.001). Survival to hospital discharge rates from OHCA due to a 'presumed cardiac' precipitant in young adults is much better than older adults, however, all cause OHCA survival is similar. Multi agency novel upstream preventive strategies aimed at tackling drug overdose may reduce this aetiology of OHCA and save lives.
Publisher: CSIRO Publishing
Date: 2014
DOI: 10.1071/AH13244
Abstract: Objective Time spent in the emergency department (ED) before admission to hospital is often considered an important key performance indicator (KPI). Throughout Australia and New Zealand, there is no standard definition of ‘time of admission’ for patients admitted through the ED. By using data submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database, the aim was to determine the differing methods used to define hospital admission time and assess how these impact on the calculation of time spent in the ED before admission to an intensive care unit (ICU). Methods Between March and December of 2010, 61 hospitals were contacted directly. Decision methods for determining time of admission to the ED were matched to 67787 patient records. Univariate and multivariate analyses were conducted to assess the relationship between decision method and the reported time spent in the ED. Results Four mechanisms of recording time of admission were identified, with time of triage being the most common (28/61 hospitals). Reported median time spent in the ED varied from 2.5 (IQR 0.83–5.35) to 5.1 h (2.82–8.68), depending on the decision method. After adjusting for illness severity, hospital type and location, decision method remained a significant factor in determining measurement of ED length of stay. Conclusions Different methods are used in Australia and New Zealand to define admission time to hospital. Professional bodies, hospitals and jurisdictions should ensure standardisation of definitions for appropriate interpretation of KPIs as well as for the interpretation of studies assessing the impact of admission time to ICU from the ED. What is known about the topic? There are standards for the maximum time spent in the ED internationally, but these standards vary greatly across Australia. The definition of such a standard is critically important not only to patient care, but also in the assessment of hospital outcomes. Key performance indicators rely on quality data to improve decision-making. What does this paper add? This paper quantifies the variability of times measured and analyses why the variability exists. It also discusses the impact of this variability on assessment of outcomes and provides suggestions to improve standardisation. What are the implications for practitioners? This paper provides a clearer view on standards regarding length of stay in the ICU, highlighting the importance of key performance indicators, as well as the quality of data that underlies them. This will lead to significant changes in the way we standardise and interpret data regarding length of stay.
Publisher: Wiley
Date: 16-08-2010
DOI: 10.1111/J.1445-2197.2010.05432.X
Abstract: The International Classification of Diseases Injury Severity Score (ICISS) has been proposed as an International Classification of Diseases (ICD)-10-based alternative to mortality prediction tools that use Abbreviated Injury Scale (AIS) data, including the Trauma and Injury Severity Score (TRISS). To date, studies have not examined the performance of ICISS using Australian trauma registry data. This study aimed to compare the performance of ICISS with other mortality prediction tools in an Australian trauma registry. This was a retrospective review of prospectively collected data from the Victorian State Trauma Registry. A training dataset was created for model development and a validation dataset for evaluation. The multiplicative ICISS model was compared with a worst injury ICISS approach, Victorian TRISS (V-TRISS, using local coefficients), maximum AIS severity and a multivariable model including ICD-10-AM codes as predictors. Models were investigated for discrimination (C-statistic) and calibration (Hosmer-Lemeshow statistic). The multivariable approach had the highest level of discrimination (C-statistic 0.90) and calibration (H-L 7.65, P= 0.468). Worst injury ICISS, V-TRISS and maximum AIS had similar performance. The multiplicative ICISS produced the lowest level of discrimination (C-statistic 0.80) and poorest calibration (H-L 50.23, P < 0.001). The performance of ICISS may be affected by the data used to develop estimates, the ICD version employed, the methods for deriving estimates and the inclusion of covariates. In this analysis, a multivariable approach using ICD-10-AM codes was the best-performing method. A multivariable ICISS approach may therefore be a useful alternative to AIS-based methods and may have comparable predictive performance to locally derived TRISS models.
Publisher: Wiley
Date: 16-05-2011
DOI: 10.1111/J.1399-6576.2011.02446.X
Abstract: Pain is a common presenting complaint and there is considerable debate regarding the best practice for analgesia in the pre-hospital environment for trauma patients with severe pain. A review of the literature was conducted using a number of electronic medical literature databases from their earliest record to the latest available at the time the search was conducted (May 2010). Medical Subject Headings, keywords and a pre-hospital search filter were used to yield relevant literature. The search strategy yielded a total of 837 references. Seven hundred and fifty of these references were excluded as they did not meet the inclusion criteria. Of the 87 articles short listed for abstract or full-text review, six reported on ketamine use as an analgesic agent in the pre-hospital setting. Two papers were prospective randomized-controlled trials, and the number of patients included in the studies ranged from 4 to 164. Three studies aimed to report on the effectiveness of ketamine for pain intensity reduction two concluded that ketamine provided safe and effective pain relief and one reported that ketamine reduced the amount of morphine required but was not associated with a reduction in pain intensity. One study identified a significantly higher prevalence of adverse effects following ketamine administration. The other studies reported no significant side effects and concluded that ketamine was safe. Ketamine is a safe and effective analgesic agent. The addition of ketamine as an analgesic agent may improve the management of patients presenting with acute traumatic pain in the pre-hospital setting.
Publisher: Wiley
Date: 10-2000
DOI: 10.1111/J.1445-5994.2000.TB00860.X
Abstract: Poor compliance with attendance at outpatient clinic appointments in patients referred from emergency departments (EDs) is a major problem in public hospitals. To determine whether the intervention of a telephone call within three days of ED attendance would improve: 1. the proportion of patients making recommended outpatient appointments and 2. the proportion of patients attending scheduled appointments. To characterise reasons for non-attendance at appointments made by patients referred from the ED. A randomised controlled trial was undertaken of 400 patients recommended to make outpatient appointments during attendance at The Royal Melbourne Hospital ED in July-August 1999. a telephone call one to three days after attendance to remind the patient about the appointment (and its importance for medical follow-up) if one had been made and to offer to make an appointment if one had not been made. 1. making the recommended appointment 2. attendance at the scheduled appointment and 3. reasons for non-attendance at scheduled appointments. The telephone intervention improved attendance at scheduled appointments from 54.4% to 70.7% (p=0.002). The proportion of patients making appointments was not significantly affected. The commonest reasons given for non-attendance were: attended general practitioner (13%), attended private specialist (6.6%), inpatient in hospital at time of appointment (6.6%), too busy or inconvenient (5.3%), claimed to have attended (5.3%) and did not differ by intervention. A significant improvement in the proportion of patients attending outpatients appointments can be made by a simple reminder telephone call one to three days after attendance at the ED.
Publisher: Elsevier BV
Date: 11-2011
DOI: 10.1016/J.BURNS.2011.04.009
Abstract: The Alfred pre-hospital fluid isotonic crystalloid resuscitation formula for major burns (body weight (kg)×%TBSA burnt=mls in the first 2 h) was adopted by Ambulance Victoria in 2007 for the early and consistent correction of fluid deficit in major burns patients. The aim of this study was to evaluate the associated change in pre-hospital fluid administration. A retrospective explicit chart review of patient records was conducted of all patients with major burns presenting to The Alfred Emergency & Trauma Centre over a 10 year period. Patient demographics, fluid resuscitation and outcomes in the period before the introduction of the new formula were compared to those in the post-introduction period. There were 126 patients with major burns (≥20% total body surface area burnt) included in the study. The median fluid volume administration pre-hospital after introduction of The Alfred formula was 0.35 (0.22-0.44) mL/kg/%TBSA burnt, which was significantly higher than 0.14 (0.04-0.26) mL/kg/%TBSA administered in the prior period (p=0.013). There was no significant change in physiological endpoints associated with the increased volume. At 24 h, the volume of fluid administered in patients when The Alfred formula was used was 4.9±1.6 mL/kg/%TBSA, which was not significantly higher than the volume administered before 2007 of 4.8±2.2 mL/%TBSA/kg (p=0.802). The Alfred pre-hospital fluid formula has resulted in patients receiving significantly more fluids early, although still below volumes suggested by the Parkland formula. There were no adverse effects of this increased volume detected over the study period. The Alfred pre-hospital fluid formula appears to be safe and more effective in delivering fluid volumes predicted by the current 'gold standard'.
Publisher: Oxford University Press (OUP)
Date: 25-03-2011
Abstract: Assessing the reliability of clinical registries is important for ensuring the availability of credible data. Therefore, this study aimed to investigate the reliability of data collected by the Australian and New Zealand Haemostasis Registry (the registry). Data from 5% of randomly selected registry cases were re-abstracted by an independent data auditor who was blinded to the results of the original data abstraction. Categorical data were investigated for agreement between original and re-abstracted data. The mean difference and standard deviations (SD) of differences were calculated for continuous variables. We estimated a 'prediction interval' as the mean difference ± twice the SD of differences. We computed a coefficient of variation as the SD of differences. The registry records all cases of off-licence use of recombinant activated factor VII (rFVIIa) at participating institutions (on-licence use of rFVIIa is not recorded). Data on 76 registry cases (6% of registry) were re-abstracted. Various parameters demonstrated high levels of inter-rater reliability, including age, gender and intensive care unit admission (88, 99 and 99% agreement, respectively). Other variables were highly unreliable, including crystalloid infusion volumes (coefficient of variation 123.01%), red blood cell units (92.05%) and time from bleeding onset to administration of rFVIIa (153.06%). Registry audits are useful for identifying variables with poor reliability. Repeated audits will not improve data reliability however, they can assist in identifying and evaluating the impact of modified data collection processes on improving data reliability.
Publisher: Wiley
Date: 29-10-2009
DOI: 10.1111/J.1440-1754.2009.01594.X
Abstract: Paediatric chest trauma is a marker of severe injury and a significant cause of morbidity and mortality. However, current trends in the Australian population are unknown. This study aims to outline the profile and management of major paediatric chest trauma in Victoria. Prospectively collected data of patients from the Victorian State Trauma Registry from July 2001 to June 2007 were retrospectively reviewed. Data on fatalities were obtained from the National Coroners Information System. Descriptive statistics were used to summarise the profiles of major trauma cases and coroners' cases. Overall, 204 cases with serious paediatric chest injuries were reported by the Victorian State Trauma Registry (n = 158) and National Coroners Information System (n = 46) (excluding overlapping cases) in 2001-2007. Paediatric chest trauma was more common in males. The Injury Severity Score ranged from 16 to 25 in most patients. Blunt trauma was responsible for 96% of cases, of which motor vehicle collisions accounted for 75%. Median hospitalisation was 9 days, and 64% of patients were admitted to intensive care. Common injuries included lung contusion (66%), haemo neumothorax (32%) and rib fracture (23%). Multiple organ injury occurred in 99% of cases, with head (62%) and abdominal (50%) injury common. Management was conservative, with only 11 cases (7%) treated surgically. The highest mortality was in the 10-15-year age group. In 52 (79%) fatalities, injury was transport related. Australian paediatric chest trauma trends are similar to international patterns. Serious injury requiring surgical intervention is rare. This limited exposure may lead to difficulty in maintaining surgical expertise in this highly specialised area.
Publisher: Wiley
Date: 28-09-2010
DOI: 10.1111/J.1742-6723.2010.01331.X
Abstract: To investigate the usefulness of stress testing before discharge in patients assessed low to intermediate risk of acute coronary syndrome (ACS). A prospective observational study was undertaken of patients presenting to the ED with suspected myocardial ischaemia. After negative initial electrocardiogram (ECG) and serum troponin testing, patients were admitted to the emergency short stay unit (ESSU) for further evaluation using a chest pain protocol that included stress testing as the final risk stratification tool. The primary outcome measure was evidence of myocardial ischaemia at stress testing. Of the 300 patients enrolled and followed up, there were no deaths at 30 days and no myocardial infarcts in patients discharged from the short stay. Two patients (0.67%) had positive serum troponin levels at 6 h after the onset of chest pain and were diagnosed with non-ST segment elevation myocardial infarctions. Three patients (1%) had abnormal stress testing and were admitted to hospital from ESSU. On review, all three patients were high risk, according to The National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines. The present study showed that an ED short stay unit can effectively evaluate and manage patients with low and intermediate risk of ACS. The study suggests that patients with low and intermediate risk for ACS might safely be discharged after normal serial ECG and cardiac biomarkers, with a view to early outpatient stress testing. With strict adherence to admission criteria, there does not appear to be any benefit of stress testing before discharge.
Publisher: Wiley
Date: 07-05-2017
DOI: 10.1002/JPPR.1309
Publisher: BMJ
Date: 30-03-2011
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2011
DOI: 10.1161/STROKEAHA.111.615674
Abstract: Warfarin is an effective drug for the prevention of thromboembolism in the elderly. The major risk for patients taking warfarin is bleeding. We aimed to assess the impact of psychosocial factors, including mood, cognition, social isolation, and health literacy on warfarin instability among community-based elderly patients. A case–control study was conducted between March 2008 and June 2009 in a community-based setting. Cases were patients previously stabilized on warfarin who recorded an international normalized ratio ≥6.0. Control subjects were patients whose international normalized ratio measurement was maintained within the therapeutic range. Patient interviews investigated potential predisposing factors to elevated International Normalized Ratio levels. A total of 486 patients were interviewed: 157 cases and 329 control subjects, with an approximate mean age of 75 years. Atrial fibrillation was the most common primary indication. Adjusted multivariate logistic regression revealed impaired cognition (OR, 1.9 95% CI, 1.0 to 3.6), depressed mood (OR, 2.2 95% CI, 1.2 to 3.9), and inadequate health literacy (OR, 4.0 % CI, 2.1 to 7.4) were associated with increased risk of an elevated International Normalized Ratio. This study identified impaired cognition, depressed mood, and inadequate health literacy as risk factors for warfarin instability. These had a similar impact to well-recognized demographic, clinical, and medication-related factors and are prevalent among the elderly. These findings suggest that elderly patients prescribed warfarin should be reviewed regularly for psychosocial deficits.
Publisher: Wiley
Date: 18-11-2021
Abstract: 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 in idual clinicians, and from a Pacific regional perspective. 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. Twelve doctors participated (11 verbal, one written response), representing six different Pacific Island countries. Four key themes were identified which reflected both the in idual 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. 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.
Publisher: Elsevier BV
Date: 2018
DOI: 10.1016/J.RESUSCITATION.2017.11.058
Abstract: In emergency ambulance calls, agonal breathing remains a barrier to the recognition of out-of-hospital cardiac arrest (OHCA), initiation of cardiopulmonary resuscitation, and rapid dispatch. We aimed to explore whether the language used by callers to describe breathing had an impact on call-taker recognition of agonal breathing and hence cardiac arrest. We analysed 176 calls of paramedic-confirmed OHCA, stratified by recognition of OHCA (89 cases recognised, 87 cases not recognised). We investigated the linguistic features of callers' response to the question "is s/he breathing?" and examined the impact on subsequent coding by call-takers. Among all cases (recognised and non-recognised), 64% (113/176) of callers said that the patients were breathing (yes-answers). We identified two categories of yes-answers: 56% (63/113) were plain answers, confirming that the patient was breathing ("he's breathing") and 44% (50/113) were qualified answers, containing additional information ("yes but gasping"). Qualified yes-answers were suggestive of agonal breathing. Yet these answers were often not pursued and most (32/50) of these calls were not recognised as OHCA at dispatch. There is potential for improved recognition of agonal breathing if call-takers are trained to be alert to any qualification following a confirmation that the patient is breathing.
Publisher: Elsevier BV
Date: 12-2022
DOI: 10.1016/J.INJURY.2022.09.052
Abstract: The number of older adults hospitalised for injury is growing rapidly. The population-adjusted incidence of isolated thoracic injuries in older adults is also growing. While some older adults are at high risk of post-traumatic complications, not all older adults will need treatment in a major trauma service (MTS). The aim of this study was to characterise older patients with isolated chest injuries, determine the rates of post-traumatic complications, including respiratory failure and pneumonia, and the factors associated with the risk of developing these complications. This was a retrospective review of patients aged 65 years and over with isolated chest trauma, from January 2007 to June 2017, using data from the Victorian State Trauma Registry. Patient characteristics and rates of complications were compared between patients with 1. isolated rib fractures, and 2. complex chest injury. Multivariable logistic regression was used to identify predictors of respiratory failure, and pneumonia. The study population comprised 5401 patients aged 65 years or more, with isolated chest injuries. Two-thirds (65%) of all patients had isolated rib fractures, and 58% of patients (n = 3156) were directly admitted to a non-major trauma centre. Complications were uncommon, with 5.45% of all patients (n = 295) having pneumonia and 3.2% (n = 175) having respiratory failure. Factors associated with increased risk of pneumonia and respiratory failure included advancing age, smoking, chronic obstructive pulmonary disease, congestive heart failure, and more severe and complex chest injury. The adjusted odds of complications were lowest amongst patients not classified as major trauma and receiving definitive treatment in non-MTS. Our findings suggest that rates of complications in older patients with isolated chest trauma in this study were low, and that there is a large group of patients with isolated, uncomplicated rib fractures, who may not need to be treated in a major trauma centre. Further work should be undertaken to appropriately risk stratify and manage older adults with isolated chest trauma.
Publisher: Wiley
Date: 12-2003
DOI: 10.1111/J.1445-5994.2003.00423.X
Abstract: Advance directives (ADs) are rarely available in Australia to guide management but may become more important as our population ages. The present study aimed to determine patient knowledge, perception and ownership rates of ADs and the factors that impact upon these variables. A cross-sectional survey of emergency department patients was undertaken. The main outcome measures were: (i) prior discussion about the extent of medical treatment and ADs, (ii) knowledge and perceptions of ADs, (iii) present AD ownership rates and (iv) likelihood of future AD ownership. Generalized linear models were used for analysis. Four hundred and three patients were enrolled. The mean age of patients was 73 years and 239 (59.3%) were male. Two hundred and forty patients (59.6%) had discussed the extent of treatment. Only 81 patients (20.1%) had discussed the use of an AD. One hundred and thirty-seven patients (34.0%) knew of one type of AD and 333 patients (82.6%) thought some ADs were a good idea. Only 32 patients (7.9%) owned an AD, although 276 (68.5%) would consider owning one. The main reason for never obtaining an AD was "always wanting full treatment" (93 patients, 23.1%). Level of education was the only characteristic that impacted significantly upon an outcome measure. Patients with a higher level of education were more likely to have known and spoken about ADs, to own an AD and to consider owning one. AD knowledge and ownership rates were low. However, most patients perceive them favourably and many would consider owning one. Intervention strategies to improve AD awareness are indicated. This may empower patients to more effectively participate in their own advance care planning.
Publisher: Elsevier BV
Date: 02-2007
DOI: 10.1016/J.JSAMS.2006.04.001
Abstract: Golfing injuries have been shown to occur frequently, and injury countermeasures have been suggested to help reduce injury risk. Performing an appropriate warm-up is thought to reduce injury risk, however there is a lack of evidence to support this notion. Therefore this study aimed to investigate the relationships between warm-up participation and injury in a cohort of female golfers. A total of 522 golfers participating in the Victorian Women's Pennant Competition completed the study. Over one-third (35.2%) of the golfers reported having sustained a golfing injury within the previous 12 months, with the lower back the most commonly injured region. Most golfers reported not warming-up prior to play or practice. Golfers who reported not warming-up on a regular basis were more likely to have reported a golfing injury in the previous 12 months than those reporting frequent warm-up participation (OR=45.2 95% CI: 13.5, 151.7). Less skilled golfers were also less likely to report sustaining a golfing injury than more skilled golfers (OR=0.2 95% CI: 0.1, 0.5). This study is one of the few to establish an association between warm-up participation and injury. Further prospective studies are warranted to determine whether warm-up reduces injury risk for golf participation.
Publisher: Elsevier BV
Date: 07-2018
DOI: 10.1016/J.RESUSCITATION.2018.04.019
Abstract: Recent studies suggest the administration of 100% oxygen to hyperoxic levels following return-of-spontaneous-circulation (ROSC) post-cardiac arrest may be harmful. However, the feasibility and safety of oxygen titration in the prehospital setting is unknown. We conducted a multi-centre, phase-2 study testing whether prehospital titration of oxygen results in an equivalent number of patients arriving at hospital with oxygen saturations SpO2 ≥ 94%. We enrolled unconscious adults with: sustained ROSC initial shockable rhythm an advanced airway and an SpO2 ≥ 95%. Initially (Sept 2015-March 2016) patients were randomised 1:1 to either 2 L/minute (L/min) oxygen (titrated) or >10 L/min oxygen (control) via a bag-valve reservoir. However, one site experienced a high number of desaturations (SpO2 < 94%) in the titrated arm and this arm was changed (April 2016) to an initial reduction of oxygen to 4 L/min then, if tolerated, to 2 L/min, and the desaturation limit was decreased to <90%. We randomised 61 patients to titrated (n = 37: 2L/min = 20 and 2-4 L/min = 17) oxygen or control (n = 24). Patients allocated to titrated oxygen were more likely to desaturate compared to controls ((SpO2 < 94%: 43% vs. 4%, p = 0.001 SpO2 90% (NCT02499042).
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2015
Publisher: Elsevier BV
Date: 11-2005
DOI: 10.1016/J.INJURY.2005.07.010
Abstract: Precise prehospital trauma triage criteria are critical for ensuring patients with severe injuries are transported to trauma centres. Most prehospital trauma triage criteria adopt a combination of physiological, anatomic and mechanism of injury components, but this approach still fails to identify a number of patients with severe injuries and often burdens trauma centres with patients suffering minor injuries. Paramedic judgement has been identified as an alternative method for the triage of trauma patients. This study critically reviewed the literature regarding the ability of paramedics to predict injury severity, and found there is no clear evidence supporting paramedic judgement as an accurate triage method. However, the studies were limited due to significant data losses, variable definitions of major trauma, differences across EMS and trauma care systems, variable paramedic experience levels and incomparable methods of data collection. The role of paramedic judgement in identifying patients with severe blunt anatomic injuries requires further investigation.
Publisher: BMJ
Date: 10-2017
DOI: 10.1136/BMJOPEN-2017-017350
Abstract: Compensable injury increases the likelihood of having persistent pain after injury. Three-quarters of patients report chronic pain after traumatic injury, which is disabling for about one-third of patients. It is important to understand why these patients report disabling pain, in order to develop targeted preventative interventions. This study examined the experience of pain and disability, and investigated their sequential interrelationships with, catastrophising, kinesiophobia and self-efficacy 1 year after compensable and non-compensable injury. Observational registry-based cohort study. Metropolitan Trauma Service in Melbourne, Victoria, Australia. Participants were recruited from the Victorian State Trauma Registry and Victorian Orthopaedic Trauma Outcomes Registry. 732 patients were referred to the study, 82 could not be contacted or were ineligible, 217 declined and 433 participated (66.6% response rate). The Brief Pain Inventory, Glasgow Outcome Scale, EuroQol Five Dimensions questionnaire, Pain Catastrophising Scale, Pain Self-Efficacy Questionnaire, Injustice Experience Questionnaire and the T a Scale of Kinesiophobia. Direct and indirect relationships (via psychological appraisals of pain/injury) between baseline characteristics (compensation, fault and injury characteristics) and pain severity, pain interference, health status and disability were examined with ordinal, linear and logistic regression, and mediation analyses. Injury severity, compensable injury and external fault attribution were consistently associated with moderate-to-severe pain, higher pain interference, poorer health status and moderate-to-severe disability. The association between compensable injury, or external fault attribution, and disability and health outcomes was mediated via pain self-efficacy and perceived injustice. Given that the associations between compensable injury, pain and disability was attributable to lower self-efficacy and higher perceptions of injustice, interventions targeting the psychological impacts of pain and injury may be especially necessary to improve long-term injury outcomes.
Publisher: BMJ
Date: 07-2017
Publisher: Wiley
Date: 13-05-2007
DOI: 10.1111/J.1742-6723.2007.00965.X
Abstract: Australasian trauma centres receive relatively low numbers of penetrating injuries from stabbings. There is limited agreement regarding protocols to guide the management of haemodynamically stable patients with penetrating injuries. This has resulted in a wide variation in practice with anecdotally high negative laparotomy rates. The aim of the present study was to review the ED procedures, investigations and disposition of this group of patients. A retrospective review of all patients presenting with abdominal penetrating injury was undertaken over a 5 year period. Data on demographics, presenting features and management were collected. There were 109 patients who were haemodynamically stable (systolic blood pressure > 90) on arrival to the trauma centre. Diagnostic ED procedures and investigations consisted of wound exploration in 47 (43.1%) patients, focused abdominal sonography in trauma in 44 (40.4%) patients and a CT abdomen in 36 (33.0%) of patients. The sensitivity for focused abdominal sonography in trauma and CT when used together was 77.8%. There were 39 laparotomies performed with a negative laparotomy rate of 23.1%. There were 10 laparoscopies performed, none went on to require a laparotomy. Patients undergoing negative laparotomies spent significantly longer times in hospital than patients managed conservatively or those undergoing laparoscopies. The number of penetrating abdominal injuries remains low. Imaging alone cannot reliably exclude intraperitoneal injury. A greater utilization of ED wound exploration and laparoscopy based on agreed guidelines could improve management. An algorithm for the management of these patients is suggested.
Publisher: Wiley
Date: 26-06-2006
DOI: 10.1111/J.1445-2197.2006.03785.X
Abstract: Although orthopaedic trauma results in significant disability and substantial financial cost, there is a paucity of large cohort studies that collectively describe the functional outcomes of a variety of these injuries. The current study aimed to investigate the outcomes of patients admitted with a range of orthopaedic injuries to adult Level 1 trauma centres. Patients were recruited from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), which included all patients with orthopaedic trauma admitted to the two adult Level 1 trauma centres in Victoria (Australia). Patients were categorised into three groups isolated orthopaedic injuries, multiple orthopaedic injuries and orthopaedic and other injuries. Demographic and injury data were collected from the medical record and hospital/trauma databases, and functional outcome instruments were given at 6 months post-injury. Of the 1303 patients recruited for VOTOR over a 12-month period, 1181 patients were eligible for the study and a response rate of 75.6% was obtained at 6 months post-injury. Patients reported ongoing pain (moderate-severe: 37.2%), disability (79.5%) and inability to return to work (35.2%). Poorer outcomes were evident in patients with orthopaedic and other injuries than those with single or multiple orthopaedic injuries alone. A large percentage of patients have ongoing pain and disability and a reduced capacity to return to work 6 months after orthopaedic trauma. Further research into the long-term outcomes of patients with orthopaedic injuries is required to identify patient subgroups and specific injuries and procedures that result in high morbidity.
Publisher: Wiley
Date: 04-2010
DOI: 10.1111/J.1445-5994.2009.02161.X
Abstract: The indicator 'death in low-mortality diagnosis-related groups (DRG)' is a patient safety indicator (PSI) that can be derived from routinely collected administrative data sources. It is included in a group of PSI that have been proposed to compare and monitor standards of hospital care in Australia. To summarize the attributes of this indicator as a measure of quality and safety in healthcare and examine issues regarding the development process, definitions and use of the indicator in practice. A structured literature search was conducted using the Ovid Medline database to identify peer-reviewed published literature which used 'death in low-mortality DRG' as a quality/safety indicator. Key quality websites were also searched. The studies were critically appraised using a standardized method. A total of 12 articles was identified which met our search criteria. Most were of low methodological quality because of their retrospective study designs. Only three studies provided evidence that the quality of care gap is higher in 'deaths in low-mortality DRG' than in other cases. Most of the studies reviewed show that there are several limitations of the indicator for assessing patient safety and quality of care. The few studies that have assessed associations with other measures of hospital quality have shown only weak and inconsistent associations. Higher quality, prospective, analytic studies are required before 'death in low-mortality DRG' is used as an indicator of quality and safety in healthcare. Based on current evidence, the most appropriate use is as a screening tool for institutions to quickly and easily identify a manageable number of medical records to investigate in more detail.
Publisher: Elsevier BV
Date: 12-2011
DOI: 10.1016/J.INJURY.2011.05.022
Abstract: To evaluate the validity of the 12-item Short Form Health Survey (SF-12), Sickness Impact Profile (SIP) and the Short Musculoskeletal Functional Assessment Questionnaire (SMFA) for use in an orthopaedic trauma population. A prospective validation trial was completed at a Level 1 adult trauma centre in Melbourne, Australia. One hundred and fifty four patients with orthopaedic trauma managed or followed-up by an orthopaedic unit were prospectively recruited. Patients with pathological fractures related to metastatic disease and/or an isolated orthopaedic injury, a documented history of mental illness or dementia or those for whom follow-up was likely to be difficult were excluded. The SF-12, SIP and SMFA were administered by a trained interviewer at one and six months. Each questionnaire was scored for the physical and mental components and then compared for content and construct validity at each time point. Complete data were collected for 134 patients at one and six months. The one and six month component scores correlated strongly between the SF-12 physical, SIP physical (r=0.513-0.669) and SMFA dysfunction (r=0.529-0.778) the SF-12 mental, SIP mental (r=0.643-0.719) and SMFA bother (r=0.564-0.602) components. The strength of association was greater for the six month time point compared to the one month measure. The SF-12 demonstrated no ceiling or floor effects, and provided a lower time burden on participants and researchers when compared to the SIP and SMFA. For large population-based surveillance research into orthopaedic injury the SF-12 provides a valid and versatile tool.
Publisher: Wiley
Date: 13-12-2017
DOI: 10.1111/TME.12377
Abstract: To evaluate the use of routinely collected data to determine the cause(s) of critical bleeding in patients who receive massive transfusion (MT). Routinely collected data are increasingly being used to describe and evaluate transfusion practice. Chart reviews were undertaken on 10 randomly selected MT patients at 48 hospitals across Australia and New Zealand to determine the cause(s) of critical bleeding. Diagnosis-related group (DRG) and International Classification of Diseases (ICD) codes were extracted separately and used to assign each patient a cause of critical bleeding. These were compared against chart review using percentage agreement and kappa statistics. A total of 427 MT patients were included with complete ICD and DRG data for 427 (100%) and 396 (93%), respectively. Good overall agreement was found between chart review and ICD codes (78·3% κ = 0·74, 95% CI 0·70-0·79) and only fair overall agreement with DRG (51% κ = 0·45, 95% CI 0·40-0·50). Both ICD and DRG were sensitive and accurate for classifying obstetric haemorrhage patients (98% sensitivity and κ > 0·94). However, compared with the ICD algorithm, DRGs were less sensitive and accurate in classifying bleeding as a result of gastrointestinal haemorrhage (74% vs 8% κ = 0·75 vs 0·1), trauma (92% vs 62% κ = 0·78 vs 0·67), cardiac (80% vs 57% κ = 0·79 vs 0·60) and vascular surgery (64% vs 56% κ = 0·69 vs 0·65). Algorithms using ICD codes can determine the cause of critical bleeding in patients requiring MT with good to excellent agreement with clinical history. DRG are less suitable to determine critical bleeding causes.
Publisher: BMJ
Date: 10-08-2010
Abstract: Clinical handover between paramedics and the trauma team is undertaken in a time-pressured environment. Paramedics are often required to handover complex problems to a multitude of staff. There is evidence that information loss occurs at this transition. The aims of this project were to (1) develop a minimum dataset to assist paramedics provide handover (2) identify attributes of effective and ineffective handover (3) determine the feasibility of advanced data transmission and (4) identify how to best display data in trauma bays. Qualitative study of paramedics and trauma team members. A thematic analysis was undertaken using grounded theory. Ten paramedics and 17 trauma team members were interviewed. A minimum dataset modified on an existing template was developed to include fields required by the trauma team to inform immediate treatment. Respondents stated that an effective handover was one which was delivered succinctly and in a structured manner, and contained only vital data necessary to direct immediate treatment. Advanced transmission of data to the receiving hospital was widely supported. While computers carried by paramedics were capable of exporting data to the receiving hospital, barriers such as time constraints, workflow issues and infection control issues impeded the ability to do this in the current environment. There is support for the adoption and further evaluation of a handover template. It can provide valuable structure to the face-to-face handover, and experience from other specialties suggests it can reduce information loss. Strategies to enable information to be transmitted in advance of the patients' arrival must address concerns voiced by paramedics.
Publisher: Elsevier BV
Date: 09-2011
Publisher: Elsevier BV
Date: 11-2011
Publisher: BMJ
Date: 12-08-2014
DOI: 10.1136/INJURYPREV-2014-041336
Abstract: Traumatic injury is a leading contributor to the overall global burden of disease. However, there is a worldwide shortage of population data to inform understanding of non-fatal injury burden. An improved understanding of the pattern of recovery following trauma is needed to better estimate the burden of injury, guide provision of rehabilitation services and care to injured people, and inform guidelines for the monitoring and evaluation of disability outcomes. To provide a comprehensive overview of patient outcomes and experiences in the first 5 years after serious injury. This is a population-based, nested prospective cohort study using quantitative data methods, supplemented by a qualitative study of a seriously injured participant s le. All 2547 paediatric and adult major trauma patients captured by the Victorian State Trauma Registry with a date of injury from 1 July 2011 to 30 June 2012 who survived to hospital discharge and did not opt-off from the registry. To analyse the quantitative data and identify factors that predict poor or good outcome, whether there is change over time, differences in rates of recovery and change between key participant subgroups, multilevel mixed effects regression models will be fitted. To analyse the qualitative data, thematic analysis will be used to identify important themes and the relationships between themes. The results of this project have the potential to inform clinical decisions and public health policy, which can reduce the burden of non-fatal injury and improve the lives of people living with the consequences of severe injury.
Publisher: Oxford University Press (OUP)
Date: 10-08-2015
Abstract: a decline in health state and re-attendance are common in people aged ≥65 years following emergency department (ED) discharge. Diverse care models have been implemented to support safe community transition. This review examined ED community transition strategies (ED-CTS) and evaluated their effectiveness. a systematic review and meta-analysis using multiple databases up to December 2013 was conducted. We assessed eligibility, methodological quality, risk of bias and extracted published data and then conducted random effects meta-analyses. Outcomes were unplanned ED representation or hospitalisation, functional decline, nursing-care home admission and mortality. five experimental and four observational studies were identified for qualitative synthesis. ED-CTS included geriatric assessment with referral for post-discharge community-based assistance, with differences apparent in components and delivery methods. Four studies were included in meta-analysis. Compared with usual care, the evidence indicates no appreciable benefit for ED-CTS for unplanned ED re-attendance up to 30 days (odds ratio (OR) 1.32, 95% confidence interval (CI) 0.99-1.76 n = 1,389), unplanned hospital admission up to 30 days (OR 0.90, 95% CI 0.70-1.16 n = 1,389) or mortality up to 18 months (OR 1.04, 95% CI 0.83-1.29 n = 1,794). Variability between studies precluded analysis of the impact of ED-CTS on functional decline and nursing-care home admission. there is limited high-quality data to guide confident recommendations about optimal ED community transition strategies, highlighting a need to encourage better integration of researchers and clinicians in the design and evaluation process, and increased reporting, including appropriate robust evaluation of efficacy and effectiveness of these innovative models of care.
Publisher: Elsevier BV
Date: 09-2023
Publisher: Springer Science and Business Media LLC
Date: 03-2010
Publisher: Wiley
Date: 2006
DOI: 10.1111/J.1445-2197.2006.03641.X
Abstract: Background: The Parkland formula is established as the ‘gold standard’ for initial fluid resuscitation for major burns. The purpose of this study was to review our fluid resuscitation practice for major burns to determine whether anecdotal observations of significant variations from the Parkland formula were wide spread and whether any difference could be used as a basis for a revision of fluid resuscitation in major burns. Methods: A retrospective review of 127 presentations to The Alfred Burns Unit with total body surface area (TBSA) affected ≥15% was conducted. A retrospective review of the resuscitation data from these patients was compared with the Parkland formula as well as other studies. Results: A total of 49 patients with complete data on fluid administration and uncomplicated burns were included in the analysis. Significantly larger volumes of fluid (5.58 mL/kg per %TBSA) were given to these patients in the first 24 h than predicted by the Parkland formula. Mean arterial pressure, pulse rate and urine output were at satisfactory levels. Clinically evident complications from fluid administration were minimal. Mortality was similar to that in other centres. Conclusion: Fluid resuscitation volumes significantly higher than those predicted by the Parkland formula were given, without adverse consequences. This retrospective review supports a prospective, multicentre, randomized, controlled study comparing this study with the Parkland formula, resulting in a better guide to initial fluid resuscitation in major burns.
Publisher: Wiley
Date: 28-06-2008
DOI: 10.1111/J.1445-2197.2008.04579.X
Abstract: Severe traumatic head injury in the elderly has been associated with poor outcomes. However, there is currently no consensus to direct management in these patients. This study outlines the demographics, injury characteristics, management and outcome of the elderly trauma patients with severe head injury across a defined population. A retrospective review of all elderly patients (age >64 years) with a Glasgow Coma Scale (GCS) score of 8 or less, and confirmed intracranial pathology or fractured skull, was undertaken over a period of 40 months from July 2001 to September 2005. Data on patient demographics, injury cause, presenting clinical features and interventions were collected. In-hospital mortality was used as the primary outcome. There were 96 patients who met the inclusion criteria. One-third of the patients were managed palliatively, one-third supportively without surgery and another third underwent surgery. Overall mortality was 70.8% (n = 68). Older age and brainstem injuries were identified as independent predictors of mortality. Mortality was reported in all patients aged 85 years or older. Although overall outcomes were poor, careful consideration should be given to active treatment as favourable outcomes were possible even in the presence of extremely low GCS scores. Prediction of outcome on the basis of age and anatomical diagnoses may help in this decision-making.
Publisher: BMJ
Date: 16-03-2013
DOI: 10.1136/EMERMED-2011-201035
Abstract: Hanging is an infrequent but devastating cause of out-of-hospital cardiac arrest (OHCA). We determine the characteristics and outcomes of hanging-associated OHCA in Melbourne Australia. A 10-year retrospective case review of all adult hangings (aged ≥16 years) associated with OHCA, was conducted using data from the Victorian Ambulance Cardiac Arrest Registry. Between 2000 and 2009, the emergency medical service (EMS) attended 33 178 adult OHCAs of which 1321 (4%) had hanging as the aetiology. The median age (IQR) of hanging-associated OHCA cases was 39 (29-51) years and 1162 were men (88%). The first recorded rhythm by EMS was asystole seen in 1276 (75.5%) patients, pulseless electrical activity (PEA) in 38 (13.4%) cases and ventricular fibrillation in 7 cases (0.5%). EMS attempted resuscitation in 208 (15.7%) patients of whom 61 (29.3%) achieved return of spontaneous circulation (ROSC) and were transported, and 7 (3.3%) survived to hospital discharge. Hanging-associated OHCAs were younger (median (IQR) 38 (29-51) years versus 74 (61-82) years, p<0.001), less likely to have a shockable rhythm (0.5% vs 17.2%, p<0.001), receive bystander cardiopulmonary resuscitation (14.1% vs 25.5%, p<0.001) or an attempted resuscitation by EMS (15.7% vs 36.1%, p<0.001) compared with OHCA cases with an aetiology of 'presumed cardiac' arrest. Multivariable logistic regression identified factors associated with EMS decision to attempt resuscitation the adjusted OR (95% CI) for 'presence of bystander cardiopulmonary resuscitation' was 15.8 (10.70-23.30) and for 'witnessed arrest' was 5.26 (1.17-23.30). Attempted resuscitation was not always futile with a survival of 3.3%. A preventive focus is needed.
Publisher: American Academy of Pediatrics (AAP)
Date: 12-2001
Abstract: Objectives. The impact of mild head injury or mild traumatic brain injury (TBI) in children is variable, and determinants of outcome remain poorly understood. There have been no previous attempts to evaluate the impact of interventions to improve outcome. Results of previous intervention studies in adults have been mixed. This study aimed to evaluate the impact of providing information on outcome measured in terms of reported symptoms, cognitive performance, and psychological adjustment in children 3 months after injury. Methods. A total of 61 children with mild TBI were assessed 1 week and 3 months after injury, and 58 children with mild TBI were assessed 3 months after injury only. They were compared with 2 control groups (N = 45 and 47) of children with minor injuries not involving the head. Participants completed measures of preinjury behavior and psychological adjustment, postconcussion symptoms, and tests of attention, speed of information processing, and memory. Children with mild TBI seen at 1 week were also given an information booklet outlining symptoms associated with mild TBI and suggested coping strategies. Those seen 3 months after injury only did not receive this booklet. Results. Children with mild TBI reported more symptoms than controls at 1 week but demonstrated no impairment on neuropsychological measures. Initial symptoms had resolved for most children by 3 months after injury, but a small group of children who had previous head injury or a history of learning or behavioral difficulties reported ongoing problems. The group not seen at 1 week and not given the information booklet reported more symptoms overall and was more stressed 3 months after injury. Conclusions. Providing an information booklet reduces anxiety and thereby lowers the incidence of ongoing problems.
Publisher: Springer Science and Business Media LLC
Date: 11-2017
DOI: 10.1017/CEM.2017.396
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2015
DOI: 10.1161/CIRCOUTCOMES.114.001185
Abstract: Although the value of clinical registries has been well recognized in developed countries, their use for measuring the quality of emergency medical service care remains relatively unknown. We report the methodology and findings of a statewide emergency medical service surveillance initiative, which is used to measure the quality of systems of care for patients with out-of-hospital cardiac arrest. Between July 1, 2002, and June 30, 2012, data for adult out-of-hospital cardiac arrest cases of presumed cardiac cause occurring in the Australian Southeastern state of Victoria were extracted from the Victorian Ambulance Cardiac Arrest Registry. Regional and temporal trends in bystander cardiopulmonary resuscitation, event survival, and survival to hospital discharge were analyzed using logistic regression and multilevel modeling. A total of 32 097 out-of-hospital cardiac arrest cases were identified, of whom 14 083 (43.9%) received treatment by the emergency medical service. The risk-adjusted odds of receiving bystander cardiopulmonary resuscitation (odds ratio [OR], 2.96 95% confidence interval, 2.62–3.33), event survival (OR, 1.55 95% confidence interval, 1.30–1.85), and survival to hospital discharge (OR, 2.81 95% confidence interval, 2.07–3.82) were significantly improved by 2011 to 2012 compared with baseline. Significant variation in rates of bystander cardiopulmonary resuscitation and survival were observed across regions, with arrests in rural regions less likely to survive to hospital discharge. The median OR for interhospital variability in survival to hospital discharge outcome was 70% (median OR, 1.70). Between 2002 and 2012, there have been significant improvements in bystander cardiopulmonary resuscitation and survival outcome for out-of-hospital cardiac arrest patients in Victoria, Australia. However, regional survival disparities and interhospital variability in outcomes pose significant challenges for future improvements in care.
Publisher: Wiley
Date: 02-2004
DOI: 10.1111/J.1742-6723.2004.00531.X
Abstract: There is anecdotal evidence that ACEM Fellows are reducing or planning to reduce their clinical workload. We investigated the extent of, and reasons for, these reductions. An anonymous, cross-sectional postal survey utilizing a study-specific questionnaire. Three hundred and twenty-three Fellows (63.5%) responded. Most were recently graduated males. In the last 5 years, the mean number of clinical hours worked per week has reduced significantly (P < 0.001) for both junior (40.6-28.9 h) and senior Fellows (30.4-23.1 h). Further significant (P < 0.001) reductions are planned. The most frequently reported reasons for reducing clinical workload were excessive workload, family life and emotional health effects, shift work and work stress. The most stressful aspects of work reported were access block, dealing with management, insufficient staffing, workload pressures and staff supervision. Clinical work reportedly impacts most upon family life, social life and emotional health. Fellows are significantly reducing their clinical workload largely in response to excessive workload and lack of resources. These findings have important implications for professional longevity and work force planning. Re-evaluation of workplace practice, especially identified stressors, is indicated.
Publisher: Wiley
Date: 10-2011
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2010
Publisher: Springer Science and Business Media LLC
Date: 04-04-2010
DOI: 10.1038/NATURE09011
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2009
Publisher: Springer Science and Business Media LLC
Date: 15-07-2013
Abstract: As demand for Emergency Department (ED) services continues to exceed increases explained by population growth, strategies to reduce ED presentations are being explored. The concept of ambulance paramedics providing an alternative model of care to the current default ‘see and transport to ED’ has intuitive appeal and has been implemented in several locations around the world. The premise is that for certain non-critically ill patients, the Extended Care Paramedic (ECP) can either ‘see and treat’ or ‘see and refer’ to another primary or community care practitioner, rather than transport to hospital. However, there has been little rigorous investigation of which types of patients can be safely identified and managed in the community, or the impact of ECPs on ED attendance. St John Ambulance Western Australia paramedics will indicate on the electronic patient care record (e-PCR) of patients attended in the Perth metropolitan area if they consider them to be suitable to be managed in the community. ‘Follow-up’ will examine these patients using ED data to determine the patient’s disposition from the ED. A clinical panel will then develop a protocol to identify those patients who can be safely managed in the community. Paramedics will then assess patients against the derived ECP protocols and identify those deemed suitable to ‘see and treat’ or ‘see and refer’. The ED disposition (and other clinical outcomes) of these ‘ECP protocol identified’ patients will enable us to assess whether it would have been appropriate to manage these patients in the community. We will also ‘track’ re-presentations to EDs within seven days of the initial presentation. This is a ‘virtual experiment’ with no direct involvement of patients or changes in clinical practice. A systems modelling approach will be used to assess the likely impact on ED crowding. To date the efficacy, cost-effectiveness and safety of alternative community-based models of emergency care have not been rigorously investigated. This study will inform the development of ECP protocols through the identification of types of patient presentation that can be considered both safe and appropriate for paramedics to manage in the community.
Publisher: SAGE Publications
Date: 07-2005
DOI: 10.1177/102490790501200304
Abstract: To describe, using the Utstein template, the characteristics of patients presenting with out-of-hospital cardiac arrest to a university teaching hospital in the New Territories of Hong Kong, and to evaluate survival. Prospective study. The emergency department of a teaching hospital in the New Territories, Hong Kong. Patients older than 12 years with non-traumatic out-of-hospital cardiac arrest who were transported to the hospital between 1 July 2002 and 31 December 2002. Demographic data, characteristics of cardiac arrest and response time intervals of the emergency medical service presented according to the Utstein style, and also survival to hospital discharge rate. A total of 124 patients were included (49.2% male mean age 71.9 years). The majority of cardiac arrests occurred in patients' home. The overall bystander cardiopulmonary resuscitation (CPR) rate was 15.3% (19/124). The most common electrocardiographic rhythm at scene was asystole, whilst pulseless ventricular tachycardia (VT)/ventricular fibrillation (VF) was found in 18.0%. The overall survival was 0.8% (1/124), and survival to hospital discharge was significantly higher for patients with VF or pulseless VT than those patients with other rhythms of cardiac arrest (11.1% versus 0%). The median witnessed/recognised collapse to defibrillation time was 14 minutes. The median prehospital time interval from collapse/recognition to arrival at hospital was 33 minutes. The prognosis of out-of-hospital cardiac arrest in Hong Kong was poor. Major improvements in every component of the chain of survival are necessary.
Publisher: Springer Science and Business Media LLC
Date: 06-10-2016
Publisher: Elsevier BV
Date: 05-2006
DOI: 10.1016/J.INJURY.2005.11.011
Abstract: The use of guidelines regarding the termination or withholding of cardiopulmonary resuscitation (CPR) in traumatic cardiac arrest patients remains controversial. This study aimed to describe the outcomes for victims of penetrating and blunt trauma who received prehospital CPR. We conducted a retrospective review of a statewide major trauma registry using data from 2001 to 2004. Subjects suffered penetrating or blunt trauma, received CPR in the field by paramedics and were transported to hospital. Demographics, vital signs, injury severity, prehospital time, length of stay and mortality data were collected and analysed. Eighty-nine patients met inclusion criteria. Eighty percent of these were blunt trauma victims, with a mortality rate of 97%, while penetrating trauma patients had a mortality rate of 89%. The overall mortality rate was 95%. Sixty-six percent of patients had a length of stay of less than 1 day. Four patients survived to discharge, of which two were penetrating and two were blunt injuries. Hypoxia and electrical injury were probable associated causes of two cardiac arrests seen in survivors of blunt injury. While only a small number of penetrating and blunt trauma patients receiving CPR survived to discharge, this therapy is not always futile. Prehospital emergency personnel need to be aware of possible hypoxic and electrical causes for cardiac arrest appearing in combination with traumatic injuries.
Publisher: Wiley
Date: 12-2001
DOI: 10.1046/J.1445-1433.2001.02274.X
Abstract: In 1999, a new major trauma system was proposed for the state of Victoria, Australia. The guidelines for the new system were aimed at delivering major trauma cases to definitive trauma care in the least time possible. The aim of the present study was to analyse the potential effect of this system on Victoria's ambulance services. The present study modelled the workload of major trauma cases in Victoria's ambulance service for one year pre- and post-introduction of the guidelines. Cases were analysed regarding whether their first hospital destination would change under the proposed guidelines, and, subsequently, whether they would require interhospital transport to a higher level trauma service. The impact on the ambulance services was modelled as annual changes in distances travelled due to predicted changes in hospital destinations. Analysis of the predicted changes indicated that, in general, Victoria's metropolitan and rural road ambulance crews would not be greatly affected. However, some metropolitan road crews may have to travel extra distances for up to 110 cases per year. The major impact was on air retrieval crews, where the annual number of interhospital transfers is predicted to increase from approximately 150 to 330. The present study demonstrated that most of the impact of a new trauma system on Victoria's ambulance services could be readily absorbed into the current workload. However, it also highlighted areas affected disproportionately within the ambulance services in particular, air retrieval. Such studies are important to enable the effective implementation of new trauma systems.
Publisher: Wiley
Date: 09-10-2015
DOI: 10.1111/ADD.13098
Publisher: Elsevier BV
Date: 05-2007
DOI: 10.1016/J.INJURY.2006.06.018
Abstract: For use in quality measurement, a quality indicator (QI) must satisfy a number of criteria: there needs to be an established link with outcome the indicator needs to measure what is considered current accepted practice the targeted population requires precise definition an appropriate risk adjustment strategy must be employed the indicator should be feasible for collection and, the measure must apply to a sufficient number of people so as to provide a measure of system-wide quality. This article discusses the use of QIs in the care of trauma patients. A series of QIs were originally promulgated by the American College of Surgeons Committee on Trauma (ACSCOT) and have been investigated for their utility in measuring quality in trauma systems by a number of US based studies. While some have advocated the implementation of several specific indicators, others have recommended discontinued use of a range of proposed QIs. This review highlights the difficulties of meeting these ideal indicator requirements in trauma care and proposes that the development of alternative indicators may provide more useful measures of quality care.
Publisher: Wiley
Date: 03-2002
DOI: 10.1046/J.1442-2026.2002.00284.X
Abstract: Emergency department patient complaints are often justified and may lead to apology, remedial action or compensation. The aim of the present study was to analyse emergency department patient complaints in order to identify procedures or practices that require change and to make recommendations for intervention strategies aimed at decreasing complaint rates. We undertook a retrospective analysis of patient complaints from 36 Victorian emergency departments during a 61 month period. Data were obtained from the Health Complaint Information Program (Health Services Commissioner). In all, 2,419 emergency department patients complained about a total of 3,418 separate issues (15.4% of all issues from all hospital departments). Of these, 1,157 complaints (47.80%) were received by telephone and 829 (34.3%) were received by letter 1,526 (63.1 %) complaints were made by a person other than the patient. Highest complaint rates were received from patients who were female, born in non-English-speaking countries and very young or very old. One thousand one hundred and forty-one issues (33.4%) related to patient treatment, including inadequate treatment (329 issues) and inadequate diagnosis (249 issues) 1079 (31.6%) issues related to communication, including poor staff attitude, discourtesy and rudeness (444 issues) 407 (11.9%) issues related to delay in treatment. Overall, 2516 issues (73.6%) were resolved satisfactorily, usually by explanation or apology. Only 59 issues (1.7%) resulted in a procedure or policy change. Remedial action was taken in 109 issues (3.2%) and compensation was paid to eight patients. Communication remains a significant factor in emergency department patient dissatisfaction. While patient complaints have resulted in major changes to policy and procedure, research and intervention strategies into communication problems are indicated. In the short term, focused staff training is recommended.
Publisher: Springer Science and Business Media LLC
Date: 22-07-2011
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2007
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2016
DOI: 10.1097/AJP.0000000000000342
Abstract: Motor vehicle collisions (MVC) are a major cause of injury, which frequently lead to chronic pain and prolonged disability. Several studies have found that seeking or receiving financial compensation following MVC leads to poorer recovery and worse pain. We evaluated the evidence for the relationship between compensation and chronic pain following MVC within a biopsychosocial framework. A comprehensive search of 5 computerized databases was conducted. Methodological quality was evaluated independently by 2 researchers according to formal criteria, and discrepancies were resolved with a third reviewer. We identified 5619 studies, from which 230 full-text articles were retrieved and 27 studies were retained for appraisal. A third of studies (37%) were of low quality, and 44% did not measure or control for factors such as injury severity or preinjury pain and disability. Most studies (70%) reported adverse outcomes, including all of the highest quality studies. Engagement with compensation systems was related to more prevalent self-reported chronic pain, mental health disorders, and reduced return to work. Recovery was poorer when fault was attributed to another, or when a lawyer was involved. Five studies compared Tort “common law” and No-Fault schemes directly and concluded that Tort claimants had poorer recovery. Although causal relationships cannot be assumed, the findings imply that aspects of loss, injustice, and secondary mental health outcomes lead to chronic pain following MVC. Further robust prospective research is required to understand the complex relationship between compensation systems and pain following road trauma, particularly the role of secondary mental health outcomes.
Publisher: AMPCo
Date: 02-2012
DOI: 10.5694/MJA11.10619
Publisher: Springer Science and Business Media LLC
Date: 11-07-2014
Publisher: Elsevier BV
Date: 08-2017
DOI: 10.1016/J.IJCARD.2017.03.134
Abstract: Traumatic cardiac arrest studies have reported improved survival rates recently, ranging from 1.7-7.5%. This population-based nationwide study aims to describe the epidemiology, interventions and outcomes, and determine predictors of survival from out-of-hospital traumatic cardiac arrest (OHTCA) in Qatar. An observational retrospective population-based study was conducted on OHTCA patients in Qatar, from January 2010 to December 2015. Traumatic cardiac arrest was redefined to include out-of-hospital traumatic cardiac arrest (OHTCA) and in-hospital traumatic cardiac arrest (IHTCA). A total of 410 OHTCA patients were included in the 6-year study period. The mean annual crude incidence rate of OHTCA was 4.0 per 100,000 population, in Qatar. OHTCA mostly occurred in males with a median age of 33. There was a preponderance of blunt injuries (94.3%) and head injuries (66.3%). Overall, the survival rate was 2.4%. Shockable rhythm, prehospital external hemorrhage control, in-hospital blood transfusion, and surgery were associated with higher odds of survival. Adrenaline (Epinephrine) lowered the odds of survival. The incidence of OHTCA was less than expected, with a low rate of survival. Thoracotomy was not associated with improved survival while Adrenaline administration lowered survival in OHTCA patients with majority blunt injuries. Interventions to enable early prehospital control of hemorrhage, blood transfusion, thoracostomy and surgery improved survival.
Publisher: BMJ
Date: 08-2009
Abstract: Poor clinical handover creates discontinuities in care leading to patient harm. However, the field of handover research continues to lack standardised definitions and reliable measurement tools to identify factors that would lead to harm reduction and improved safety strategies. This paper introduces a conceptual framework to underpin a research agenda around the important patient safety topic of clinical handover. Five frameworks with potential application to clinical handover were identified in a consultation process with clinicians, researchers and policy makers. The framework consists of three key handover elements-information, responsibility and/or accountability and system-in relation to three key measurement elements-policy, practice and evaluation. Using this framework an analysis of current "gaps" in the measurement of handover was completed. The paper argues that measurement will identify gaps in knowledge about handover practice and promote rigor in the design and evaluation of interventions to reduce patient harm.
Publisher: Wiley
Date: 22-05-2017
Publisher: Elsevier BV
Date: 02-2008
DOI: 10.1016/J.NCL.2007.11.004
Abstract: Many sports have neurologic injury from incidental head contact however, combat sports allow head contact, and a potential exists for acute and chronic neurologic injuries. Although each combat sport differs in which regions of the body can be used for contact, they are similar in competitor exposure time. Their acute injury rates are similar thus their injuries can appropriately be considered together. Injuries of all types occur in combat sports, with injuries in between one fifth to one half of all fights in boxing, karate, and tae kwon do. Most boxing injuries are to the head and neck region. In other combat sports, the head and neck region are the second (after the lower limbs) or the first most common injury site.
Publisher: Elsevier BV
Date: 04-2012
DOI: 10.1016/J.RESUSCITATION.2011.09.025
Abstract: Many consider attempted resuscitation for traumatic out-of-hospital cardiac arrest (OHCA) futile. This study aims to describe the characteristics and profile of adult traumatic OHCA. The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify all trauma related cases of OHCA in patients aged ≥16 years. Between 2000 and 2009, EMS attended 33,178 OHCAs of which 2187 (6.6%) had a traumatic aetiology. The median age (IQR) of traumatic OHCA cases was 36 (25-55) years and 1612 were male (77.5%). Bystander CPR was performed in 201 cases (10.2%) with median (IQR) EMS response time 8 (6-11)min. The first recorded rhythm by EMS was asystole seen in 1650 (75.4%), PEA in 294 (13.4%) cases and VF in 35 cases (1.6%). Cardiac output was present in 208 (9.5%) cases who subsequently had an EMS witnessed OHCA. EMS attempted resuscitation in 545 (24.9%) patients of whom 84 (15.4%) achieved ROSC and were transported, and 27 (5.1%) survived to hospital discharge 107 were transported with CPR of whom 8 (7.4%) survived to hospital discharge. Where EMS attempted resuscitation in traumatic OHCAs, survival for VF was 11.8% (n=4), PEA 5.1% (n=10) and asystole 2.4% (n=3). In EMS witnessed traumatic OHCA, resuscitation was attempted in 175 cases (84.1%), 35 (16.8%) patients achieved sustained ROSC before transport of whom 5 (14%) survived to leave hospital and 60 (28.8%) were transported with CPR of whom 6 (10%) survived to leave hospital. Compared to OHCA cases with 'presumed cardiac' aetiology traumatic OHCAs were younger [median years (IQR): 36 (25-55) vs 74 (61-82)], had resuscitation attempted less (25% vs 48%), were less likely to have a shockable rhythm (1.6% vs 17.1%), were more likely to be witnessed (62.8% vs 38.1%) and were less likely to receive bystander CPR (10.2% vs 25.5%) (p<0.001, respectively). Multivariate logistic regression identified factors associated with EMS decision to attempt resuscitation. The odds ratio [OR (95% CI)] for 'presence of bystander CPR' was 5.94 (4.11-8.58) and for 'witnessed arrest' was 2.60 (1.86-3.63). In this paramedic delivered EMS attempted resuscitation was not always futile in traumatic OHCA with a survival of 5.1%. The quality of survival needs further study.
Publisher: BMJ
Date: 20-01-2011
Abstract: This retrospective, electronic patient care record review examined a consecutive s le of patients presenting with pain to the metropolitan region of Ambulance Victoria over a 12 month period in 2008. Seven factors were found to be associated with the likelihood of clinically important pain reduction following multivariate analyses. These included age, time criticality of the patient, pain aetiology, initial pain severity, analgesic agent or combination administered to the patient and prehospital time.
Publisher: Elsevier BV
Date: 03-2019
DOI: 10.1016/J.HLC.2018.02.007
Abstract: Late gadolinium enhancement (LGE) with cardiac magnetic resonance (CMR) is commonly assumed to represent myocardial fibrosis however, comparative human histological data are limited, and there is no consensus on the most accurate method for LGE quantitation. We evaluated the relationship between CMR assessment of regional fibrosis and infarct size assessment using serial biomarkers after ST elevation acute myocardial infarction (STEMI). Ninety-three patients treated for STEMI (59±10 years, 86% male) underwent CMR 6 months after infarction. Infarct size was quantified by CMR-LGE using manual and range of semi-automated thresholds (range: 2-10 standard deviations [SD]) above reference myocardium and the full width-half maximum (FWHM) technique, and compared with the rise in serum biomarkers. The agreement between CMR and biomarker in the identification of large infarcts based on peak troponin (TnI) levels was also analysed. Quantification methods had a strong influence on the infarct size assessment with CMR-LGE. Significant correlations were observed between LGE and biomarkers across all of the signal intensity thresholds. Whilst there was a wide variation with respect to the estimation of total LGE size (from 6.8±7.7 to 32.1±11.3 grams), the variation in the correlation with peak troponin level was much smaller (r-values ranging from 0.670 to 0.876). There was good agreement between CMR-LGE and biomarker assessment of infarct size the best agreement between CMR-LGE and large infarction using a threshold of 8SD for peak TnI>50ng/mL (Cohen's kappa (κ)=0.722), and a threshold of 4SD for peak TnI >95ng/mL (κ=0.761). The correlation between CMR-LGE quantification of infarct size and biomarker release following STEMI at a range of semi-automated thresholds was consistently strong, with good agreement between measures across a range of thresholds.
Publisher: Wiley
Date: 12-2006
Publisher: Elsevier BV
Date: 06-2015
DOI: 10.1016/J.BURNS.2015.01.016
Abstract: In Australia and New Zealand (ANZ), health care is provided for ∼26 million people dispersed across the eight million square kilometres of the two countries. Providing optimal care prior to and during transfer across such vast distances is challenging. Lengthening the time taken to definitive burn care has a negative impact on burn outcome. The aims of this study were to determine if transfer time and admission pathway influenced burn mortality and to identify the factors predicting burn mortality in ANZ. The study included all adult burn patient admission data from 15 of 17 burn services submitted to the Australian and New Zealand Burn Association bi-national registry (2010-2012). Multivariate logistic regression analyses were conducted to address the study aims. Of the 2892 patients, 69 (2.4%) died following burn. Time to admission and direct admission to a burn centre did not independently influence burn mortality except when patients with inhalation injury took >16 h to transfer to definitive care. The risk of death was increased 5.7 times in the presence of inhalation injury. Burn size and age lified the risk of death while gender did not. In ANZ, pre-hospital transport systems and peripheral hospital stabilisation were not associated with an increased risk of death due to burn except when inhalation injury was present. The results of this study indicate that burn patients with inhalation injury should be stabilised and transferred to a burn service within 16 h of burn.
Publisher: Springer Science and Business Media LLC
Date: 30-12-2015
DOI: 10.1017/CEM.2015.99
Publisher: Oxford University Press (OUP)
Date: 08-12-2017
Abstract: to profile the trajectory of, and risk factors for, functional decline in older patients in the 30 days following Emergency Department (ED) discharge. prospective cohort study of community-dwelling patients aged ≥65 years, discharged home from a metropolitan Melbourne ED, 31 July 2012 to 30 November 2013. The primary outcome was functional decline, comprising either increased dependency in personal activities of daily living (ADL) or in skills required for living independently instrumental ADL (IADL), deterioration in cognitive function, nursing home admission or death. Univariate analyses were used to select risk factors and logistic regression models constructed to predict functional decline. at 30 days, 34.4% experienced functional decline with 16.7% becoming more dependent in personal ADL, 17.5% more dependant in IADL and 18.4% suffering deterioration in cognitive function. Factors independently associated with decline were functional impairment prior to the visit in personal ADL (Odds Ratio [OR] 3.21, 95% confidence interval [CI] 2.26–4.53) or in IADL (OR 6.69, 95% CI 4.31–10.38). The relative odds were less for patients with moderately impaired cognition relative to those with normal cognition (OR 0.38, 95% CI 0.19–0.75). There was a 68% decline in the relative odds of functional decline for those with any impairment in IADL who used an aid for mobility (OR 0.32, 95% CI 0.14–0.7). older people with pre-existing ADL impairment were at high risk of functional decline in the 30 days following ED presentation. This effect was largely mitigated for those who used a mobility aid. Early intervention with functional assessments and appropriate implementation of support services and mobility aids could reduce functional decline after discharge.
Publisher: BMJ
Date: 11-2020
DOI: 10.1136/BMJOPEN-2020-042351
Abstract: Most calls to ambulance result in emergency ambulance dispatch (direct dispatch) following primary telephone triage. Ambulance Victoria uses clinician-led secondary telephone triage for patients identified as low-acuity during primary triage to refer them to alternative care pathways however, some are returned for ambulance dispatch (secondary dispatch). Older adult patients are frequent users of ambulance services however, little is known about the appropriateness of subsequent secondary dispatches. To examine the appropriateness of secondary dispatch through a comparison of the characteristics and ambulance outcomes of older patients dispatched an emergency ambulance via direct or secondary dispatch. A retrospective cohort study of ambulance patient data between September 2009 and June 2012 was conducted. The secondary telephone triage service operated in metropolitan Melbourne, Victoria, Australia during the study period. There were 90 086 patients included aged 65 years and over who had an emergency ambulance dispatch via direct or secondary dispatch with one of the five most common secondary dispatch paramedic diagnoses. Descriptive analyses compared characteristics, treatment and transportation rates between direct and secondary dispatch patients. The dispatch groups were similar in demographics, vital signs and hospital transportation rates. However, secondary dispatch patients were half as likely to be treated by paramedics (OR 0.51 CI 0.48 to 0.55 p .001). Increasing age was associated with decreasing treatment (p .005) and increasing transportation rates (p .005). Secondary triage could identify patients who would ultimately be transported to an emergency department. However, the lower paramedic treatment rates suggest many secondary dispatch patients may have been suitable for referral to alternative low-acuity transport or referral options.
Publisher: Wiley
Date: 10-2008
DOI: 10.1111/J.1445-5994.2008.01629.X
Abstract: Although alcohol and recreational drugs are recognized as significant risk factors for motor vehicle collisions (MVC), the contribution of sleepiness alone is less clear. We therefore sought to identify the contribution of sleepiness to the risk of a MVC in injured drivers, independent of drugs and alcohol. A prospective questionnaire and examination of sleep-related risk factors in drivers surviving MVC in a major hospital-based trauma centre was carried out. Forty of 112 injured drivers screened were interviewed, of whom approximately 50% had at least one sleep-related risk factor, 20% having two or more. Of the MVC deemed sleep-related by questionnaire, only 25% were identified by the Australian Transport Safety Bureau definitions. Shift work was the greatest sleep-related factor identified contributing to MVC. Sleepiness, particularly related to shift work, needs to be emphasized as a risk factor for MVC. Australian Transport Safety Bureau definitions of sleep-related MVC are too lenient.
Publisher: Elsevier BV
Date: 05-2017
DOI: 10.1016/J.INJURY.2016.11.021
Abstract: Fibrinogen may be reduced following traumatic injury due to loss from haemorrhage, increased consumption and reduced synthesis. In the absence of clinical trials, guidelines for fibrinogen replacement are based on expert opinion and vary internationally. We aimed to determine prevalence and predictors of low fibrinogen on admission in major trauma patients and investigate association of fibrinogen levels with patient outcomes. Data on all major trauma patients (January 2007-July 2011) identified through a prospective statewide trauma registry in Victoria, Australia were linked with laboratory and transfusion data. Major trauma included any of the following: death after injury, injury severity score (ISS) >15, admission to intensive care unit requiring mechanical ventilation, or urgent surgery for intrathoracic, intracranial, intra-abdominal procedures or fixation of pelvic or spinal fractures. Associations between initial fibrinogen level and in-hospital mortality were analysed using multiple logistic regression. Of 4773 patients identified, 114 (2.4%) had fibrinogen less than 1g/L, 283 (5.9%) 1.0-1.5g/L, 617 (12.9%) 1.6-1.9g/L, 3024 (63.4%) 2-4g/L and 735 (15%) >4g/L. Median fibrinogen was 2.6g/L (interquartile range 2.1-3.4). After adjusting for age, gender, ISS, injury type, pH, temperature, Glasgow Coma Score (GCS), initial international normalised ratio and platelet count, the lowest fibrinogen categories, compared with normal range, were associated with increased in-hospital mortality (adjusted odds ratio [OR] for less than 1g/L 3.28 [95% CI 1.71-6.28, p<0.01], 1-1.5g/L adjusted OR 2.08 [95% CI 1.36-3.16, p<0.01] and 1.6-1.9g/L adjusted OR 1.39 [95% CI 0.97-2.00, p=0.08]). Predictors of initial fibrinogen <1.5g/L were younger age, lower GCS, systolic blood pressure 25 and lower pH and temperature. Initial fibrinogen levels less than the normal range are independently associated with higher in-hospital mortality in major trauma patients. Future studies are warranted to investigate whether earlier and/or greater fibrinogen replacement improves clinical outcomes.
Publisher: Wiley
Date: 06-01-2021
Abstract: The aim of the present study was to describe the epidemiology and clinical features of patients presenting to the ED with suspected and confirmed COVID‐19 during Australia's ‘second wave’. The COVID‐19 ED (COVED) Project is an ongoing prospective cohort study in Australian EDs. This analysis presents data from 12 sites across four Australian states for the period from 1 July to 31 August 2020. All adult patients who met the criteria for ‘suspected COVID‐19’ and underwent testing for SARS‐CoV‐2 in the ED were eligible for inclusion. Study outcomes included a positive SARS‐CoV‐2 test result, mechanical ventilation and in‐hospital mortality. There were 106 136 presentations to the participating EDs and 12 055 (11.4% 95% confidence interval [CI] 11.2–11.6) underwent testing for SARS‐CoV‐2. Of these, 255 (2%) patients returned a positive result. Among positive cases, 13 (5%) received mechanical ventilation during their hospital admission compared to 122 (2%) of the SARS‐CoV‐2 negative patients (odds ratio 2.7 95% CI 1.5–4.9, P = 0.001). Nineteen (7%) SARS‐CoV‐2 positive patients died in hospital compared to 212 (3%) of the SARS‐CoV‐2 negative patients (odds ratio 2.3 95% CI 1.4–3.7, P = 0.001). Strong clinical predictors of the SARS‐CoV‐2 test result included self‐reported fever, sore throat, bilateral infiltrates on chest X‐ray, and absence of a leucocytosis on first ED blood tests ( P 0.05). In this prospective multi‐site study during Australia's ‘second wave’, a substantial proportion of ED presentations required SARS‐CoV‐2 testing and isolation. Presence of SARS‐CoV‐2 on nasopharyngeal swab was associated with an increase in the odds of death and mechanical ventilation in hospital.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2014
Publisher: Wiley
Date: 17-01-2017
Abstract: Research underpins evidence-based practice, but there are significant barriers to conducting research relevant to each clinical discipline. Understanding these barriers could allow strategies to reduce their impact. The present study was undertaken to understand specific barriers to research for emergency medicine (EM) trainees. EM trainees attending research short courses were surveyed. Free-text responses were classified into themes and a list of pre-specified potential barriers was used for ranking purposes. The responders (n = 61/90 67.8%) were young, mostly male with low confidence in leading a research project and limited previous research experience. There were 155 unique barriers identified from 55 respondents, which fitted into nine categories. The most frequently perceived barrier was time (29%), followed by skills (22.6%) and cultural factors (19.4%). Most trainees (n = 54/56, 96.4%) believed that the barriers could be overcome. Strategies suggested included protection of time, mentoring and education, as well as top-down improved research culture. Barriers to research in EM are similar to other specialities and were perceived to be manageable. Reorganisation and refocus of the Australasian College for Emergency Medicine training curriculum may be an option to foster an environment to promote research.
Publisher: Wiley
Date: 25-04-2012
DOI: 10.1111/J.1742-6723.2012.01556.X
Abstract: Early detection of acute traumatic coagulopathy (ATC) might be useful to guide trauma resuscitation. This study aimed to compare results from a point-of-care (POC) international normalised ratio (INR) measuring device with plasma INR in acute trauma patients. This was a single-centre, prospective, blinded comparative study. All trauma patients meeting trauma call-out criteria in a major trauma centre were screened. Patients predicted to have ATC were identified by the Coagulopathy of Severe Trauma score and a convenience s le of 72 patients included in this study. Whole blood was used to measure INR at the bedside, whereas blood from the same s le was sent to the hospital laboratory for plasma INR testing. Agreement between the laboratory and bedside INR was determined using a Bland-Altman plot. There were 38 (52.8%) patients with ATC by laboratory measure, defined as INR >1.5 or activated partial thrombin time >60 s, whereas the POC system identified 28 (38.9%) patients with an INR >1.5. Assuming the laboratory measure as the gold standard, the POC system had a specificity of 88.2% (95% confidence interval 71.6-96.2) and a sensitivity of 63.1% (95% confidence interval 46.0-77.7). Bland-Altman plots demonstrated inadequate agreement between the two methods of INR measurement for the major trauma patient. POC INR measurements using this method during the trauma reception and resuscitative phases cannot be used to identify or exclude patients with ATC. Further studies are required to determine if there is any role for POC INR measures during trauma resuscitation.
Publisher: Wiley
Date: 02-2004
Publisher: Mary Ann Liebert Inc
Date: 15-02-2018
Abstract: This systematic review and meta-analysis aimed to determine the prognostic value of S-100β protein to identify patients with post-concussion symptoms after a mild traumatic brain injury (mTBI). A search strategy was submitted to seven databases from their inception to October 2016. In idual patient data were requested. Cohort studies evaluating the association between S-100β protein level and post-concussion symptoms assessed at least seven days after the mTBI were considered. Outcomes were dichotomized as persistent (≥3 months) or early (≥7 days <3 months). Our search strategy yielded 23,298 citations of which 29 studies including between seven and 223 patients (n = 2505) were included. Post-concussion syndrome (PCS) (16 studies) and neuropsychological symptoms (9 studies) were the most frequently assessed outcomes. The odds of having persistent PCS (odds ratio [OR] 0.62, 95% confidence interval [CI]: 0.34-1.12, p = 0.11, I
Publisher: Wiley
Date: 11-2004
Publisher: American College of Physicians
Date: 17-03-2009
DOI: 10.7326/0003-4819-150-6-200903170-00004
Abstract: B-type natriuretic peptide (BNP) is used to diagnose heart failure, but the effects of using the test on all dyspneic patients is uncertain. To assess whether BNP testing alters clinical outcomes and health services use of acutely dyspneic patients. Randomized, single-blind study. Patients were assigned to a treatment group through randomized numbers in a sealed envelope. Patients were blinded to the intervention, but clinicians and those who assessed trial outcomes were not. 2 Australian teaching hospital emergency departments. 612 consecutive patients who presented with acute severe dyspnea from August 2005 to March 2007. BNP testing (n = 306) or no testing (n = 306). Admission rates, length of stay, and emergency department medications (primary outcomes) mortality and readmission rates (secondary outcomes). There were no between-group differences in hospital admission rates (85.6% [BNP group] vs. 86.6% [control group] difference, -1.0 percentage point [95% CI, -6.5 to 4.5 percentage points] P = 0.73), length of admission (median, 4.4 days [interquartile range, 2 to 9 days] vs. 5.0 days [interquartile range, 2 to 9 days] P = 0.94), or management of patients in the emergency department. Test discrimination was good (area under the receiver-operating characteristic curve, 0.87 [CI, 0.83 to 0.91]). Adverse events were not measured. Most patients were very short of breath and required hospitalization the findings might not apply for evaluating patients with milder degrees of breathlessness. Measurement of BNP in all emergency department patients with severe shortness of breath had no apparent effects on clinical outcomes or use of health services. The findings do not support routine use of BNP testing in all severely dyspneic patients in the emergency department. Janssen-Cilag.
Publisher: Elsevier BV
Date: 05-2012
DOI: 10.1016/J.INJURY.2010.10.003
Abstract: Pre-hospital trauma triage criteria are used to expedite the transport of severely injured patients to major trauma services. The current Victorian adult pre-hospital trauma triage criteria consist of physiological, anatomical and mechanistic elements. The purpose of this study was to evaluate the performance of the current triage criteria and, if necessary propose refined criteria to improve the under and over-triage rates. The study was conducted in Melbourne, Victoria, which has a fully integrated State Trauma System. Trauma data was sourced from the pre-hospital Victorian Ambulance Clinical Information System and the Victorian State Trauma Registry. Confirmed major trauma was defined at hospital discharge as one or more of death, ISS>15, ICU ventilation or urgent surgery. Data was matched through probabilistic linkage. The triage criteria were evaluated using multivariate logistic regression and classification tree modelling. Diagnostic statistics, including sensitivity and specificity were calculated to assess triage performance. Over 12-months there were 1166 'confirmed major trauma' patients and 44,166 'non-major trauma' patients. Evaluation showed the current triage criteria needed refinement, and multiple revised pre-hospital trauma triage models were constructed. Based on the best overall combination of diagnostic statistics, a revised model was chosen with a sensitivity of 97.8% (vs. 95.3% in the current model), a specificity of 82.7% (vs. 62.7%) and an accuracy of 83.0% (vs. 63.4%). The over-triage rate was 17.3% (vs. 37.3%) and the under-triage rate was 2.2% (vs. 4.7%). Evaluation showed that the specificity and sensitivity of the current trauma triage criteria could be improved. The implementation of a revised triage model should identify more confirmed major trauma patients. Likewise, over-triage of non-major trauma patients to major trauma services would be significantly reduced. The refined criteria should also decrease discretionary decision-making by paramedics in the field.
Publisher: Wiley
Date: 02-2006
DOI: 10.1111/J.1742-6723.2006.00801.X
Abstract: To determine whether the 'Timed Up and Go' (TUG) test is a useful test for predicting re-attendance at an ED, emergency hospital admission or death within 90 days in elderly patients discharged from the ED. This was a prospective blinded cohort study at a tertiary referral ED. Patients completed a TUG test during their Allied Health assessment prior to discharge from the department. After 90 days, patient ED attendances, emergency admissions to hospital or deaths were recorded and confirmed by phone. Data were analysed using logistic regression and reported as odds ratios (OR) or log-transformation and Pearson analysis. One hundred patients were enrolled: 78 (78%, 95% confidence interval [CI] 70-86%) patients remained event free, 22 (22%, 95% CI 14-30%) patients re-attended an ED and 15 (15%, 95% CI 8-22%) were admitted to hospital as an emergency admission. There was no significant difference between TUG test times and whether patients re-attended an ED (OR 1.0 [0.93-1.06] P = 0.9) or were admitted to hospital (OR 0.99 [0.91-1.07] P = 0.74). There was no significant correlation between a patient's TUG test time and the number of days to ED re-attendance (Pearson correlation coefficient 0.38 [-0.04 to 0.69] P = 0.08) or admission (Pearson correlation coefficient 0.32 [-0.23 to 0.71] P = 0.25). This study did not detect any predictive value of the TUG test for ED re-attendance or hospital admission within 90 days of discharge among aged ED patients.
Publisher: Wiley
Date: 05-2010
DOI: 10.1111/J.1423-0410.2009.01276.X
Abstract: Recombinant activated factor VIIa (rFVIIa) is increasingly being used in non-haemophiliac patients for the treatment of severe bleeding refractory to standard interventions. Optimal dosing regimens remain debated in cardiac surgery. Therefore, this study investigated the use of different rFVIIa dosing practices on response to bleeding and patient outcomes in cardiac surgery patients using data from the Haemostasis Registry. Data were extracted from the Haemostasis Registry that records cases of off-licence rFVIIa use in participating institutions. Univariate analyses compared patients receiving 100 microg/kg of rFVIIa on key parameters. Logistic regression models investigated the relationship between independent variables and 28-day mortality. Complete data was available on 804 cardiac surgery patients who received rFVIIa. Of these, 42 (5.2%) were treated with doses < or =40 microg/kg, while the dose group containing the most patients was 81-100 microg/kg (368, 45.77%). Results demonstrated no significant differences in the rate of thromboembolic adverse events, response to bleeding or 28-day mortality. These findings raise the important question of whether lower doses of rFVIIa may be as effective as higher doses in the treatment of severe bleeding in cardiac surgery patients.
Publisher: Wiley
Date: 03-09-2012
DOI: 10.1111/J.1600-0838.2012.01523.X
Abstract: The aim of this study was to evaluate the impact of serious sport and active recreation injury on 12-month physical activity levels. Adults admitted to hospital with sport and active recreation-related injuries, and captured by the Victorian Orthopaedic Trauma Outcomes Registry were recruited to the study. Changes between preinjury and 12 month post-injury physical activity was assessed using the short International Physical Activity Questionnaire (IPAQ). Independent demographic, injury, and hospital variables were assessed for associations with changes in physical activity levels, using multivariate linear regression. A total of 324 patients were recruited, of which 98% were followed up at 12 months. Mean short IPAQ scores decreased from 7650 METS (95% CI: 7180, 8120) preinjury to 3880 METS (95% CI: 3530, 4250) post-injury, independent of functional recovery. Education level and occupation group were the only variables independently associated with changes in physical activity levels post-injury. These results highlighted that sport and active recreation injuries lead to significant reductions in physical activity levels. Hence, the prevention of sport and active recreation injuries is important when considering promotion of activity at a population level.
Publisher: Wiley
Date: 08-2010
DOI: 10.1111/J.1742-6723.2010.01309.X
Abstract: To establish the incidence and pattern of injuries in patients presenting to hospital with tram-related injuries. Data on tram-related injury pertaining to 2001-2008 calendar years were extracted from three datasets: the population-based Victorian State Trauma Registry for major trauma cases, the Victorian Emergency Minimum Dataset for ED presentations and the National Coroners' Information System for deaths. Incidence rates adjusted for the population of Melbourne, and trends in the incidence of tram-related ED presentations and major trauma cases, were analysed and presented as incidence rate ratios (IRR). There were 1769 patients who presented to ED after trauma related to trams in Melbourne during the study period. Of these, 107 patients had injuries classified as major trauma. There was a significant increase in the rate of ED presentations (IRR 1.03, P = 0.010) with falls (46%) the most commonly reported mechanism. Most falls occurred inside the trams. There was also a significant increase in the incidence rates of major trauma cases (IRR 1.12, P = 0.006) with pedestrians accounting for most major trauma cases. Most cases of trauma related to trams have minor injuries and are discharged following ED management. Primary prevention of falls in trams and the separation of pedestrians from trams are key areas requiring immediate improvement. In the face of increasing trauma associated with trams, continuing safety surveillance and targeted public safety messages are important to sustain trams as safe and effective mode of transport.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-1999
DOI: 10.1097/00001199-199908000-00005
Abstract: To investigate outcome in children with mild traumatic head injury (THI) at 1 week and 3 months postinjury and to identify factors associated with persisting problems. Postconcussional symptomatology, behavior ratings, and neuropsychological test performance were examined at 1 week and 3 months postinjury. Participants were recruited from successive presentations to emergency departments of two major hospitals. 130 Children with mild THI were compared with 96 children having other minor injuries as controls. Children with mild THI experienced headaches, dizziness, and fatigue but exhibited no cognitive impairments, relative to controls, at 1 week postinjury. By 3 months, symptoms had resolved. However, 17% of children showed significant ongoing problems. They were more likely to have a history of previous head injury, learning difficulties, neurological or psychiatric problems, or family stressors. Persisting problems following mild head injury in children are more common in those with previous head injury, preexisting learning difficulties, or neurological, psychiatric, or family problems. These "at-risk" children should be identified in the emergency department and monitored.
Publisher: Wiley
Date: 06-2001
DOI: 10.1046/J.1442-2026.2001.00208.X
Abstract: To study the outcome of victims of out-of-hospital cardiac arrest presenting to the Metropolitan Ambulance Service in asystole, in Melbourne, Australia. A retrospective case-note review of all patients presenting to the Metropolitan Ambulance Service in asystole for 1997 was performed. Metropolitan Ambulance Service case notes and hospital records were examined to determine the presenting rhythm and the patients' outcome. In a 12-month period, 778 patients met the entry criteria. Age mean was 67 years, 36% female, 64% male. Metropolitan Ambulance Service response time to scene time was a mean of 9.76 min. Resuscitation was commenced on 37% of patients. There was one survivor (0.12%). Adult victims of out-of-hospital cardiac arrest presenting as asystole should not receive treatment.
Publisher: Wiley
Date: 12-1994
Publisher: AMPCo
Date: 05-2014
DOI: 10.5694/MJA13.10856
Abstract: To examine the impact of population density on incidence and outcome of out-of-hospital cardiac arrest (OHCA). Data were extracted from the Victorian Ambulance Cardiac Arrest Registry for all adult OHCA cases of presumed cardiac aetiology attended by the emergency medical service (EMS) between 1 January 2003 and 31 December 2011. Cases were allocated into one of five population density groups according to their statistical local area: very low density (≤ 10 people/km(2)), low density (11-200 people/km(2)), medium density (201-1000 people/km(2)), high density (1001-3000 people/km(2)), and very high density (> 3000 people/km(2)). Survival to hospital and survival to hospital discharge. The EMS attended 27 705 adult presumed cardiac OHCA cases across 204 Victorian regions. In 12 007 of these (43.3%), resuscitation was attempted by the EMS. Incidence was lower and arrest characteristics were consistently less favourable for lower population density groups. Survival outcomes, including return of spontaneous circulation, survival to hospital and survival to hospital discharge, were significantly poorer in less densely populated groups (P < 0.001 for all comparisons). When compared with very low density populations, the risk-adjusted odds ratios of surviving to hospital discharge were: low density, 1.88 (95% CI, 1.15-3.07) medium density, 2.49 (95% CI, 1.55-4.02) high density, 3.47 (95% CI, 2.20-5.48) and very high density, 4.32 (95% CI, 2.67-6.99). Population density is independently associated with survival after OHCA, and significant variation in the incidence and characteristics of these events are observed across the state.
Publisher: Elsevier BV
Date: 07-2012
Publisher: American Thoracic Society
Date: 15-01-2020
Publisher: AMPCo
Date: 02-2013
DOI: 10.5694/MJA12.10648
Publisher: Wiley
Date: 28-05-2018
DOI: 10.1111/ACEM.13432
Abstract: The ability of emergency physicians (EPs) to identify hydronephrosis using point-of-care ultrasound (POCUS) has been assessed in the past using computed tomography (CT) scans as the reference standard. We aimed to determine the ability of EPs to identify and grade hydronephrosis on POCUS using the consensus interpretation of POCUS by emergency radiologists as the reference standard. The study was conducted at an urban academic emergency department (ED) as a secondary analysis of previously collected ultrasound data from the EP-performed POCUS databank. Patients were eligible for inclusion if they had both POCUS and CT scanning performed during the index ED visit. Two board-certified emergency radiologists and six EPs interpreted each POCUS study independently. The interpretations were compared with the consensus interpretation by emergency radiologists. Additionally, the POCUS interpretations were also compared with the corresponding CT findings. Institutional approval was obtained for conducting this study. All the analyses were performed using Stata MP 14.0 (StataCorp). A total of 651 patient image-data sets were eligible for inclusion in this study. Hydronephrosis was reported in 69.6% of POCUS examinations by radiologists and 72.7% of CT scans (p = 0.22). Using the consensus radiology interpretation of POCUS as the reference standard, EPs had an overall sensitivity of 85.7% (95% confidence interval [CI] = 84.3%-87.0%), specificity of 65.9% (95% CI = 63.1%-68.7%), positive likelihood ratio of 2.5 (95% CI = 2.3-2.7), and negative likelihood ratio of 0.22 (95% CI = 0.19-0.24) for hydronephrosis. When using CT scan as the reference standard, the EPs had an overall sensitivity of 81.1% (95% CI = 79.6% to 82.5%), specificity of 59.4% (95% CI = 56.4%-62.5%), positive likelihood ratio of 2.0 (95% CI = 1.8-2.2), and negative likelihood ratio of 0.32 (95% CI = 0.29-0.35) for hydronephrosis. The specificity of EPs was improved to 94.6% (95% CI = 93.7%-95.4%) for categorizing the degree of hydronephrosis as "moderate or severe" versus "none or mild," with positive likelihood ratio of 6.33 (95% CI = 5.3-7.5) and negative likelihood ratio of 0.69 (95% CI = 0.66-0.73). Emergency physicians were found to have moderate to high sensitivity for identifying hydronephrosis on POCUS when compared with the consensus interpretation of the same studies by emergency radiologists. These POCUS findings by EPs produced more definitive results when at least moderate degree of hydronephrosis was present.
Publisher: Informa UK Limited
Date: 09-2005
DOI: 10.1080/17457300500088972
Abstract: The purpose of this study was to identify and describe injuries sustained by children less than 15 years of age associated with golfing equipment resulting in presentation to an emergency department. These findings can then be used to highlight potential injury prevention strategies. Retrospective analysis of data from the Victorian Emergency Minimum Dataset was performed. Golf-related injury cases were identified for the period April 1997 - December 2002. Cases where the text description of the injury event included the word "golf" were extracted for analysis. Text narratives of all cases were reviewed and cases occurring during golf play or practice or at a golf course were excluded from the analysis. There were 309 presentations to an emergency department for treatment of an injury caused by golfing equipment in children less than 15 years of age. The majority of presentations were male (71.5%) and children aged 5-9 years presented most commonly (53.1%). Head injuries were the most common reason for presentation (84.4%), with open wounds being the most common type of injury (68.5%). Being struck by an object (96.8%) was the most frequent cause of injury. Whilst relatively uncommon, golf equipment injuries to children could be prevented by attention to community safety and awareness of correct storage of golfing equipment. In addition, education of children regarding the safe handling and use of golf equipment could be useful. This could help reduce the number of emergency department visits and hospital admissions, thereby contributing to the reduction of costs associated with injury.
Publisher: Elsevier BV
Date: 2018
DOI: 10.1016/J.INJURY.2017.08.024
Abstract: Pulmonary thromboembolism (PTE) is a dangerous complication of traumatic injury, with varied risk profiles and treatment options. This review aims to describe reported incidence and variables associated with PTE among severely injured patients. Searches were conducted using PubMed, Cochrane and MEDLINE. Relevant studies were identified by two independent reviewers based on predetermined inclusion criteria. Incidence of PTE was the primary outcome measure. Variables associated with PTE was the secondary outcome measure. The Newcastle-Ottawa Scale was used to assess quality of included studies. There were eight studies that satisfied inclusion criteria. The diagnosed incidence of PTE in these populations ranged from 0.35 to 24%. The most common variables associated with PTE were pelvic or lower limb injury, chest injury, higher total Injury Severity Score, male sex and age. Variables that were less commonly associated with PTE were previous warfarin use, head injury, high serum lactate, soft tissue injury, more than one operation, more than three days on a ventilator, presence of a subclavian central venous catheter, need for a blood transfusion, systolic blood pressure <90mmHg, abdominal injury, presence of a deep venous thrombosis, inferior vena cava filter placement and isolated liver spleen or spinal injuries. The reported incidence of PTE after major trauma is variable and dependent on inclusion criteria, diagnostic criteria and study design. Identified variables differed to those reported for venous thromboembolism in other populations. It is difficult to predict populations at risk of clinically significant PTE following injury using available evidence. Further studies linked to patient-specific variables will assist in more precise risk-stratification and interventions.
Publisher: Wiley
Date: 12-2002
DOI: 10.1046/J.1442-2026.2002.00380.X
Abstract: To externally validate a chest pain protocol that triages low risk patients with chest pain to an unmonitored bed. Retrospective study of all patients admitted from the emergency department of a tertiary referral public teaching hospital with an admission diagnosis of 'unstable angina' or suspected ischemic chest pain. Data was collected on adverse outcomes and analysed on the basis of intention-to-treat according to the chest pain protocol. There were no life-threatening arrhythmias, cardiac arrests or deaths within the first 72 h of admission in the group assigned to an unmonitored bed by the chest pain protocol ([0/244] 0.0%: 95% confidence interval 0.0-1.5%). Four patients had an uncomplicated myocardial infarction, two patients had recurrent ischemic chest pain and one patient developed acute pulmonary oedema ([7/244] 2.9%: 95% confidence interval 1.2-5.8%). This retrospective study externally validated the chest pain protocol. Care in a monitored bed would not have altered outcomes for patients triaged to an unmonitored bed by the chest pain protocol. Compared to current guidelines, application of the chest pain protocol could increase the availability of monitored beds.
Publisher: Elsevier BV
Date: 2012
DOI: 10.1016/J.INJURY.2010.10.015
Abstract: Acute traumatic coagulopathy is observed in 10-25% of patients post major trauma and its management forms an integral part of haemostatic resuscitation. The identification and treatment of this coagulopathy is difficult and there is uncertainty regarding optimal therapeutic guidelines during the early phases of trauma resuscitation. This study aimed to examine the association between acute coagulopathy and early deaths post major trauma. A retrospective review of data over a 5 year period was performed to determine the associations between variables considered to contribute to mortality for adult major trauma patients (Injury Severity Score (ISS)>15) receiving blood transfusions as part of their initial resuscitation. Early death, defined as death in ED, or death in the operating theatre (OT), Intensive Care Unit (ICU) or wards within 24 h of admission was the primary end-point. Patients with non-survivable head injury on initial imaging were excluded. Univariate associations were calculated and multivariable logistic regression analysis was used to determine independent associations with mortality. There were 772 patients included in this study with a median ISS of 29 (19-41), with 91.7% blunt trauma. All-cause in-hospital mortality was 17.5%, while 77 (9.7%) patients died early. Increasing age (OR 1.04), a GCS of 3-8 (OR 5.05), and the presence of acute coagulopathy (OR 8.77) were significant independent variables associated with early death. Acute traumatic coagulopathy, independent of injury severity, transfusion practice or other physiological markers for haemorrhage, was associated with early death in major trauma patients requiring a blood transfusion. Early recognition and management of coagulopathy, independent of massive transfusion guidelines, may improve outcome from trauma resuscitation. Further studies are required for the early recognition of acute traumatic coagulopathy to enable the development of an evidence base for management.
Publisher: Public Library of Science (PLoS)
Date: 31-05-2011
Publisher: Cambridge University Press (CUP)
Date: 30-03-2016
DOI: 10.1017/S1049023X16000248
Abstract: The objective of this study was to assess the accuracy and safety of two pre-defined checklists to identify prehospital post-ictal or hypoglycemic patients who could be discharged at the scene. A retrospective cohort study of lower acuity, adult patients attended by paramedics in 2013, and who were either post-ictal or hypoglycemic, was conducted. Two self-care pathway assessment checklists (one each for post-ictal and hypoglycemia) designed as clinical decision tools for paramedics to identify patients suitable for discharge at the scene were used. The intention of the checklists was to provide paramedics with justification to not transport a patient if all checklist criteria were met. Actual patient destination (emergency department [ED] or discharge at the scene) and subsequent events (eg, ambulance requests) were compared between patients who did and did not fulfill the checklists. The performance of the checklists against the destination determined by paramedics was also assessed. Totals of 629 post-ictal and 609 hypoglycemic patients were identified. Of these, 91 (14.5%) and 37 (6.1%) patients fulfilled the respective checklist. Among those who fulfilled the checklist, 25 (27.5%) post-ictal and 18 (48.6%) hypoglycemic patients were discharged at the scene, and 21 (23.1%) and seven (18.9%) were admitted to hospital after ED assessment. Amongst post-ictal patients, those fulfilling the checklist had more subsequent ambulance requests (P=.01) and ED attendances with seizure-related conditions (P=.04) within three days than those who did not. Amongst hypoglycemic patients, there were no significant differences in subsequent events between those who did and did not meet the criteria. Paramedics discharged five times more hypoglycemic patients at the scene than the checklist predicted with no significant differences in the rate of subsequent events. Four deaths (0.66%) occurred within seven days in the hypoglycemic cohort, and none of them were attributed directly to hypoglycemia. The checklists did not accurately identify patients suitable for discharge at the scene within the Emergency Medical Service. Patients who fulfilled the post-ictal checklist made more subsequent health care service requests within three days than those who did not. Both checklists showed similar occurrence of subsequent events to paramedics’ decision, but the hypoglycemia checklist identified fewer patients who could be discharged at the scene than paramedics actually discharged. Reliance on these checklists may increase transportations to ED and delay initiation of appropriate treatment at a hospital. Tohira H , Fatovich D , Williams TA , Bremner A , Arendts G , Rogers IR , Celenza A , Mountain D , Cameron P , Sprivulis P , Ahern T , Finn J . Paramedic checklists do not accurately identify post-ictal or hypoglycaemic patients suitable for discharge at the scene . Prehosp Disaster Med . 2016 31 ( 3 ): 282 – 293 .
Publisher: Wiley
Date: 13-08-2021
Abstract: The aim of the present study was to describe the characteristics and outcomes of patients presenting to Australian EDs with suspected and confirmed COVID‐19 during 2020, and to determine the predictors of in‐hospital death for SARS‐CoV‐2 positive patients. This analysis from the COVED Project presents data from 12 sites across four Australian states for the period from 1 April to 30 November 2020. All adult patients who met local criteria for suspected COVID‐19 and underwent testing for SARS‐CoV‐2 in the ED were eligible for inclusion. Study outcomes were mechanical ventilation and in‐hospital mortality. Among 24 405 eligible ED presentations over the whole study period, 423 tested positive for SARS‐CoV‐2. During the ‘second wave’ from 1 July to 30 September 2020, 26 (6%) of 406 SARS‐CoV‐2 patients received invasive mechanical ventilation, compared to 175 (2%) of the 9024 SARS‐CoV‐2 negative patients (odds ratio [OR] 3.5 95% confidence interval [CI] 2.3–5.2, P 0.001), and 41 (10%) SARS‐CoV‐2 positive patients died in hospital compared to 312 (3%) SARS‐CoV‐2 negative patients (OR 3.2 95% CI 2.2–4.4, P = 0.001). For SARS‐CoV‐2 positive patients, the strongest independent predictors of hospital death were age (OR 1.1 95% CI 1.1–1.1, P 0.001), higher triage category (OR 3.5 95% CI 1.3–9.4, P = 0.012), obesity (OR 4.2 95% CI 1.2–14.3, P = 0.024) and receiving immunosuppressive treatment (OR 8.2 95% CI 1.8–36.7, P = 0.006). ED patients who tested positive for SARS‐CoV‐2 had higher odds of mechanical ventilation and death in hospital. The strongest predictors of death were age, a higher triage category, obesity and receiving immunosuppressive treatment.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2010
Publisher: Elsevier BV
Date: 11-2013
DOI: 10.1016/J.INJURY.2012.08.033
Abstract: Many trauma registries have used the 1990 revision of the Abbreviated Injury Scale (AIS AIS90) to code injuries sustained by trauma patients. Due to changes made to the AIS codeset since its release, AIS90-coded data lacks currency in the assessment of injury severity. The ability to map between the 1998 revision of AIS (AIS98) and the current (2008) AIS version (AIS08) already exists. The development of a map for transforming AIS90-coded data into AIS98 would therefore enable contemporary injury severity estimates to be derived from AIS90-coded data. Differences between the AIS90 and AIS98 codesets were identified, and AIS98 maps were generated for AIS90 codes which changed or were not present in AIS98. The effectiveness of this map in describing the severity of trauma using AIS90 and AIS98 was evaluated using a large state registry dataset, which coded injury data using AIS90 over several years. Changes in Injury Severity Scores (ISS) calculated using AIS90 and mapped AIS98 codesets were assessed using three distinct methods. Forty-nine codes (out of 1312) from the AIS90 codeset changed or were not present in AIS98. Twenty-four codes required the assignment of maps to AIS98 equivalents. AIS90-coded data from 78,075 trauma cases were used to evaluate the map. Agreement in calculated ISS between coded AIS90 data and mapped AIS98 data was very high (kappa=0.971). The ISS changed in 1902 cases (2.4%), and the mean difference in ISS across all cases was 0.006 points. The number of cases classified as major trauma using AIS98 decreased by 0.8% compared with AIS90. A total of 3102 cases (4.0%) sustained at least one AIS90 injury which required mapping to AIS98. This study identified the differences between the AIS90 and AIS98 codesets, and generated maps for the conversion process. In practice, the differences between AIS90- and AIS98-coded data were very small. As a result, AIS90-coded data can be mapped to the current AIS version (AIS08) via AIS98, with little apparent impact on the functional accuracy of the mapped dataset produced.
Publisher: Elsevier BV
Date: 2006
DOI: 10.1016/J.JCLINEPI.2005.05.007
Abstract: To develop prediction models for outcomes following trauma that met prespecified performance criteria. To compare three methods of developing prediction models: logistic regression, classification trees, and artificial neural networks. Models were developed using a 1996-2001 dataset from a major trauma center in Victoria, Australia. Developed models were subjected to external validation using the first year of data collection, 2001-2002, from a state-wide trauma registry for Victoria. Different authors developed models for each method. All authors were blinded to the validation dataset when developing models. Prediction models were developed for an intensive care unit stay following trauma (prevalence 23%) using information collected at the scene of the injury. None of the three methods gave a model that satisfied the performance criteria of sensitivity >80%, positive predictive value >50% in the validation dataset. Prediction models were also developed for death (prevalence 2.9%) using hospital-collected information. The performance criteria of sensitivity >95%, specificity >20% in the validation dataset were not satisfied by any model. No statistical method of model development was optimal. Prespecified performance criteria provide useful guides to interpreting the performance of developed models.
Publisher: Wiley
Date: 12-1999
Publisher: BMJ
Date: 04-10-2013
DOI: 10.1136/EMERMED-2012-201531
Abstract: We describe improved reporting of paediatric out-of-hospital cardiac arrest (OHCA) by adding coronial findings to a cardiac arrest registry. Non-traumatic OHCA occurring in paediatric patients aged less than 16 years were identified using the Victorian Ambulance Cardiac Arrest Registry and available coronial findings reviewed. Between the years 2001 and 2009, emergency medical services (EMS) attended 26 974 non-traumatic OHCA of which 390 (1.4%) occurred in children less than 16 years of age. We successfully linked 301 patients with the coronial registry excluding patients discharged alive from hospital (n=22) and patients with terminal illness (n=16), this represents 86% of OHCA attended by the ambulance. Agreement between the paramedic cause of OHCA and the coronial cause of death was 66.5% (κ 0.16) for presumed cardiac, 74.4% (κ 0.43) for sudden infant death syndrome (SIDS), 81.1% (κ 0.17) for respiratory, 92.7% (κ 0.18) for neurological and 98.3% (κ 0.27) for drug overdose precipitants to OHCA. Undiagnosed congenital heart disease was a rare cause of OHCA (n=3, 1%). Intentional injury was found on autopsy in 13 cases six cases were clinically thought to be SIDS and two cases presumed cardiac. Co-sleeping was found in 35 cases (39%) of SIDS. This study highlights the limitations associated with ascribing the cause of OHCA on the basis of clinical details. Improved reporting is possible by linkage with coronial data. Such robust data inform EMS service providers but also the wider healthcare system where preventive, diagnostic and treatment strategies can be maximised.
Publisher: Elsevier BV
Date: 03-2011
DOI: 10.1016/J.INJURY.2010.11.047
Abstract: Traumatic brain injury (TBI) is a major public health issue, which results in significant mortality and long term disability. The profound impact of TBI is not only felt by the in iduals who suffer the injury but also their care-givers and society as a whole. Clinicians and researchers require reliable and valid measures of long term outcome not only to truly quantify the burden of TBI and the scale of functional impairment in survivors, but also to allow early appropriate allocation of rehabilitation supports. In addition, clinical trials which aim to improve outcomes in this devastating condition require high quality measures to accurately assess the impact of the interventions being studied. In this article, we review the properties of an ideal measure of outcome in the TBI population. Then, we describe the key components and performance of the measurement tools most commonly used to quantify outcome in clinical studies in TBI. These measurement tools include: the Glasgow Outcome Scale (GOS) and extended Glasgow Outcome Scale (GOSe) Disability Rating Scale (DRS) Functional Independence Measure (FIM) Functional Assessment Measure (FAM) Functional Status Examination (FSE) and the TBI-specific and generic quality of life measures used in TBI patients (SF-36 and SF-12, WHOQOL-BREF, SIP, EQ-5D, EBIQ, and QOLIBRI).
Publisher: Oxford University Press (OUP)
Date: 30-11-2007
Abstract: Quality indicators (QIs) are routinely used in health systems, often on the assumption that they provide a valid reflection of the outcome of care. This study investigated the construct validity of 14 trauma QIs through their ability to identify patients at risk of poor outcomes, including increased mortality, longer lengths of stay and greater use of the intensive care unit (ICU). Data were analysed from the Victorian State Trauma Registry from January 2001 to March 2006. Patients included blunt trauma, injury severity score >15 and aged >16 years. Univariate analyses and logistic regression modeling were used to adjust for significant covariates. The study included 5104 cases. Three QIs were associated with increased mortality (abdominal surgery >24 h after arrival, blunt compound tibial fracture treatment >8 h after arrival and non-fixation of femoral diaphyseal fracture) and three with increased lengths of stay (cranial or abdominal surgery >24 h after arrival and patients developing deep vein thromboses, pulmonary emboli or decubitus ulcers, the latter also associated with increased ICU use). All remaining QIs exhibited reduced risks of poor outcomes or no significant associations. The investigated QIs generally demonstrated poor construct validity and limited usefulness in predicting outcomes. Although QIs associated with poor patient outcomes may represent an avenue for further refinement, additional investigation of QIs in comparative trauma systems could provide insight into the utility of these measures at the system level.
Publisher: Cambridge University Press
Date: 27-11-2014
Publisher: Elsevier BV
Date: 02-1997
DOI: 10.1111/J.1467-842X.1997.TB01654.X
Abstract: The study examined the frequency and patterns of assault within a large regional population of Victoria. The records of 860 victims of physical assault who presented to the Geelong Hospital emergency department during 1993 and 1994 were analysed retrospectively. The policy data on 1427 reported cases of physical assault, from the same catchment area and over a similar period of time, were also examined. The hospital data revealed that 65 per cent of assault victims were males aged from 15 to 34 years, that 58 per cent of presentations were within four hours of midnight, and 68 per cent were on Friday, Saturday or Sunday. Most assaults occurred on the streets, on footpaths, in open spaces or within dwellings, and the highest incidence was during the summer months. The police data showed similar patterns but from a different population of victims. It also showed an upward trend in the rates of assault in Victorian regional areas. The award-winning Geelong 'Local Industry Accord', a police and community intervention program, may have contributed to the decline in violence, particularly within the Geelong city centre, and has been suggested as a model for other community-based intervention programs. For intervention programs to be successful, the demography of assault within communities must be established and target groups identified. Hospital, police and victim surveys data do not identify accurately the population of assault victims. Improved methods of data collection and compatibility between databases already in existence may provide more accurate statistics upon which intervention programs may be based and their success evaluated.
Publisher: Elsevier BV
Date: 05-2015
DOI: 10.1016/J.BURNS.2014.07.027
Abstract: Scalds are a common injury in children and a frequent reason for hospitalisation despite being a preventable injury. This retrospective two year study reports data from 730 children aged 14 years or younger who sustained a scald between 2009 and 2010 and were admitted to a burns centre in Australia or New Zealand. Data were extracted from the Burn Registry of Australia and New Zealand (BRANZ), which included data from 13 burns centres in Australia and New Zealand. Scald injury contributed 56% (95% CI 53-59%) of all pediatric burns. There were two high risk groups male toddlers age one to two, contributing 34% (95% CI 31-38%) of all scalds, and indigenous children who were over 3 times more likely to experience a scald requiring admission to a burns unit than their non-indigenous peers. First aid cooling by non-professionals was initiated in 89% (95% CI 86-91%) of cases but only 20% (95% CI 16-23%) performed it as recommended. This study highlights that effective burn first aid reduces hospital stay and reinforces the need to encourage, carers and bystanders to deliver effective first aid and the importance of targeted prevention c aigns that reduce the burden of pediatric scald burns in Australia and New Zealand.
Publisher: Wiley
Date: 30-07-2008
DOI: 10.1111/J.1742-6723.2008.01110.X
Abstract: To determine the accuracy of current clinical diagnosis in recreational drug-related attendances to emergency by blood analysis. A prospective convenience s le of 103 patients who attended hospital with suspected recreational drug-related presentations was collected. Doctors' clinical impression of drugs responsible for presentation was compared with a detailed forensic blood analysis for recreational drugs. Among 103 s les, 80 (78%, 95% confidence intervals [CI] 70-86%) were found to have correct clinical suspicion of the recreational drug responsible for clinical presentation confirmed by laboratory analysis. Clinical diagnosis was most accurate for gamma-hydroxy butyrate (GHB) (sensitivity 97%, specificity 91%) and less accurate for hetamines (sensitivity 61%, specificity 79%), alcohol (sensitivity 42%, specificity 84%) and opiates (sensitivity 46%, specificity 100%). Multiple drug ingestion was found in 70% (95% CI 61-79%) of s les. Sensitivity and specificity of clinical impression for prediction of multiple drug ingestion presence is 75% (95% CI 66-83%) and 85% (95% CI 78-92%), respectively. Clinical diagnosis in recreational drug-related attendances to the ED was correct in most cases. Drugs, such as GHB, were the most accurately diagnosed. Inaccuracy in recognizing other drugs, like hetamines, opiates and alcohol, occurs where a coingestant produces a more profound clinical picture. Multiple drug ingestion is a common scenario in recreational drug presentations to emergency.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2012
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2012
Publisher: Elsevier BV
Date: 2011
Publisher: Elsevier BV
Date: 2008
Publisher: Wiley
Date: 23-06-2022
Abstract: 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. 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. 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. 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.
Publisher: American Psychological Association (APA)
Date: 2012
DOI: 10.1037/A0027888
Abstract: There is continuing controversy regarding predictors of poor outcome following mild traumatic brain injury (mTBI). This study aimed to prospectively examine the influence of preinjury factors, injury-related factors, and postinjury factors on outcome following mTBI. Participants were 123 patients with mTBI and 100 trauma patient controls recruited and assessed in the emergency department and followed up 1 week and 3 months postinjury. Outcome was measured in terms of reported postconcussional symptoms. Measures included the ImPACT Post-Concussional Symptom Scale and cognitive concussion battery, including Attention, Verbal and Visual memory, Processing Speed and Reaction Time modules, pre- and postinjury SF-36 and MINI Psychiatric status ratings, VAS Pain Inventory, Hospital Anxiety and Depression Scale, PTSD Checklist-Specific, and Revised Social Readjustment Scale. Presence of mTBI predicted postconcussional symptoms 1 week postinjury, along with being female and premorbid psychiatric history, with elevated HADS anxiety a concurrent indicator. However, at 3 months, preinjury physical or psychiatric problems but not mTBI most strongly predicted continuing symptoms, with concurrent indicators including HADS anxiety, PTSD symptoms, other life stressors and pain. HADS anxiety and age predicted 3-month PCS in the mTBI group, whereas PTSD symptoms and other life stressors were most significant for the controls. Cognitive measures were not predictive of PCS at 1 week or 3 months. Given the evident influence of both premorbid and concurrent psychiatric problems, especially anxiety, on postinjury symptoms, managing the anxiety response in vulnerable in iduals with mTBI may be important to minimize ongoing sequelae.
Publisher: Elsevier BV
Date: 03-2015
DOI: 10.1016/J.RESUSCITATION.2014.12.009
Abstract: The significance of pre-arrest factors in out-of-hospital cardiac arrests (OHCA) witnessed by emergency medical services (EMS) is not well established. The purpose of this study was to assess the association between prodromal symptoms and pre-arrest clinical observations on the arresting rhythm and survival in EMS witnessed OHCA. Between 1st January 2003 and 31st December 2011, 1056 adult EMS witnessed arrests of a presumed cardiac aetiology were identified from the Victorian Ambulance Cardiac Arrest Registry. Pre-arrest prodromal features and clinical characteristics were extracted from the patient care record. Backward elimination logistic regression was used to identify pre-arrest factors associated with an initial shockable rhythm and survival to hospital discharge. The median age was 73.0 years, 690 (65.3%) were male, and the rhythm of arrest was shockable in 465 (44.0%) cases. The most commonly reported prodromal symptoms prior to arrest were chest pain (48.8%), dyspnoea (41.8%) and altered consciousness (37.8%). An unrecordable systolic blood pressure was observed in 34.4%, a respiratory rate 24min(-1) was present in 43.1%, and 45.5% had a Glasgow coma score <15. In the multivariable analysis, the following pre-arrest factors were significantly associated with survival: age, public location, aged care facility, chest pain, arm or shoulder pain, dyspnoea, dizziness, vomiting, ventricular tachycardia, pulse rate, systolic blood pressure, respiratory rate, Glasgow coma score, aspirin and inotrope administration. Pre-arrest factors are strongly associated with the arresting rhythm and survival following EMS witnessed OHCA. Potential opportunities to improve outcomes exist by way of early recognition and management of patients at risk of OHCA.
Publisher: Elsevier BV
Date: 05-2012
Publisher: BMJ
Date: 23-06-2015
DOI: 10.1136/INJURYPREV-2014-041271
Abstract: Participation in falls prevention activities by older people following presentation to the emergency department (ED) with a fall is suboptimal. This randomised controlled trial (RCT) will test the RESPOND programme, an intervention designed to improve older persons' participation in falls prevention activities through delivery of patient-centred education and behaviour change strategies. A RCT at two tertiary referral EDs in Melbourne and Perth, Australia. 528 community-dwelling people aged 60-90 years presenting to the ED with a fall and discharged home will be recruited. People who require an interpreter or hands-on assistance to walk live in residential aged care or >50 km from the trial hospital have terminal illness, cognitive impairment, documented aggressive behaviour or a history of psychosis are receiving palliative care or are unable to use a telephone will be excluded. Participants will be randomly allocated to the RESPOND intervention or standard care control group. RESPOND incorporates (1) a home-based risk factor assessment (2) education, coaching, goal setting and follow-up telephone support for management of one or more of four risk factors with evidence of effective interventions and (3) healthcare provider communication and community linkage delivered over 6 months. Primary outcomes are falls and fall injuries per person-year. RESPOND builds on prior falls prevention learnings and aims to help in iduals make guided decisions about how they will manage their falls risk. Patient-centred models have been successfully trialled in chronic and cardiovascular disease however, evidence to support this approach in falls prevention is limited. The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000336684).
Publisher: Mary Ann Liebert Inc
Date: 15-04-2018
Abstract: Severe traumatic brain injury (TBI) is associated with poor outcomes however, little is known about whether these outcomes are improving over time. This study examined temporal trends in functional outcomes of severe TBI at six months post-injury. We conducted a retrospective cohort study (January 1, 2006 to December 31, 2015) of hospitalized adult (≥16 years) patients with severe TBI using data from the population-based Victorian State Trauma Registry. The primary outcome was the Glasgow Outcome Scale-Extended (GOS-E) at six months post-injury, dichotomized as upper severe disability or worse (GOS-E ≤4, termed "unfavorable outcome") and lower moderate disability or better (GOS-E ≥5 termed "favorable outcome"). Multivariable logistic regression was used to investigate temporal trends in functional outcomes at six months post-injury. Of the 1966 patients with severe TBI who were followed up at six months post-injury (median age, 42 years (interquartile range [IQR]: 25-68) male, 73%), a majority of patients had an unfavorable outcome (GOS-E ≤4 n = 1372, 70%). After adjusting for confounders, there was no change in functional outcomes over time (adjusted odds ratio [AOR] = 1.02, 95% confidence interval [CI]: 0.98,1.06 p = 0.35). Similarly, there was no change in the adjusted odds of death (GOS-E = 1) at six months post-injury (AOR = 1.04, 95% CI: 1.00,1.08 p = 0.08). Using a population-wide, high quality, comprehensive registry, we demonstrated no change in death or functional outcomes after severe TBI between 2006 and 2015 in a mature trauma system. There is a clear need to identify targeted improvements in the treatment of these patients with the aim of reducing in-hospital death and improving long-term outcomes.
Publisher: Elsevier BV
Date: 07-2015
Publisher: Wiley
Date: 21-10-2013
DOI: 10.1111/ANS.12417
Abstract: The effectiveness of massive transfusion protocols (MTPs) has been assumed from low quality studies with multiple biases. This review aimed to (i) evaluate the association between the institution of an MTP and mortality and (ii) determine the effect of MTPs on transfusion practice post trauma. A systematic review of studies that examined patient outcomes before and after the institution of an MTP in the same centre was conducted. The design and results of each study were described. Heterogeneity was assessed using the Q test and the I(2) statistic. Odds ratios (ORs) for dichotomous outcomes from each study were pooled. There were eight studies that satisfied inclusion criteria with marked heterogeneity in study populations (I(2) = 72.1%, P = 0.001). Two studies showed significantly improved mortality following implementation of an MTP, and six studies showed no significant change. Pooled OR for the effect of an MTP on short-term mortality was 0.73 (95% confidence interval: 0.48-1.11). The effect of MTPs on transfusion practice was varied. Despite the popularity of MTPs and directives mandating their use in trauma centres, in before-after studies, MTPs have not always been associated with improved mortality. Evidence-based standardization of MTPs, improved compliance and analysis of broader endpoints were identified as areas for further research.
Publisher: Elsevier BV
Date: 09-2012
DOI: 10.1016/J.INJURY.2011.06.005
Abstract: Patients with mental illness or depression may sustain self-inflicted injuries that require admission to an Intensive Care Unit (ICU). It is unknown whether the intent of injury leads to a greater likelihood of dying over and above the severity of the initial injury. Given the economic and societal burden of injury of self-harm, we designed this study to compare hospital outcomes of intentionally injured patients presenting to a tertiary ICU compared to unintentional injuries. The regional trauma database was interrogated to produce two datasets that included all adult trauma patients admitted to the Alfred Intensive Care Unit between 01/07/2002 and 30/06/2007. The first included patients that sustained intentional injuries, the second comprised un-intentional injuries and acted as a control group. Logistic regression was used to model factors associated with mortality. Intentionally injured patients made up 4.17% of the total burns, blunt and penetrating trauma admissions to the Alfred ICU over the five-year study period. There was a trend towards higher mortality overall and in all subgroups of patients with intentional injuries when compared to those with un-intentional mechanisms of injury. After adjusting for injury severity and age, a mechanism of injury involving intentional injury was independently associated with a doubling of the odds of death. Our study is the first paper in the literature to describe an increased the risk of death within a group of patients admitted to a trauma and burns ICU following deliberate self-harm.
Publisher: Wiley
Date: 10-1999
Publisher: Elsevier BV
Date: 10-2011
DOI: 10.1016/J.INJURY.2011.06.003
Abstract: Traumatic disruption of the pelvic ring is uncommon but is associated with a high risk of mortality. These injuries are predominantly due to high energy blunt trauma such as a fall from height, road or workplace trauma, and severe associated injuries are prevalent, increasing the complexity of managing this patient group. The aim of this population-based study was to investigate predictors of mortality following severe pelvic ring fractures managed in an inclusive, regionalised trauma system. Cases aged≥15 years from 1st July 2001 to 30th June 2008 were extracted from the population-based statewide Victorian State Trauma Registry for analysis. Patient demographic, prehospital and admission characteristics were considered as potential predictors of mortality. Multivariate logistic regression was used to identify predictors of mortality with adjusted odds ratios (AOR) and 95% confidence intervals (CI) calculated. There were 348 cases over the 8-year period. The mortality rate was 19%. Patients aged≥65 years were at higher odds of mortality (AOR 7.6, 95% CI: 2.8, 20.4) than patients aged 15-34 years. Patients hypotensive at the scene (AOR 5.5, 95% CI: 2.3, 13.2), and on arrival at the definitive hospital of care (AOR 3.7, 955 CI: 1.7, 8.0), were more likely to die than patients without hypotension. The presence of a severe chest injury was associated with an increased odds of mortality (AOR 2.8, 95% CI: 1.3, 6.1), whilst patients injured in intentional events were also more likely to die than patients involved in unintentional events (AOR 4.9, 95% CI: 1.6, 15.6). There was no association between the hospital of definitive management and mortality after adjustment for other variables, despite differences in the protocols for managing these patients at the major trauma services (Level 1 trauma centres). The findings highlight the importance of effective control of haemodynamic instability for reducing the risk of mortality. As most patients survive these injuries, further research should focus on long term morbidity and the impact of different treatment approaches.
Publisher: Massachusetts Medical Society
Date: 16-10-2014
No related grants have been discovered for Peter Cameron.