ORCID Profile
0000-0002-4655-5023
Current Organisations
Western Health
,
University of Melbourne
,
University of New South Wales
,
Queensland University of Technology
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Publisher: Wiley
Date: 02-02-2018
DOI: 10.1111/RESP.13259
Abstract: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common presentation to emergency departments (ED) but data regarding its epidemiology and outcomes are scarce. We describe the epidemiology, clinical features, treatment and outcome of patients treated for AECOPD in ED. This was a planned sub-study of patients with an ED diagnosis of AECOPD identified in the Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) study. The AANZDEM was a prospective, interrupted time series cohort study conducted in 46 ED in Australia, New Zealand, Singapore, Hong Kong and Malaysia over three 72-h periods in May, August and October 2014. Primary outcomes were patient epidemiology, clinical features, treatment and outcomes (hospital length of stay (LOS) and mortality). Forty-six ED participated. There were 415 patients with an ED primary diagnosis of AECOPD (13.6% of the overall cohort 95% CI: 12.5-14.9%). Median age was 73 years, 60% males and 65% arrived by ambulance. Ninety-one percent had an existing COPD diagnosis. Eighty percent of patients received inhaled bronchodilators, 66% received systemic corticosteroids and 57% of those with pH < 7.30 were treated with non-invasive ventilation (NIV). Seventy-eight percent of patients were admitted to hospital, 7% to an intensive care unit. In-hospital mortality was 4% and median LOS was 4 days (95% CI: 2-7). Patients treated in ED for AECOPD commonly arrive by ambulance, have a high admission rate and significant in-hospital mortality. Compliance with evidence-based treatments in ED is suboptimal affording an opportunity to improve care and potentially outcomes.
Publisher: Elsevier BV
Date: 09-2012
DOI: 10.1016/J.HLC.2012.05.005
Abstract: Acute coronary syndrome (ACS) is a common life-threatening condition but the majority of patients are at low risk of acute adverse events. In 2005, the GRACE Freedom-from-Event score (GFFES) was developed to identify patients with a low risk of adverse in-hospital events. Our aim was to externally validate this score. A prospective observational cohort of patients was admitted to a cardiology service with admission diagnoses of chest pain, unstable angina or myocardial infarction (MI). Clinical and investigational data were collected. Defined major adverse cardiac events (MACE) were death, new MI, stroke, acute pulmonary oedema, cardiac arrest or sustained ventricular tachycardia, high degree atrioventricular block, cardiogenic shock, pacemaker or intra-aortic balloon pump insertion, assisted ventilation or new acute renal failure occurring during the index admission. The primary outcome of interest was the predictive performance of the GFFES for MACE, by ROC curve and clinical performance analysis. 238 patients were studied median age 67, 56.7% were male. Seventy-eight patients (32.8%) were classified as low risk by the score (GFFES score≥287). There were no MACE in the low risk group. The AUC for predictive performance of the GFFES was 0.74 (95% CI 0.62-0.86). Sensitivity was 100% (95% CI 71.7-100%), specificity 34.7% (95% CI 28.5-41.3%) and negative predictive value 100% (95% CI 94.2-100%). In this single site prospective validation, GFFES showed good discrimination, sensitivity and negative predictive value. It may be a useful tool for assigning patients to appropriate levels of care based on risk.
Publisher: BMJ
Date: 2008
Abstract: Evidence suggests that the rate of recurrent headache after treatment of migraine in the emergency department (ED) is high. The mechanisms for this are unclear, but neurogenic inflammation may play a role. There is conflicting evidence about whether adjuvant dexamethasone reduces the rate of recurrent headache. The aim of this study was to compare the rate of recurrent headache in patients with migraine randomised to receive a single dose of oral dexamethasone or placebo at discharge after treatment in the ED with intravenous phenothiazine. A double-blind, randomised, placebo-controlled trial was conducted in the ED of three community teaching hospitals. Adult patients with physician-diagnosed migraine were treated with intravenous phenothiazine and at discharge were randomised to receive either 8 mg oral dexamethasone or placebo as a single dose. Follow-up was by telephone at 48-72 h and the proportion of patients with recurrent headache overall and in the subgroup with headache duration <24 h was recorded. 63 patients (76% women) of median age 39 years were enrolled, 61 of whom (97%) completed follow-up. The pooled rate of recurrent headache was 33%. 32 were randomised to placebo and 31 to dexamethasone. The rate of recurrent headache in the dexamethasone and control groups was 27% (8/30) vs 39% (12/31) (relative risk (RR) 0.69, 95% CI 0.33 to 1.45, p = 0.47). For 40 patients with headache lasting <24 h the rate of recurrent headache in the dexamethasone and control groups was 15% (3/20) vs 45% (9/20), a reduction in absolute risk of 30% (RR 0.33, 95% CI 0.11 to 1.05, p = 0.08). A single oral dose of dexamethasone following phenothiazine treatment for migraine in the ED did not reduce the rate of recurrent headache. There is weak evidence for a possible benefit in the subgroup who present within <24 h of symptom onset. A multicentre trial to confirm this finding is warranted.
Publisher: BMJ
Date: 18-12-2019
DOI: 10.1136/BMJ.L6705
Publisher: Springer Science and Business Media LLC
Date: 16-10-2014
Publisher: Elsevier BV
Date: 2001
Abstract: We sought to determine the minimum clinically significant difference in visual analog scale (VAS) pain score for children. We performed a prospective, single-group, repeated-measures study of children between 8 and 15 years presenting to an urban pediatric emergency department with acute pain. On presentation to the ED, patients marked the level of their pain on a 100-mm nonhatched VAS scale. At 20-minute intervals thereafter, they were asked to give a verbal categoric rating of their pain as "heaps better," "a bit better," "much the same," "a bit worse," or "heaps worse" and to mark the level of pain on a VAS scale of the same type as used previously. A maximum of 3 comparisons was recorded for each child. The minimum clinically significant difference in VAS pain score was defined as the mean difference between current and preceding scores when the subject reported "a bit worse" or "a bit better" pain. Seventy-three children were enrolled in the study, yielding 103 evaluable comparisons in which pain was rated as "a bit better" or "a bit worse." The minimum clinically significant difference in VAS score was 10 mm (95% confidence interval 7 to 12 mm). This study found the minimum clinically significant difference in VAS pain score for children aged 8 to 15 years (on a 100-mm VAS scale) to be 10 mm (95% confidence interval 7 to 12 mm). In studies of populations, differences of less than this amount, even if statistically significant, are unlikely to be of clinical significance.
Publisher: Wiley
Date: 05-07-2013
DOI: 10.1111/JOCN.12274
Abstract: To explore emergency department (ED) nurses' perceptions of current practices and essential components of effective change of shift nursing handover. Ineffective nursing handover can negatively impact on patient outcomes. Evidence suggests that nursing handover in ED is highly variable. Proposed handover models in the literature are structured for inpatient settings and may not be suitable for ED settings. A mixed methods study (survey and group interviews) was conducted in a metropolitan ED in Melbourne, Australia. During February-June 2011, a survey (n = 63) investigated perceptions of current practices and preferences for handover structure. Analyses are descriptive. In the same period, group interviews (n = 41) explored nurses' opinions about essential features and information of an effective nursing handover in the ED environment. A modified nominal group technique generated data that were analysed using content analysis. Most nurses (96%) perceived receiving adequate information during handover however, gaps were identified, including omission of important information regarding medications, vital signs and nursing care needs. Group interviews identified five essential features of effective handover: systematic approach, treatment, appropriate environment, reference to documentation/charts and efficient communication. Essential information included patient details, presenting problem, future care/disposition plan, treatment and nursing observations. Handover structures in the ED may not provide essential information to ensure adequate continuity of nursing care. ED nurses consider optimal handover to be specific for patients for whom they are caring, conducted at the bedside, structured and containing key elements (patient details, presenting problem, treatment, nursing observations, plan). Provision of a handover framework incorporating key features and essential information has the potential to improve the efficiency of handover. Use of this framework may enhance the transfer of accurate and essential information to enable safe and high standards of nursing care in the ED.
Publisher: Wiley
Date: 12-2008
DOI: 10.1111/J.1553-2712.2008.00265.X
Abstract: The derivation and validation studies for the Canadian Cervical-Spine (C-Spine) Rule (CCR) and the Canadian Computed Tomography (CT) Head Rule (CCHR) have been published in major medical journals. The objectives were to determine: 1) physician awareness and use of these rules in Australasia, Canada, the United Kingdom, and the United States and 2) physician characteristics associated with awareness and use. A self-administered e-mail and postal survey was sent to members of four national emergency physician (EP) associations using a modified Dillman technique. Results were analyzed using repeated-measures logistic regression models. The response rate was 54.8% (1,150/2,100). Reported awareness of the CCR ranged from 97% (Canada) to 65% (United States) for the CCHR it ranged from 86% (Canada) to 31% (United States). Reported use of the CCR ranged from 73% (Canada) to 30% (United States) for the CCHR, it was 57% (Canada) to 12% (United States). Predictors of awareness were country, type of rule, full-time employment, younger age, and teaching hospital (p < 0.05). Significant differences in use of the CCR by country were observed, but not for the CCHR. Teaching hospitals were more likely to use the CCR than nonteaching hospitals, but less likely to use the CCHR. This large international study found notable differences among countries with regard to knowledge and use of the CCR and CCHR. Awareness and use of both rules were highest in Canada and lowest in the United States. While younger physicians, those employed full-time, and those working in teaching hospitals were more likely to be aware of a decision rule, age and employment status were not significant predictors of use. A better understanding of factors related to awareness and use of emergency medicine (EM) decision rules will enhance our understanding of knowledge translation and facilitate strategies to enhance dissemination and implementation of future rules.
Publisher: Wiley
Date: 17-09-2020
Publisher: Wiley
Date: 02-2006
DOI: 10.1111/J.1742-6723.2006.00803.X
Abstract: For patients with diabetic ketoacidosis (DKA), arterial blood gas (BG) s ling for measurement of pH and bicarbonate has been considered an essential part of initial evaluation and monitoring of progress. There is growing evidence that venous values can be clinically acceptable alternatives to arterial measurements. This article summarizes the recent evidence regarding the validity of venous BG s ling in DKA. Medline search for the years 1995 to present, hand search of reference lists, search of on-line evidence-based medicine sites. In patients with DKA the weighted average difference between arterial and venous pH was 0.02 pH units (95% limits of agreement -0.009 to +0.021 pH units) and between arterial and venous bicarbonate was -1.88 mEq/L. There is reasonable evidence that venous and arterial pH have sufficient agreement as to be clinically interchangeable in patients with DKA who are haemodynamically stable and without respiratory failure. There is some evidence that venous and arterial bicarbonate also agree closely in DKA but this requires confirmation.
Publisher: Springer Science and Business Media LLC
Date: 04-02-2010
Publisher: Wiley
Date: 11-2012
DOI: 10.1111/ACEM.12016
Abstract: This study was conducted to determine if there is practice variation for emergency physicians' (EPs) management of recent-onset atrial fibrillation (RAF) in various world regions (Canada, United States, United Kingdom, and Australasia). The authors completed a mail and e-mail survey of members from four national emergency medicine (EM) associations. One prenotification letter and three survey letters were sent to members of the Canadian Association of Emergency Physicians (CAEP Canada-1,177 members surveyed), American College of Emergency Physicians (ACEP United States-500), College of Emergency Medicine UK (CEM United Kingdom-1,864), and Australasian College for Emergency Medicine (ACEM Australasia-1,188) as per the modified Dillman technique. The survey contained 23 questions related to the management of adult patients with symptomatic RAF (either a first episode or paroxysmal-recurrent) where onset is less than 48 hours and cardioversion is considered a treatment option. Data were analyzed using descriptive and chi-square statistics. Response rates were as follows: overall, 40.5% Canada, 43.0% United States, 50.1% United Kingdom, 38.1% and Australasia, 38.0%. Physician demographics were as follows: 72% male and mean (±SD) age 41.7 (±8.39) years. The proportions of physicians attempting rate control as their initial strategy are United States, 94.0% Canada, 70.7% Australasia, 61.1% and United Kingdom, 43.1% (p < 0.0001). Diltiazem is the predominant agent for rate control in Canada (65.36%) and the United States (95.22%), while metoprolol is used in Australasia (65.94%) and the United Kingdom (67.64%). Cardioversion is attempted at varying rates in Canada (65.9%), Australasia (49.9%), United Kingdom (49.5%), and the United States (25.9%) (p < 0.0001). Pharmacologic cardioversion is attempted first in all regions, with the preferred drug being procainamide in Canada (61.93%) and amiodarone in Australasia (63.39%), the United Kingdom (47.97%), and the United States (22.41% p < 0.0001). If drugs fail, electrical cardioversion is then attempted in Canada (70.64%), Australasia (46.19%), the United States (29.69%), and the United Kingdom (27.78% p < 0.0001). There is much variation in emergency department (ED) management of RAF among world regions, most markedly for use of rate versus rhythm control, choice of drugs, and use of electrical cardioversion. Canadians are more likely to use an aggressive approach for management of RAF, whereas Americans are more likely to employ conservative management. U.K. and Australasian EPs fall somewhere in the middle. These differences demonstrate the need for better evidence, or better synthesis of existing knowledge, to create guidelines to guide ED management of this common dysrhythmia.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2011
Publisher: BMJ
Date: 05-2012
DOI: 10.1136/BMJ.E2904
Publisher: Elsevier BV
Date: 2002
DOI: 10.1016/S0736-4679(01)00431-0
Abstract: This prospective study of patients with acute respiratory illness or potential ventilatory compromise compared pCO(2) and pH on an arterial and a venous blood s le with the aims of determining whether venous pH and pCO(2) can replace arterial values in the management of patients with acute respiratory disease and to determine whether there is a cut-off level of venous pCO(2) that can accurately screen for significant hypercarbia (pCO(2) > 50 mm Hg). Data were analyzed using bias plot and receiver operator characteristic (ROC) curve methods. There were 196 s le-pairs analyzed 56 (29%) had significant hypercarbia. For pH, there was very good agreement with venous s les being an average of 0.034 pH units lower than arterial s les. With respect to pCO(2), there was only fair agreement, with the pCO(2) on average 5.8 mm Hg higher in venous s les and 95% limits of agreement -8.8 to +20.5 mm Hg. The ROC curve analysis showed that a venous pCO(2) level of 45 mm Hg was a potential screening cutoff (sensitivity for the detection of hypercarbia of 100%, specificity 57%). This study shows that venous pH is an acceptable substitute for arterial measurement but there is not sufficient agreement for venous pCO(2) to be able to replace arterial pCO(2) in the clinical evaluation of ventilatory function. Venous pCO(2) may be able to be used as a screening test for hypercarbia using a screening cut-off of 45 mm Hg.
Publisher: Korean Society of Pediatric Emergency Medicine
Date: 30-06-2019
Publisher: Elsevier BV
Date: 06-2006
DOI: 10.1016/J.ANNEMERGMED.2006.01.022
Abstract: We determine the rate of adverse effects associated with the use of intravenous (IV) epinephrine by infusion for the treatment of severe asthma in the emergency department (ED). This retrospective, structured, medical record review included adult patients who presented to the ED of Western Hospital between 1998 and 2003 and who were triaged as category 1, 2, or 3, had a discharge diagnosis of asthma, and were administered IV epinephrine in the ED. Patients were excluded if they were older than 55 years or if a diagnosis of asthma was not confirmed. The primary outcome measures were occurrence of cardiac arrhythmia or ischemia, local tissue ischemia, hypotension or hypertension, neurologic injury, or death related to epinephrine infusion. Two hundred twenty episodes of care met the inclusion criteria. Adverse events occurred in 67 episodes (30.5% 95% confidence interval [CI] 24.5% to 37.1%) however, most were minor and self-limiting. There were no deaths. Major adverse events occurred in 3.6% of cases (8/220 95% CI 1.7% to 7.3%), including 2 cases of supraventricular tachycardia, 1 case of chest pain with ECG changes, 1 case of incidental elevated troponin, and 4 cases of hypotension requiring intervention. IV epinephrine is associated with a low rate of major and a moderate rate of minor adverse events in patients with severe asthma however, a causal relationship has not been established. Further research investigating effectiveness, as well as safety, is warranted.
Publisher: CSIRO Publishing
Date: 24-07-2023
DOI: 10.1071/AH23135
Publisher: Wiley
Date: 02-2020
DOI: 10.1111/IMJ.14323
Publisher: Elsevier BV
Date: 08-2011
Publisher: Wiley
Date: 06-2001
DOI: 10.1046/J.1442-2026.2001.00210.X
Abstract: It has been suggested that the use of additional electrocardiogram leads might improve the diagnostic sensitivity of this test, thus potentially expanding eligibility for thrombolysis for patients suffering myocardial infarction. The aims of this study were to evaluate the role of the 15-lead electrocardiogram in the emergency department chest pain population and to determine whether the routine use of the extra leads expands the group of patients eligible to receive thrombolysis. Blinded, in idual and independent analysis by two emergency physicians of paired 12- and 15-lead electrocardiograms from adult patients with a primary complaint of chest pain. The main outcome measure was the diagnosis of myocardial infarction eligible for thrombolysis. Data were analysed using descriptive statistics and kappa statistics for agreement between raters. 540 electrocardiograms (270 sets) were analysed. Myocardial infarction qualifying for thrombolysis was identified (by consensus) in 21 cases. In no case did the 15-lead electrocardiograph identify a myocardial infarction qualifying for thrombolysis that was not identified on the 12-lead electrocardiogram. In this study, the 15-lead electrocardiogram did not increase the number of thrombolysis-eligible myocardial infarctions identified when compared with the 12-lead electrocardiogram. This study is limited by the small patient s le size, and a large multicentre trial is recommended to compare the 12- and 15-lead electrocardiograms in the emergency department population where the incidence of posterior and right-sided myocardial infarction is ultimately known.
Publisher: Wiley
Date: 04-2018
DOI: 10.1111/IMJ.13753
Abstract: This retrospective cohort study compared the diagnostic utility (sensitivity, specificity and negative predictive value (NPV)) of the age-times-10 adjusted d-dimer cut-off used in combination with the original and simplified Well's pulmonary embolism (PE) scores and the original and simplified revised Geneva scores to identify patients in whom PE is classified as unlikely according to each score. The PE risk scores performed similarly with high sensitivity (97.6, 97.1, 96.9 and 97.1% respectively) and NPV (99.3, 99.3, 99.2 and 99.2% respectively). Each missed only one PE. The age-times-10 age-adjusted d-dimer assay cut-off performed similarly with each of the clinical risk scores tested with high sensitivity and NPV.
Publisher: Elsevier BV
Date: 04-2005
DOI: 10.1016/J.ANNEMERGMED.2004.11.011
Abstract: We assess the methodologic quality of studies using medical record review methodology in 4 international emergency medicine journals. A secondary aim was to compare methodology quality among these journals and across years. This was an observational study of articles whose main methodology was medical record review published in Academic Emergency Medicine (AEM) , Annals of Emergency Medicine (Annals) , Emergency Medicine Journal (EMJ) , and Emergency Medicine Australasia (EMA) between January 2002 and May 2004. Eligible articles were reviewed for reporting of a clear hypothesis or objective, training of abstractors, defined inclusion and exclusion criteria, use of a standard abstraction form, definition of important variables, monitoring of abstractor performance, blinding of abstractors to study hypothesis, reporting of interrater reliability, s le size or power calculation, reporting of ethics approval or waiver, and disclosure of funding source. The primary outcome was the proportion of articles meeting each criterion. Secondary outcomes were comparison of the proportions of articles meeting each criterion among journals and by years. One hundred seven articles were analyzed 31 were published in AEM, 29 in Annals, 29 in EMJ, and 18 in EMA . A clear aim was reported in 93% of articles, standardized abstraction forms were reported in 51%, interrater reliability was reported in 25%, ethics approval or waiver was reported in 68%, and s le size or power calculation was reported in 10%. Adherence to the quality criteria for medical record reviews was suboptimal, and there were significant differences among journals in overall methodologic quality.
Publisher: Springer Science and Business Media LLC
Date: 03-2011
Abstract: Butyrophenones have been reported to provide effective migraine relief in the emergency department (ED). We conducted a systematic review of the evidence for their use in the ED. We searched the Cochrane , Medline , Embase , and CINAHL databases. Included studies were randomized trials of a parenteral butyrophenone (droperidol, haloperidol) versus placebo or a comparator in migraine or benign headache with results available in English. Study quality was determined using the Jadad score. Six articles were included. Primary outcomes were subjective or objective headache relief (& 50% improvement in visual analogue scale scores). Secondary outcomes included side effects. We reported pooled odds ratios (ORs) with their 95% confidence intervals (CIs) for subjective or objective headache relief for butyrophenones versus placebo or comparator agents. Three studies reported subjective headache relief with a butyrophenone versus placebo or meperidine in migraine. Two studies reported objective headache relief with droperidol versus prochlorperazine, whereas one study compared droperidol versus olanzapine in benign headache. The pooled OR for subjective headache relief was 8.08 (95% CI 1.54–42.30) for a butyrophenone versus placebo, whereas it was 1.50 (95% CI 0.33–6.77) for droperidol versus meperidine in migraine. The pooled OR for objective headache relief was 2.96 (95% CI 1.36–6.43) for droperidol versus prochlorperazine in benign headache. Rates of side effects were 10 to 45% akathesia and sedation were the most common. Butyrophenones are effective for the relief of migraine or benign headache. However, adverse effects make it difficult to recommend butyrophenones above agents with similar effectiveness and fewer problems.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2002
DOI: 10.1097/00006565-200206000-00002
Abstract: To determine whether parent and child visual analogue scale (VAS) scores for the pain associated with acute conditions in the child agree sufficiently for these methods of measurement to be considered interchangeable in pain and analgesia research. This was a prospective, two-group, repeated measures, blinded study in an urban pediatric emergency department. Children aged 8 to 15 years seeking treatment for painful conditions and the parents of these children were asked to rate the child's pain independently using a VAS on as many as four occasions at 20-minute intervals. Both participants were blinded to their previous rating and the rating of the other participant. The main outcome measure was the correlation of child and parent VAS pain scores by Pearson correlation and bias plot (Bland-Altman) analysis of agreement between tests. Seventy-eight child-parent sets participated, yielding 289 VAS pain score comparison pairs for evaluation. The correlation between child and parent VAS pain scores was 0.63 (95% CI, 0.56-0.70). Bias plot analysis revealed a bias of 5% and 95% limits of agreement from -38 to +47 mm. The degree of difference between child and parent scores was variable, but there was an increasing tendency for parents to underestimate the child's pain when the child recorded VAS pain scores at the higher end of the scale. Parents' VAS score ratings of their children's pain correlate only moderately with the children's VAS pain scores and show poor levels of agreement. The difference between the measures is variable and appears to be more marked when the child reports a higher VAS score. This research raises doubt about whether parental rating of a child's pain is an appropriate surrogate marker in pediatric pain and analgesia research.
Publisher: BMJ
Date: 10-02-2022
DOI: 10.1136/EMERMED-2021-211370
Abstract: Most headache presentations to emergency departments (ED) have benign causes however, approximately 10% will have serious pathology. International guidelines recommend that patients describing the onset of headache as ‘thunderclap’ undergo neuroimaging and further investigation. The association of this feature with serious headache cause is unclear. The objective of this study was to determine if patients presenting with thunderclap headache are significantly more likely to have serious underlying pathology than patients with more gradual onset and to determine compliance with guidelines for investigation. This was a planned secondary analysis of an international, multicentre, observational study of adult ED patients presenting with a main complaint of headache. Data regarding demographics, investigation strategies and final ED diagnoses were collected. Thunderclap headache was defined as severe headache of immediate or almost immediate onset and peak intensity. Proportion of patients with serious pathology in thunderclap and non-thunderclap groups were compared by χ² test. 644 of 4536 patients presented with thunderclap headache (14.2%). CT brain imaging and lumbar puncture were performed in 62.7% and 10.6% of cases, respectively. Among patients with thunderclap headache, serious pathology was identified in 10.9% (95%CI 8.7% to 13.5%) of cases—significantly higher than the proportion found in patients with a different headache onset (6.6% (95% CI 5.9% to 7.4%), p .001.). The incidence of subarachnoid haemorrhage (SAH) was 3.6% (95% CI 2.4% to 5.3%) in those with thunderclap headache vs 0.3% (95% CI 0.2% to 0.5%) in those without (p .001). All cases of SAH were diagnosed on CT imaging. Non-serious intracranial pathology was diagnosed in 87.7% of patients with thunderclap headache. Thunderclap headache presenting to the ED appears be associated with higher risk for serious intracranial pathology, including SAH, although most patients with this type of headache had a benign cause. Neuroimaging rates did not align with international guidelines, suggesting potential need for further work on standardisation.
Publisher: BMJ
Date: 17-10-2014
DOI: 10.1136/EMERMED-2013-202879
Abstract: Blood gas analysis is important for assessment of ventilatory function. Traditionally, arterial analysis has been used. A method for mathematically arterialising venous blood gas values has been developed. Our aim was to validate this method in patients undergoing non-invasive ventilation (NIV) in an emergency department (ED). This post hoc substudy of a prospective cohort study included adult patients undergoing NIV for acute respiratory compromise. When arterial blood gas analysis was required for clinical purposes, a venous s le was also drawn. Mathematically arterialised values were calculated independent of arterial values. Primary outcome of interest was agreement between mathematically arterialised venous and arterial values for pH and pCO2. Bland-Altman agreement plot analysis was used. Eighty s le-pairs (58 patients) were studied. Mean difference for arterial pH (actual-calculated) was 0.01 pH units (95% limits of agreement: -0.04, 0.06). Mean difference for pCO2 (actual-calculated) was -0.06 kPa (95% limits of agreement: -1.34, 1.22). For patients undergoing NIV in an ED, agreement between mathematically arterialised venous values and arterial values was close for pH but only moderate for pCO2. Depending on clinician tolerance for agreement, this method may be a clinically useful alternative to arterial blood gas analysis in the ED.
Publisher: Elsevier BV
Date: 12-2008
DOI: 10.1016/J.RMED.2008.07.026
Abstract: The aim of this study was to compare classification of pneumothoraces into size groups for treatment using the British Thoracic Society [BTS], American College of Chest Physicians [ACCP] and Belgian Society of Pulmonology [BSP] guidelines and the range of pneumothorax sizes in each group calculated using the volumetrically-derived Collins' method. This was a retrospective cohort study. Participants were patients with primary spontaneous pneumothorax [PSP] attending emergency departments of two teaching hospitals between 1996 and 2005. Participants were identified from a pre-existing database. Data collected included demographics, side of PSP and interpleural distances for size classification based on BTS, ACCP, BSP and Collins' method requirements measured on inspiratory X-rays. The outcome of interest was comparison of classification into size groups according to each guideline. Analysis was by descriptive statistics, overall agreement and Kappa analysis for agreement between guideline pairs. Forty-nine episodes [44 patients] were studied. Median age was 22 years 66% of patients were male. Median PSP size [Collins' method inspiratory films] was 24% range 5-100%. Based on inspiratory films, the BTS guideline classified 10% of PSP as large compared with 47% by the BSP guideline and 49% by the ACCP guideline. The three guidelines agreed in their classification in only 47% of cases. Size classification of PSP based on available treatment guideline definitions shows poor agreement. This goes some way to explain management variation between regions and limits comparability of reported outcomes. There is a strong case for international agreement in size classification/estimation in order to facilitate high-quality studies into optimal management approaches.
Publisher: Elsevier BV
Date: 12-2014
DOI: 10.1016/J.HLC.2014.05.014
Abstract: This study aimed to determine the prevalence and differences between Non-ST elevation Myocardial Infarction (NSTEMI) with an occluded culprit artery (NSTEMIOA) and NSTEMI with a patent culprit artery (NSTEMIPA). We conducted a retrospective observational study on NSTEMI patients admitted between 01/01/2010 to 30/06/2010. The inclusion criteria were diagnosis of NSTEMI and inpatient coronary angiogram. Patients were followed up for 12 months. The primary endpoints of interest were the differentiating characteristics between NSTEMIOA and NSTEMIOA. The secondary endpoints of interest were clinical outcomes in 12 months and the effect of delay in percutaneous coronary intervention on the extent of myocardial damage. Of 143 NSTEMI patients, 34 (24%) patients had NSTEMIOA. NSTEMIOA patients had higher rates of hypercholesterolaemia (85.3% vs. 64.2%, p=0.015), ST-depression abnormality on ECGs (32.4% vs. 11.9%, p=0.008), multi-vessel disease on coronary angiogram (76.5% vs. 48.6%, p=0.004) and LV dysfunction on echo (75% vs 48%, p=0.016). At 12 months post-discharge, there was a trend of higher heart failure rate in NSTEMIOA subgroup but otherwise no difference between the two cohorts in death, myocardial infarction, revascularisation, arrhythmia, and re-admission for angina. There was no correlation between the peak CK level and the timing of percutaneous revascularisation in both cohorts. A quarter of NSTEMI patients had an occluded culprit coronary artery. They were more likely to have hypercholesterolaemia, ECG abnormalities, multi-vessel disease and LV dysfunction.
Publisher: Wiley
Date: 11-12-2016
DOI: 10.1111/CRJ.12583
Abstract: Bundles of care are gaining popularity for treating acute severe illness. To describe compliance with bundle of care elements (in idually and as a "bundle") for patients treated for chronic obstructive pulmonary disease (COPD) exacerbations in the emergency department (ED). Retrospective observational study of patients presenting in the 2014 calendar year with an ED diagnosis of COPD. The primary outcomes of interest were compliance with key bundle of care elements (in idually and as a "bundle"). Analysis is descriptive. 381 patients were studied. Median age was 71 (IQR 64-80), 60% were male and 77% arrived by ambulance. Median duration of symptoms was 3 days (IQR 2-6 days). Compliance with the bundle elements was 90% for administration of controlled oxygen therapy (if oxygen given), 87% for administration of inhaled bronchodilators, 79% for administration of systemic corticosteroids, 75% of administration of antibiotics if evidence of infection, 77% for taking of a blood gas in non-mild disease, 98% for taking of a chest X-ray, and 74% for administration of NIV if pH <7.3. Compliance with all appropriate elements of the defined bundle of care was 49%. There was no difference in mean length of stay for admitted patients (P = .44), in-hospital mortality (P = 1.00) or re-admission within 30 days (P = .72) by bundle compliance. Compliance with in idual assessment and treatment recommendations was generally high however, compliance with the overall recommended bundle was only 49%. This indicates that there is an opportunity to improve care in these patients.
Publisher: Wiley
Date: 03-04-2023
Abstract: This research aimed to examine the legal and regulatory obligations of authorities and healthcare professionals in the provision of prison emergency health services and to identify problems in the provision of emergency care to prisoners by using case ex les from coronial findings. Review of legal and regulatory obligations and a search of coronial cases for deaths related to the provision of emergency healthcare in prisons in the past 10 years in Victoria, New South Wales and Queensland. The case review identified several themes – issues with prison authority policies and procedures that delay access to timely healthcare or compromise the quality of care, operational and logistical factors, clinical issues and stigmatic issues including prison staff attitudes to prisoners requesting urgent healthcare assistance. Coronial findings and royal commissions have repeatedly identified deficiencies in the emergency healthcare provided to prisoners in Australia. These deficiencies are operational, clinical and stigmatic and not limited to a single prison or jurisdiction. Applying a health quality of care framework focussed on prevention and chronic health management, appropriate assessment and escalation when urgent medical assistance is requested, and a structured audit framework could avoid future preventable deaths in prisons.
Publisher: Wiley
Date: 09-06-2018
Publisher: Wiley
Date: 25-07-2019
Publisher: Elsevier BV
Date: 02-2007
DOI: 10.1016/J.RESUSCITATION.2006.12.001
Abstract: As part of a health system improvement project, the Republic of Croatia has been conducting a pilot project aimed at rationalizing care delivery across the primary care, hospital and secondary care systems. One component was the development of an emergency department at Dr T Bardek Hospital in Koprivnica and training of its staff. This paper describes how a training programme was conducted, using an established emergency department in Australia as the training host, and the outcome of the project. This type of training programme could form a model for specialist Emergency Medicine training in the future.
Publisher: Wiley
Date: 28-06-2014
DOI: 10.1111/JOCN.12308
Abstract: To explore patients' perspectives of bedside handover by nurses in the emergency department (ED). International guidelines promote standardisation in clinical handover. Poor handover can lead to adverse incidents and expose patients to harm. Studies have shown that nurses and patients have favourable opinions about handover that is conducted at the bedside in hospital wards however, there is a lack of evidence for patients' perspective of nursing handover in the ED environment. Qualitative descriptive study. Semi-structured interviews with 30 ED patients occurred within one hour of bedside handover. Data were analysed using thematic content analysis. Two main themes were identified in the data. First, patients perceive that participating in bedside handover enhances in idual care. It provides the opportunity for patients to clarify discrepancies and to contribute further information during the handover process, and is valued by patients. Patients are reassured about the competence of nurses and continuum of care after hearing handover conversations. Second, maintaining privacy and confidentiality during bedside handover is important for patients. Preference was expressed for handover to be conducted in the ED cubicle area to protect privacy of patient information and for discretion to be used with sensitive or new information. Bedside handover is an acceptable method of performing handover for patients in the ED who value the opportunity to contribute and clarify information, and are reassured that their information is communicated in a private location. From the patients' perspective, nursing handover that is performed at the bedside enhances the quality and continuum of care and maintains privacy and confidentiality of information. Nurses should use discretion when dealing with sensitive or new patient information.
Publisher: Wiley
Date: 12-10-2022
Abstract: To determine characteristics, precipitating circumstances, clinical care, outcome and disposition of patients brought to the ED under section 351 (s351, police detention and transport) powers of the Mental Health Act 2014 (Vic) (MHAV). This is an observational cohort study conducted in two metropolitan teaching hospitals in Victoria. Participants were adult patients brought to ED under s351 of the MHAV. Data collected included demographics, event circumstances, pre‐hospital and ED interventions and outcome. Analyses are descriptive. The present study included 438 patient encounters. Median age was 34 years. In 84% of encounters (368/438) patients were co‐transported with ambulance. The most common primary reason for detainment was suicide risk/intent (296/438, 67.6%) followed by abnormal behaviour without threat to self or others (92/438, 21%). In ED, parenteral sedation was administered in 11% (48/438). Physical restraint was applied in 17.6% (77/438). Psychiatric admission was required in 23.5% (103/438). In 63 cases, psychiatric admission was involuntary (14.4%). Most patients (297/438, 67.8%) were discharged home. A subset of patients had recurrent s351 presentations. Eighteen (5.6%) patients accounted for 22% (96/438) of all events. Most patients brought to ED under s351 of the MHAV had expressed intention to self‐harm, did not require medical intervention and were discharged home. It could be questioned whether the current application of s351 is consistent with the least restrictive principles of the MHAV, especially as there is no apparent monitoring or reporting of the use of these powers. There were a concerning number of patients with multiple s351 events over a short period.
Publisher: Wiley
Date: 04-2002
DOI: 10.1046/J.1444-0903.2001.00197.X
Abstract: Thrombolysis for patients with acute myocardial infarction (AMI) is of greatest benefit when treatment is commenced as soon as possible after symptom onset. The British Heart Foundation (BHF) recently set a benchmark recommending that eligible patients with AMI receive thrombolytic therapy less than 90 min after calling for medical assistance. The purpose of this study was to compare the performance of an urban emergency service to this benchmark. A secondary objective was to determine whether patients treated outside this time were at a greater risk of mortality. This study consisted of an explicit retrospective analysis of medical records for all patients who presented by ambulance to the Emergency Department (ED) of Western Hospital and received thrombolysis for AMI within 12 h of symptom onset. The study was conducted for the 18-month period between 1 January 1999 and 30 June 2000. Information collected included times of: (i) symptom onset, (ii) call for ambulance, (iii) ambulance response, (iv) transport to hospital and (v) thrombolysis, as well as final diagnosis and in-hospital mortality. For the purposes of this study, call-to-needle time (CTN) was defined as the time between calling the ambulance and commencement of thrombolytic therapy. One hundred and twenty-seven patients met the inclusion criteria. Median CTN was 81 min (range 42-279 min). Sixty-four per cent of patients were treated within the 90-min benchmark. The relative risk of mortality for patients treated outside the 90-min benchmark was 2.6 (95% CI 0.98-6.72). This study showed that the BHF benchmark for CTN was not being met for over one-third of patients in the study region, with potential impact on mortality after AMI. Further research is needed to establish: (i) whether there is relationship between longer transportation times and mortality, (ii) whether the findings of this study may be applied to other regions and (iii) what strategies might be employed to reduce CTN.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2010
Publisher: BMJ
Date: 31-12-2014
DOI: 10.1136/EMERMED-2014-204442
Abstract: Recent evidence suggests that an undetectable troponin level at emergency department (ED) presentation can rule out the presence of myocardial infarction (MI) in low-risk patients. The aim of this study was to investigate whether an undetectable troponin I (TnI) level at presentation using a contemporary troponin assay can accurately rule out MI at various front-door thrombolysis in myocardial infarction (fTIMI) score cut-offs. Planned substudy of a prospective observational cohort study of patients presenting to ED with chest pain without ECG evidence of ischaemia who underwent a 'rule out' acute coronary syndrome process. Clinical, investigational and outcome data were collected. A contemporary TnI assay (Siemens TnI Ultra) was used. Primary outcome of interest was diagnostic accuracy for MI of undetectable initial TnI at presentation at various fTIMI scores (sensitivity, specificity, positive predictive value and negative predictive value (NPV)). 1076 patients were studied, of whom 156 had a final diagnosis of MI (14.5%). For patients with undetectable TnI and fTIMI scores 0, 0-1, 0-2 and 0-6, sensitivities were 98.7%, 98.1%, 97.4% and 97.4%, respectively, specificities were 22.6%, 41.7%, 53.8% and 69.9%, respectively, and NPV were 99%, 99.2%, 99.2% and 99.4%, respectively. If early presenters (<2 h of symptoms) were excluded, undetectable initial troponin had 100% sensitivity (95% CI 95.2% to 100%) and NPV (95% CI 98.8% to 100%). Using a contemporary TnI assay, undetectable initial TnI has high but not perfect sensitivity and NPV, unless early presenters are excluded. ACTRN12612000990820.
Publisher: Wiley
Date: 02-2008
DOI: 10.1111/J.1553-2712.2008.00035.X
Abstract: One of the first stages in the development of new clinical decision rules (CDRs) is determination of need. This study examined the clinical priorities of emergency physicians (EPs) working in Australasia, Canada, the United Kingdom, and the United States for the development of future CDRs. The authors administered an e-mail and postal survey to members of the national emergency medicine (EM) associations in Australasia, Canada, the United Kingdom, and the United States. Results were analyzed via frequency distributions. The total response rate was 54.8% (1,150/2,100). The respondents were primarily male (74%), with a mean age of 42.5 years (SD +/- 8), and a mean of 12 years of experience (SD +/- 7). The top 10 clinical priorities (% selected) were: 1) investigation of febrile child < 36 months (62%) 2) identification of central or serious vertigo (42%) 3) lumbar puncture or admission of febrile child < 3 months (41%) 4) imaging for suspected transient ischemic attack (39%) 5) admission for anterior chest pain (37%) 6) computed tomography (CT) angiography for pulmonary embolus (30%) 7) admission for suicide risk (29%) 8) ultrasound for pain or bleeding in the first trimester of pregnancy (28%) 9) nonspecific weakness in elders (26%) and 10) CT for abdominal pain (25%). Between study countries, there was consistency in identification of clinical problems, but variation in prioritization. This international survey identified the s led EPs' priorities for the future development of CDRs. The top priority overall was investigation of the febrile child < 36 months. These results will be valuable to researchers for future development of CDRs in EM that are relevant internationally.
Publisher: Elsevier BV
Date: 03-2007
DOI: 10.1016/J.IJCARD.2006.03.023
Abstract: Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) has a lower success rate than PCI of non-occluded coronary stenosis. Failure to cross the occlusive lesion with a guide wire is the main cause of unsuccessful PCI of a CTO. Multi-imaging modalities may provide valuable information for PCI of CTO. This paper reviews the role of invasive and non-invasive imaging modalities such as intravascular ultrasound, optical coherent reflectometry, CT coronary angiography and cardiac magnetic resonance imaging in facilitating percutaneous coronary intervention of CTO.
Publisher: Wiley
Date: 25-07-2019
Abstract: To describe treatment of children presenting to an Australian ED with a final ED diagnosis of migraine. Planned substudy of a retrospective cohort study of the epidemiology of headache in children was done. Primary outcome of interest was treatment administered in the ED. Thirty-five children were studied. The most commonly used medications were non-steroidal anti-inflammatory drugs, paracetamol and ondansetron. Specific antimigraine therapy was used uncommonly. Fourteen percent of children received an opiate. Treatment of migraine in children was not consistent with the available evidence regarding agents' relative effectiveness. The use of opiates is concerningly high.
Publisher: Springer Science and Business Media LLC
Date: 18-03-2008
Publisher: Wiley
Date: 06-03-2000
Publisher: Wiley
Date: 27-05-2003
Publisher: Springer Science and Business Media LLC
Date: 05-2011
Abstract: The Quebec shoulder dislocation rule is a recently derived clinical decision rule to guide physicians on the selective use of radiography in patients with shoulder dislocation. The aim of this studywas to validate the Quebec shoulder dislocation rule. This was a secondary analysis of data collected in a retrospective cohort study. All patients presenting to the emergency department (ED) between January 1, 2003, and October 31, 2008, with a diagnosis of shoulder dislocation or fracture-dislocation were identified from ED management databases. Data collected included demographics, mechanism of injury, and presence of fracture. The outcome of interest was predictive performance of the Quebec shoulder dislocation rule for patients aged under 40 years on this cohort. Data analysis is descriptive. Of the 346 patients identified, 196 were aged under 40 years, and 174 (89%) were male the median age was 25 years (interquartile range 21–29 years), and 58 were recurrent dislocations. One hundred sixteen patients (59%) met the Quebec high-risk criteria, and 80 (41%) were classified as low risk. In the 196 patients aged less than 40 years, 12 fractures as defined were identified (6%). When applied to this cohort, the Quebec clinical decision rule had a sensitivity of 0.42 (95% CI 0.16–0.71), a specificity of 0.40 (95% CI 0.33–0.47), and a negative predictive value of 0.91 (95% CI 0.82–0.96). The Quebec shoulder dislocation rule had poor sensitivity for clinically significant fractures associated with shoulder dislocations in young patients (aged 16–39 years) presenting to an Australian emergency department. Its use cannot be recommended.
Publisher: Wiley
Date: 08-11-2013
Abstract: Children sometimes require minor procedures in the ED for which sedation is needed. Information from Victorian EDs indicated that processes for paediatric procedural sedation were variable, both within and between health services. The aims of this project were to improve safety and reduce variation in practice with respect to paediatric procedural sedation in EDs by rolling out a standardised paediatric sedation programme in Victorian EDs. The project was managed by a clinical network with support of an expert reference group however, implementation was conducted at the local ED level. The approach was multi-modal and grounded in quality and safety theory. It included revision of evidence-based training materials, information sheets and risk assessment rocedure documentation forms, information on a child and family-centred approach, a before-and-after clinical governance assessment, and train-the-trainer activities. The project was evaluated by clinical audit of cases, analysis of before-and-after clinical governance assessments, numbers of staff completing training and credentialing, and qualitative feedback on the programme from ED staff. Fourteen EDs completed the project 10 metropolitan and four regional/rural. Significant shifts in nine key clinical governance items were found, including structured training and credentialing, provision of parent information sheet, and monitoring of adverse events. The clinical audit showed >75% compliance, with seven indicators including recording of weight, fasting time and baseline observations, composition of sedation team, and documentation that discharge criteria were met. Nine hundred and seventy-one staff were trained within the project period. This multi-modal implementation strategy has achieved clinical practice improvement across organisational boundaries.
Publisher: S. Karger AG
Date: 2022
DOI: 10.1159/000520548
Abstract: b i Background and Aim: /i /b Migraine headache is commonly diagnosed in emergency departments (ED). There is relatively little real-world information about the epidemiology, investigation, management, adherence to therapeutic guidelines and disposition of patients treated in ED with a final diagnosis of migraine. The primary aim of the current study is to get a snapshot of assessment and management patterns of acute migraine presentations to the different settings of EDs with a view to raise awareness. b i Methods: /i /b This is a planned sub-study of a prospective study conducted in 67 health services in 10 countries including Australia, New Zealand, Southeast Asia, Europe, and the UK investigating the epidemiology and outcome of adult patients presenting to ED with nontraumatic headache. Outcomes of interest for this study are demographics, clinical features (including severity), patterns of investigation, treatment, disposition, and outcome of patients diagnosed as having migraine as their final ED diagnosis. b i Results: /i /b The cohort comprises 1,101 patients with a mean age of 39 years (SD ± 13.5 73.7% [811]) were female. Most patients had had migraine diagnosed previously (77.7%). Neuroimaging was performed in 25.9% with a very low diagnostic yield or significant findings (0.07%). Treatment of mild migraine was in accordance with current guidelines, but few patients with moderate or severe symptoms received recommended treatment. Paracetamol (46.3%) and nonsteroidal anti-inflammatory drugs (42.7%) were the most commonly prescribed agents. Metoclopramide (22.8%), ondansetron (19.2%), chlorpromazine (12.8%), and prochlorperazine (12.8%) were also used. b i Conclusions: /i /b This study suggests that therapeutic practices are not congruent with current guidelines, especially for patients with severe symptoms. Efforts to improve and sustain compliance with existing management best practices are required.
Publisher: Elsevier BV
Date: 02-2011
DOI: 10.1016/J.RMED.2010.11.010
Abstract: Transcutaneous carbon dioxide (PtCO(2)) monitoring offers a potentially non-invasive and continuous means to determine the arterial carbon dioxide tension (PaCO(2)). ED studies of agreement between PtCO(2) and PaCO(2) have had conflicting findings and have not been targeted to subgroups with severe ventilatory disturbance such as those requiring non-invasive ventilation [NIV]. Our aim is to determine agreement between PtCO(2) and PaCO(2) for patients undergoing NIV for respiratory failure. This prospective observational study included a convenience s le of patients undergoing NIV for respiratory failure who required arterial blood gas analysis as part of their care. Data collected included patient demographics, indication for NIV, diagnosis, vital signs, and pH, PaCO(2) and PtCO(2). The outcome of interest was agreement between PaCO(2) and PtCO(2). Analysis was made using descriptive statistics, Bland-Altman techniques, Mann-Whitney U test and Fisher/Chi square tests. 46 comparisons were analysed. Median age was 69 [IQR 65-79], 67% male median PaCO(2) 60 mmHg [IQR 46-70] and median pH 7.35 [IQR 7.30-7.38]. Average difference between PaCO(2) and PtCO(2) was 6.1 mmHg with 95% limits of agreement -10.1-22.3 mmHg. Thirty seven comparisons [80%] were within 10 mmHg [95% CI 66-90%]. Difference >10 mmHg was associated with increasing PaCO(2) [p = 0.001 median difference 19.6 mmHg, 95% CI 9.2-30.4 mmHg]. All cases with difference >10 mmHg had PaCO(2) > 60 mmHg. In patients undergoing NIV, agreement between PaCO(2) and PtCO(2) was sub-optimal, with unacceptably wide 95% limits of agreement. PtCO(2) cannot be recommended as a substitute for PaCO(2) testing in this group.
Publisher: BMJ
Date: 31-12-2014
DOI: 10.1136/EMERMED-2014-204326
Abstract: Blood gas analysis is an integral part of the assessment of emergency department (ED) patients with acute respiratory or metabolic disease. Traditionally ABG analyses have been used, but increasingly, emergency clinicians are using venous blood gas (VBG) analyses. This has been challenged, especially by respiratory physicians, as being too inaccurate. This clinical review, using case ex les, summarises the evidence supporting use of VBG to guide management decisions. Arteriovenous agreement for pH is such that values are clinically interchangeable and agreement for bicarbonate is also close. Agreement for pCO2 is poor with 95% limits of agreement of the order of 20 mm Hg (2.67 kPa) however, there is solid evidence that a venous pCO2 ≤45 mm Hg (6 kPa) reliably excludes clinically significant hypercarbia. Evidence regarding arteriovenous agreement for base excess is unclear. Given knowledge of the performance characteristics of VBG analyses, integration of the clinical findings with VBG results is often sufficient to safely guide treatment decision making.
Publisher: Wiley
Date: 27-04-2017
Publisher: Wiley
Date: 12-2011
Publisher: Wiley
Date: 03-01-2023
Abstract: Paediatric forearm fractures are common. Anecdotally, there is a trend towards ED reduction of selected fractures under procedural sedation. We aimed to determine the rate of subsequent operative intervention for fracture re‐displacement. Retrospective observational study of children with a forearm/wrist fracture undergoing fracture reduction in ED. Outcome of interest was operative intervention for fracture re‐displacement within 6 weeks. Among 176 patients studied, operative intervention occurred in nine patients (5.1%, 95% confidence interval 2.7–9.4%). Reduction of paediatric forearm fractures under procedural sedation by ED clinicians is increasingly common and results in a low rate of subsequent operative intervention.
Publisher: BMJ
Date: 06-1996
DOI: 10.1136/IP.2.2.98
Abstract: Despite the widespread promotion of safety standards no epidemiological studies have adequately evaluated their effectiveness in preventing injury in falls from playground equipment. This study evaluated the effectiveness of the height and surfacing requirements of the New Zealand standard for playgrounds and playground equipment. Early childhood education centres and schools in two major cities in the South Island of New Zealand. Data were collected on 300 children aged 14 years or less who had fallen from playground equipment. Of these, 110 (cases) had sustained injury and received medical attention, while 190 (controls) had not sustained injury requiring medical attention. Logistic regression models fitted to the data indicated that the risk of injury being sustained in a fall was increased if the equipment failed to comply with the maximum fall height (odds ratio (OR) = 3.0 95% confidence interval (CI) 0.7 to 13.1), surfacing (OR = 2.3 95% CI 1.0 to 5.0), or safe fall height (OR = 2.1 95% CI 1.1 to 4.0) requirements. Falls from heights in excess of 1.5 metres increased the risk of injury 4.1 times that of falls from 1.5 metres or less and it was estimated that a 45% reduction in children attending emergency departments could be achieved if the maximum fall height was lowered to 1.5 metres. Although the height and surfacing requirements of the New Zealand standard are effective in preventing injury in falls from playground equipment, consideration should be given to lowering the maximum permissible fall height to 1.5 metres.
Publisher: Wiley
Date: 27-01-2021
Abstract: Some emergency medicine research, especially retrospective studies using medical records review, rely on waiver of consent for use of personal health information (PHI) contained in clinical records. This is a secondary use of PHI and waiver of consent raises ethical, legal and practical issues. Granting of a waiver of consent is often (but not always) approved by a human research ethics committee and requires separate but inter‐related consideration of the legal and ethical issues. In part, this involves a balancing of the public interest versus the risk to privacy and an evaluation of whether subjects would, mostly likely, have agreed to the use of their PHI had they been asked. To date, there are no robust data about whether use of PHI without consent for research would be acceptable to people who attend Australasian EDs for care.
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: Wiley
Date: 02-2010
Publisher: Wiley
Date: 31-10-2003
Publisher: Wiley
Date: 10-2013
Publisher: Wiley
Date: 17-03-2022
Abstract: Expert evidence plays a central role in establishing the relevant standard of care in medical litigation. In Australia, little is known about the expert witnesses who provide evidence about the standard of care provided in ED. A s le of recent published case law suggests that a proportion of expert evidence about breach of the standard of reasonable care in ED is provided by medical practitioners who are not emergency physicians and/or have no recent practice experience in an ED. This may potentially distort the identification of the relevant standard of care. In the United States, the American College of Emergency Physicians has attempted to address this issue by developing and promulgating expert witness guidelines. Is there a case for the Australasian College for Emergency Medicine to assume an advocacy role and/or develop standards in this area?
Publisher: Wiley
Date: 14-02-2012
DOI: 10.1111/J.1742-6723.2012.01536.X
Abstract: To investigate the prognostic utility of Heart Foundation (Australia) risk stratification table in an ED chest pain population. A planned sub-study of a prospective observational study of adult patients with potentially cardiac chest pain who underwent evaluation for acute coronary syndrome (ACS) was conducted. Data collected included demographical, clinical, ECG, biomarker and outcome data. Outcome of interest was diagnostic utility of the classification system for ACS or myocardial infarction (MI) at index presentation and major adverse cardiac events (MACE) within 7 and 30 days. MACE included death, cardiac arrest, revascularization, cardiogenic shock, arrhythmia and prevalent (cause of presentation) and incident (occurring within the follow-up period) MI. Analysis was by descriptive and receiver-operator curve analyses. Seven hundred and sixty-eight patients were studied 109 had MI (14.2%, 95% confidence interval [CI] 11.9-16.8%). There were 88 MACE at 7 days (13.5%, 95% CI 11.1-16.4%) and 93 MACE at 30 days (14.4%%, 95% CI 11.9-17.3%). Diagnostic performance (c-statistic) of the National Heart Foundation risk classification for ACS, MI, 7 and 30 day MACE was 0.74 for each (95% CI 0.71-0.77). Although sensitivity of the high-risk classification for MI, 7 and 30 day MACE was high (99-100%), specificity was low (48-50%). The Heart Foundation risk classification shows only fair predictive performance for MI, 7 and 30 day MACE. With specificity of approximately 50%, the recommendation for coronary care admission for all high-risk patients is hard to justify.
Publisher: BMJ
Date: 02-2017
Publisher: Wiley
Date: 03-08-2020
Publisher: Informa UK Limited
Date: 02-2005
DOI: 10.1080/09603120400018717
Abstract: In recent years childhood asthma has increased. Although the precipitants of childhood asthma are yet to be established possible contributing factors are local ambient air pollutants. This study aims to assess associations of regional ambient air pollutants on emergency department childhood asthma presentations across four regions of the city of Melbourne, Australia. Daily emergency department (ED) presentations for asthma in children were studied for the years 2000 and 2001. Estimates of local air pollutant levels were obtained using simulation modelling techniques. Generalized Additive Models were used to examine associations between combined local levels of air pollutants and childhood asthma ED presentations adjusting for seasonal variation, day of week effects, and meteorological variables. There was consistent associations between childhood ED asthma presentations and regional concentration of PM10, with a strongest association of RR = 1.17 (95% CI 1.05 to 1.31) in the central district of Melbourne. NO2 and Ozone was associated with increased childhood asthma ED presentations in the Western districts. This study suggests that regional concentrations of PM10 may have a significant effect on childhood asthma morbidity. In addition, ozone may play a role however, its effect may vary by geographical region.
Publisher: Wiley
Date: 06-07-2020
Publisher: Wiley
Date: 19-12-2020
Abstract: For seriously ill children, weight is often required to direct critical interventions. As it is not always feasible to measure weight in emergencies, age-based weight prediction formulae may be used as an alternative. The Best Guess formulae, derived in Australia, have been shown to be among the most accurate age-based methods in Australian children. They were validated in 2010. The present study aims to re-validate the Best Guess formulae and compare their performance to the previous validation cohort. A prospective observational study was conducted in the paediatric ED of a community teaching hospital. It included a convenience s le of children aged 1 month to 10 years who presented between July 2018 and April 2019. Seriously ill children were excluded. Data collected included measured weight, height, gender, age and ethnic group. The outcomes of interest were predictive performance of Best Guess formulae and comparison of predictive accuracy with a 2005 cohort from the same ED. A total of 961 patients were included 42% girls, median age 3 years. The s le was ethnically erse. Mean percent difference in weight was -3.3% with the formulae usually over-estimating weight. Overall, agreement within 10% was 41.8% agreement within 20% was 72.6%. Predictive accuracy was not significantly different between the cohorts. The Best Guess method has not reduced in accuracy as a weight estimation method in emergent situations in this Australian cohort, despite a tendency to slightly over-estimate children's weight. Further study is needed to test the Best Guess method's accuracy in ethnic subgroups.
Publisher: Wiley
Date: 14-11-2007
DOI: 10.1111/J.1742-6723.2007.01025.X
Abstract: A new method for estimation of weight in children based on their age has been proposed. The present study aims to validate the Best Guess formulae in a new population of children. This was a secondary analysis of a database collected for a prospective, observational, cohort study conducted in the Paediatric ED of Sunshine Hospital. Children aged 1-11 years who presented to the ED between 18 August 2005 and 25 February 2006 were included. Actual weight, height, age and ethnicity were obtained. Agreement between estimated weight using the Best Guess formulae and measured weight is reported using mean bias, 95% limits of agreement and proportion within 20% of actual weight. A total of 410 cases were included in the present study. Forty-six per cent were female and median age was 4 years. The mean bias in the 1-5 year group was 0.9 kg, with 95% limits of agreement -3.5 to +5.3 kg. Seventy-six per cent of estimations were within 20% of measured weight. The mean bias in the 5-11 year group was 0.4 kg, with 95% limits of agreement -14.4 to +15.2 kg. In this group, 64% of estimations were within 20% of measured weight. The Best Guess formulae performed moderately well in estimating children's weight, but had a tendency to overestimate weight, particularly in children with lower body mass index.
Publisher: Elsevier BV
Date: 08-2004
DOI: 10.1016/J.RMED.2004.01.008
Abstract: To determine if severity assessment after 1 h of treatment is better than assessment at presentation for predicting the requirement for hospital admission for emergency department (ED) patients with acute asthma. Prospective, observational study conducted in 36 Australian ED for a 2-week period in 2001 involving patients aged 1-55 years presenting with asthma. Data collected included severity assessment according to the National Asthma Guidelines (Australia) at presentation and 1 h, and disposition. Descriptive analysis was applied. 720 cases were analysed. Patients with 'mild' asthma at either assessment time had a greater than 80% chance of discharge home. Patients assessed as 'severe' at either assessment had a greater than 85% chance of requiring hospital admission, but the 1 h assessment was better at predicting the need for Intensive Care Unit (ICU) admission. For the 'moderate' group, the initial assessment was a poor predictor of the need for admission however those who met the criteria for 'moderate' severity at 1 h had an 84% chance of requiring admission. Assessment of asthma severity after 1 h of treatment is better than initial severity assessment for determining the need for hospital admission for patients initially assessed as having 'moderate' asthma and for predicting the need for ICU in patients initially assessed as 'severe'.
Publisher: Elsevier BV
Date: 05-2005
DOI: 10.1016/J.JEMERMED.2004.10.017
Abstract: To validate a previously derived venous pCO2 (pvCO2) cut-off for ruling out arterial hypercarbia in patients with chronic obstructive pulmonary disease (COPD), matched arterial and venous blood gas s les were taken from a convenience s le of patients who presented to the Emergency Department (ED) with COPD deemed by their treating doctor to require arterial blood gas (ABG) analysis as part of their care. The screening cut-off was defined as pvCO2 of > 45 mm Hg and arterial hypercarbia was defined as arterial pCO2 (paCO2) of > 50 mm Hg. Descriptive statistics were employed. Sensitivity, specificity and negative predictive value were calculated. There were 112 patients enrolled in the study, of whom 107 had complete data for analysis. Forty-three patients had arterial hypercarbia (range of 51 to 90 mm Hg, median 60 mm Hg). All cases of arterial hypercarbia were detected by the screening cut-off (sensitivity 100% 43/43 95% CI 91-100% specificity 47%, 95% CI 35-59%). The negative predictive value of pvCO2 < 45 mm Hg was 100% (30/30, 95% CI 89-100%). Assuming the ABG was performed to assess hypercarbia, 29% of ABGs potentially could have been avoided if a venous screening test was employed. In conclusion, pvCO2 can be used as a screening test for arterial hypercarbia, and if employed, can potentially reduce the requirement for ABG s ling.
Publisher: Wiley
Date: 05-12-2018
Publisher: Wiley
Date: 12-2000
Publisher: Wiley
Date: 2008
DOI: 10.1111/J.1445-5994.2007.01540.X
Abstract: There are a several published guidelines recommending treatment pathways for patients with primary spontaneous pneumothorax (PSP). Little is known about how these patients are actually treated in Australia. The aim of this study was to establish treatment patterns for Australian patients with PSP. This was a multicentre retrospective observational study conducted at 19 emergency departments across Australia of adult patients with PSP presenting in the calendar year 2005. In Australia, there is considerable deviation from published guidelines for the management of PSP. In light of the lack of high-quality evidence to assist in choosing treatment approaches, a randomized controlled trial of management strategies is recommended.
Publisher: BMJ
Date: 24-11-2009
Abstract: The aims of this study were to compare the estimated size of primary spontaneous pneumothorax (PSP) calculated on inspiratory and expiratory radiographs using the volumetrically derived Collins method and to determine whether radiograph type influences size classification for treatment according to published guidelines. This retrospective cohort study included patients treated for PSP in the emergency departments of two metropolitan teaching hospitals. Data collected included patient demographics and interpleural distances required to calculate pneumothorax size by the Collins method and to classify PSP according to guidelines. The outcomes of interest were the difference in size estimate between radiograph types and agreement in size classification for treatment according to guidelines. Analysis is by bias-plot analysis, kappa analysis and descriptive statistics. A total of 49 pneumothoraces (44 patients) were studied. Median age was 22 years 66% were men. Median PSP size on inspiratory radiographs was 24% (IQR 14% to 31%, range 5% to 100%). The average size difference between expiratory and inspiratory films was 9%, with size on expiratory radiographs being larger. The 95% limits of agreement were wide (-5% to 23%). For each guideline, size estimation on expiratory rather than inspiratory radiographs would have suggested a change in treatment for an additional seven patients (14%, 95% CI 7% to 27%). On average, PSP size calculated on expiratory radiographs is 9% higher than that calculated on matched inspiratory radiographs. Applying current management guidelines, the size difference between inspiratory and expiratory x-rays may alter initial treatment recommendation for some patients.
Publisher: Wiley
Date: 12-2010
DOI: 10.1111/J.1742-6723.2010.01344.X
Abstract: The objectives of the present review are to describe the agreement between variables on arterial and venous blood gas analysis (in particular pH, pCO(2) , bicarbonate and base excess) and to identify unanswered questions. MEDLINE search of papers published from 1966 to January 2010 for studies comparing arterial and peripheral venous blood gas values for any of pH, pCO(2) , bicarbonate and base excess in adult patients with any condition in an emergency department setting. The outcome of interest was mean difference weighted for study s le size with 95% limits of agreement. The weighted mean arterio-venous difference in pH was 0.035 pH units (n= 1252), with narrow limits of agreement. The weighted mean arterio-venous difference for pCO(2) was 5.7 mmHg (n= 760), but with 95% limits of agreement up to the order of ±20 mmHg. For bicarbonate, the weighted mean difference between arterial and venous values was -1.41 mmol/L (n= 905), with 95% limits of agreement of the order of ±5 mmol/L. Regarding base excess, the mean arterio-venous difference is 0.089 mmol/L (n= 103). There is insufficient data to determine if these relationships persist in shocked patients or those with mixed acid-base disorders. For patients who are not in shock, venous pH, bicarbonate and base excess have sufficient agreement to be clinically interchangeable for arterial values. Agreement between arterial and venous pCO(2) is too poor and unpredictable to be clinically useful as a one-off test but venous pCO(2) might be useful to screen for arterial hypercarbia or to monitor trends in pCO(2) for selected patients.
Publisher: BMJ
Date: 19-04-2013
Publisher: Wiley
Date: 12-2009
DOI: 10.1111/J.1553-2712.2009.00581.X
Abstract: The objective was to describe the association between verbal descriptors of nausea severity and visual analog scale (VAS) ratings in an undifferentiated emergency department (ED) population and to calculate the minimum clinically significant difference (MCSD) in VAS rating of nausea severity in this population. A prospective observational study was conducted at three EDs on a convenience s le of stable, consenting adult patients presenting with nausea as part of their symptom complex. Data included demographics, adjectival description of nausea severity (none, mild, moderate, or severe), and VAS rating (standard 100-mm line) at enrollment, 30 minutes, and 60 minutes. At 30 and 60 minutes they were also asked to describe any change in nausea severity from the previous rating ("a lot less,""a little less,""the same,""a little more,""a lot more"). The MCSD was defined as the average VAS change when a patient reported "a little less" or "a little more" nausea. A total of 247 patients provided 693 matched adjectival ratings and VAS scores. Median age was 45 years, and 100 (40%) were male. The median VAS measures for none, mild, moderate, and severe nausea were 2, 23, 53, and 83 mm, respectively. VAS distributions in the verbal categories were statistically different from each other (Spearman rank correlation coefficient = 0.90 p < 0.0001). The MCSD was 22 mm (95% CI = 20 to 24 mm). There is very good correlation between verbal descriptors of nausea and VAS ratings. The MCSD for VAS nausea ratings in an ED population is 22 mm.
Publisher: BMJ
Date: 09-2004
Publisher: Elsevier BV
Date: 06-2009
DOI: 10.1016/J.AJEM.2008.04.003
Abstract: The aim of this study was to establish the impact of patient sex on the provision of analgesia by paramedics for patients reporting pain in the prehospital setting. This retrospective cohort study of paramedic patient care records included all adult patients with a Glasgow Coma Score higher than 12 transported to hospital by ambulance in a major metropolitan area over a 7-day period in 2005. Data collected included demographics, patient report of pain and its type and severity, provision of analgesia by paramedics, and type of analgesia provided. The outcomes of interest were sex differences in the provision of analgesia. Data analysis was by descriptive statistics, chi2 test, and logistic regression. Of the 3357 patients transported in the study period, 1766 (53%) reported pain this forms the study s le. Fifty-two percent were female, median age was 61 years, and median initial pain score (on a 0-10 verbal numeric rating scale) was 6. Forty-five percent of patients reporting pain did not receive analgesia (791/1766) (95% confidence interval [CI], 43%-47%), with no significant difference between sexes (P = .93). There were, however, significant sex differences in the type of analgesia administered, with males more likely to receive morphine (17% 95% CI, 15%-20%) than females (13% 95% CI, 11%-15%) (P = .01). The difference remains significant when controlled for type of pain, age, and pain severity (odds ratio, 0.61, 95% CI, 0.44-0.84). Sex is not associated with the rate of paramedic-initiated analgesia, but is associated with differences in the type of analgesia administered.
Publisher: Wiley
Date: 13-05-2007
DOI: 10.1111/J.1742-6723.2007.00966.X
Abstract: Incidence of life threatening arrhythmia for patients who present to the ED with low-risk chest pain (CP) (non-ischaemic electrocardiograms and normal cardiac marker profiles) is rare. These patients are often transported with cardiac monitoring by nurse escort from the ED. We aimed to show that this group of patients are at low risk of experiencing life-threatening arrhythmia disturbances. This was a prospective, observational study of ED low-risk CP patients who presented in the period September 2005 and March 2006 and were transported with cardiac monitoring. Data were collected via chart review, and nurse escorts prospectively documented transport details. The primary study outcome was the development of a life threatening arrhythmia requiring treatment during transport from the ED. Data analysis included descriptive statistics and interrater agreement. During the study period there were 231 patients admitted to monitored beds from the ED, of whom 170 (74%) were low risk and enrolled in the study. No patient sustained an adverse event during transport from the ED (0% 95% confidence interval 0-2.2%). Mean (+/-SD) time required for nurse escort to and from the radiology department and coronary care unit was 9.0 (+/-3.1) and 16 (+/-6.5) min, respectively. CP patients who present to the ED with normal electrocardiograms and cardiac marker profiles are at low risk (<1%) of experiencing an adverse event during transport from the ED. This subset of patients might not require cardiac monitoring or nurse escort during transportation from the ED.
Publisher: Wiley
Date: 02-08-2022
DOI: 10.5694/MJA2.51670
Publisher: Springer Science and Business Media LLC
Date: 07-02-2014
Abstract: Appropriate disposition of emergency department (ED) patients with chest pain is dependent on clinical evaluation of risk. A number of chest pain risk stratification tools have been proposed. The aim of this study was to compare the predictive performance for major adverse cardiac events (MACE) using risk assessment tools from the National Heart Foundation of Australia (HFA), the Goldman risk score and the Thrombolysis in Myocardial Infarction risk score (TIMI RS). This prospective observational study evaluated ED patients aged ≥30 years with non-traumatic chest pain for which no definitive non-ischemic cause was found. Data collected included demographic and clinical information, investigation findings and occurrence of MACE by 30 days. The outcome of interest was the comparative predictive performance of the risk tools for MACE at 30 days, as analyzed by receiver operator curves (ROC). Two hundred eighty-one patients were studied the rate of MACE was 14.1%. Area under the curve (AUC) of the HFA, TIMI RS and Goldman tools for the endpoint of MACE was 0.54, 0.71 and 0.67, respectively, with the difference between the tools in predictive ability for MACE being highly significant [chi 2 (3) = 67.21, N = 276, p 0.0001]. The TIMI RS and Goldman tools performed better than the HFA in this undifferentiated ED chest pain population, but selection of cutoffs balancing sensitivity and specificity was problematic. There is an urgent need for validated risk stratification tools specific for the ED chest pain population.
Publisher: Elsevier BV
Date: 08-2000
DOI: 10.1016/S0736-4679(00)00219-5
Abstract: The aim of this study was to correlate patient satisfaction with pain management in the Emergency Department (ED) with initial and discharge visual analog scale (VAS) pain score, verbal pain rating at discharge, and change in VAS pain score between presentation and discharge. It was conducted as a prospective observational study of patients who presented to an urban, adult ED experiencing pain and who were later discharged. Fifty-four patients completed the study of whom 70% rated the management of their pain as 'good' or 'very good.' There was no correlation between patient satisfaction with pain management initial VAS pain score, discharge VAS pain score, verbal rating of pain at discharge, or change in VAS pain score between presentation and discharge. The study suggests that patient satisfaction with pain management does not correlate with initial or discharge VAS pain score, verbal rating of pain at discharge or change in pain score in the ED. Therefore, information about the quality of analgesia provided in an ED cannot be inferred from patient satisfaction surveys.
Publisher: BMJ
Date: 03-09-2011
Publisher: Wiley
Date: 10-2011
Publisher: Wiley
Date: 10-2023
DOI: 10.1111/IMJ.16243
Publisher: Wiley
Date: 02-09-2019
Abstract: Whole body computed tomography (WBCT) scanning for trauma has gained popularity but its role in low-risk patients is controversial. We aimed to determine the rate of serious axial/truncal injury and emergency intervention in conscious, stable patients undergoing WBCT for blunt trauma in two non-trauma centre EDs in the Victorian trauma system. Retrospective cohort study by medical record and radiology report review. Patients were included if they were conscious, haemodynamically stable adults presenting by ambulance and having WBCT scan. Exclusion criteria were age <16 years, no history of trauma, Glasgow Coma Scale <14, systolic blood pressure <90 mmHg and intoxication with alcohol or drugs. Data collected included demographics, clinical findings, results of CT scans and emergency interventions (emergency truncal surgery, transfer to a trauma centre and/or transfusion within 24 h). The outcomes of interest were the rate of defined serious axial/truncal injury and emergency interventions. One hundred and four patients were studied. Median age was 45 years 67% were men. Median injury severity score (ISS) was 1.5 (interquartile range 0-5) only one patient had an ISS ≥15. Ninety (87%, 78-92%) patients had no defined serious injury. Five (5%) patients had a defined emergency intervention - four trauma centre transfers and one transfusion. Two of these were not trauma-related. The rate of serious axial/truncal injury was low. The high rate of normal scans makes it likely that the risk:benefit ratio between injury identification and radiation related cancer risk is unacceptably high. This data supports a selective CT strategy in low-risk trauma patients.
Publisher: Wiley
Date: 02-12-2021
Publisher: Elsevier BV
Date: 09-1994
DOI: 10.1016/0736-4679(94)90408-1
Abstract: This study on low contamination wounds was conducted to compare the pain of local infiltration anaesthesia administered into the skin surrounding the wound with administration directly into the incised edges of the wound. Eighty-one adult patients were randomized by date of presentation to receive infiltration anesthesia by one of the two methods. Pain of anesthetic administration was rated on a visual analogue scale and recorded as a pain score in millimeters. The results demonstrated that the average pain score for infiltration into the wound was significantly lower than the average pain score for infiltration into skin surrounding the wound.
Publisher: Wiley
Date: 05-02-2008
DOI: 10.1111/J.1360-0443.2007.02097.X
Abstract: This paper reviews available literature regarding the effectiveness, safety and utility of intranasal (i.n.) naloxone for the treatment of heroin overdose. Scientific literature in the form of published articles during the period January 1984 to August 2007 were identified by searching several databases including Medline, Cinahl and Embase for the following terms: naloxone, narcan, intranasal, nose. The data extracted included study design, patient selection, numbers, outcomes and adverse events. Reports of the pharmacological investigation and administration of i.n. naloxone for heroin overdose are included in this review. Treatment of heroin overdose by administration of i.n. naloxone has been introduced as first-line treatment in some jurisdictions in North America, and is currently under investigation in Australia. Currently there is not enough evidence to support i.n. naloxone as first-line intervention by paramedics for treatment of heroin overdose in the pre-hospital setting. Further research is required to confirm its clinical effectiveness, safety and utility. If proved effective, the i.n. route may be useful for drug administration in community settings (including peer-based administration), as it reduces risk of needlestick injury in a population at higher risk of blood-borne viruses. Problematically, naloxone is not manufactured currently in an ideal form for i.n. administration.
Publisher: Wiley
Date: 09-09-2013
Abstract: It has been suggested that blood cultures drawn from vascular catheters have a higher false positive rate than those drawn by venepuncture. In the face of institutionally imposed practice change prohibiting obtaining blood cultures from intravenous (i.v.) catheters in the ED, our aim of was to compare the rate of contaminated blood cultures between those taken from recently placed i.v. catheters and those taken by direct venepuncture. Prospective, non-randomised, observational study comparing the rate of contaminated blood cultures for specimens taken from recently placed (<1 h) i.v. catheters and direct venepuncture in adult ED patients. Outcome of interest was the rate of false positive cultures. Analysis was by comparison of proportions (χ(2) -test). Four hundred seventy-two blood culture sets were studied. There were 65 positive cultures, of which 49 (75% 95% confidence interval [CI], 63-85%) were classified as true positive. The overall rate of contaminated blood cultures was 3.4% (95% CI, 2.0-5.6%). There was no difference in false positive rate between blood cultures taken via venepuncture and those taken from a recently placed i.v. cannula (P = 0.52 odds ratio, 0.9 95% CI, 0.33-2.44). We found no difference in contaminated blood culture rate between recently placed i.v. catheters and direct venepuncture when infection control procedures were followed.
Publisher: Wiley
Date: 26-03-2007
DOI: 10.1197/J.AEM.2006.12.009
Abstract: An estimate of a child's weight is required for critical interventions, particularly pharmacotherapy. Weight measurement is not always practical, so weight estimation methods are used. Recently, a new weight estimation formula was suggested. The Argall formula estimates weight in kilograms as follows: (age in years + 2) x 3. To validate the Argall weight formula. This was a prospective, observational, cohort study conducted in the pediatric emergency department (ED) of Sunshine Hospital. Children aged up to 11 years who presented to the ED during August 18, 2005, to February 25, 2006, were included. Actual weight, height, age, and ethnicity were obtained. Data were analyzed by descriptive statistics (proportion, mean, median, and SD). Agreement between estimated weight using the Argall formula and measured weight is reported by using mean bias, SD, and root mean square error (RMSE) analysis. Four hundred ten cases were included, 46% were female, and the median age was 4 years. The Argall formula had a mean bias of -1.66 kg and RMSE of 5.65. Only 37% of Argall estimates were within 10% of the child's actual weight. The formula performed less well in children weighing more than 35 kg but performed better in Asian children than white children. The Argall weight estimation formula has poor accuracy for weight estimation in Australian children, in particular those weighing more than 35 kg.
Publisher: Wiley
Date: 16-01-2023
Publisher: Wiley
Date: 08-02-2011
DOI: 10.1111/J.1742-6723.2011.01388.X
Abstract: Troponin assays have high diagnostic value for myocardial infarction (MI), but sensitivity has been weak early after chest pain onset. New, so-called 'sensitive' troponin assays have recently been introduced. Two studies report high sensitivity for assays taken at ED presentation, but studied selected populations. Our aim was to evaluate the diagnostic performance for MI of a sensitive troponin assay measured at ED presentation in an unselected chest pain population without ECG evidence of ischaemia. This is a sub-study of a prospective cohort study of adult patients with potentially cardiac chest pain who underwent evaluation for acute coronary syndrome. Patients with clear ECG evidence of acute ischaemia or an alternative diagnosis were excluded. Data collected included demographic, clinical, ECG, biomarker and outcome data. A 'positive' troponin was defined as >99th percentile of the assay used. MI diagnosis was as judged by the treating cardiologist. The outcomes of interest were sensitivity, specificity and likelihood ratios (LR) for positive troponin assay taken at ED presentation. Data were analysed by clinical performance analysis. Totally 952 were studied. Median age was 61 years 56.4% were male and median TIMI score was 2. There were 129 MI (13.6, 95% CI 11.5-15.9). Sensitivity of TnI at ED presentation was 76.7% (95% CI 68.5-83.7%), specificity 93.6% (95% CI 91.7-95.1%), with LR positive 11.92 and LR negative 0.25. Sensitive TnI assay at ED presentation has insufficient diagnostic accuracy for detection of MI. Serial biomarker assays in patients with negative initial TnI are required.
Publisher: Wiley
Date: 06-2002
DOI: 10.1046/J.1442-2026.2002.00309.X
Abstract: To determine the most effective cut-off of TRISS-derived probability of survival (TRISS-PS) for the selection of trauma deaths for audit, using a large s le of trauma deaths from the United Kingdom (UK). TRISS-PS and avoidability of death (as judged by an independent peer review panel) were compared for a s le of 222 trauma deaths. Sensitivity, specificity and predictive values were calculated for the 0.5 screening cut-off. ROC curves were derived to assess the ability of different levels of TRISS-PS to identify avoidable deaths. Calculations were made for both the raw s le and the s le adjusted for the s ling method used. For the weight-adjusted s le, the sensitivity of TRISS-PS greater than 0.5 for the detection of avoidable death is 80% (95% CI 61-91%), the specificity is 86% (95% CI 80-90%), PPV 42% (95% CI 29-56%) and NPV 97% (95% CI 93-99%). Twenty percent of avoidable deaths would have been 'missed' if the 0.5 level of audit filter had been used. Based on the same s le, the best cut-off is at TRISS-PS 0.33, with a sensitivity of 90% and specificity of 80%. It is estimated that this cut-off would have selected 62 deaths for audit and failed to identify 2 out of 25 avoidable deaths. The previously accepted audit filter of TRISS-PS of greater than 0.5 fails to identify a significant proportion of avoidable deaths. This study suggests that the most effective level of audit filter cut-off of TRISS-PS for the trauma system studied is 0.33. This level would identify 90% of avoidable deaths with 80% specificity. Similar ROC curve analysis could be used to determine appropriate TRISS-PS cut-offs for institutions or other trauma systems.
Publisher: Headache Medicine
Date: 31-03-2023
DOI: 10.48208/HEADACHEMED.2023.9
Abstract: IntroductionHeadache is a common reason for presentation to emergency departments (ED) around the world. In many countries, ED are not speciality-focussed, however, in Colombia and some other countries, specialist neurological hospitals have ED with a strong neurological focus. For patients presenting with headache, these ED may have different epidemiology, investigation strategies and treatment patterns from general ED. The objective of this study was to describe the epidemiology of headache presenting to the ED of Instituto Neurológico de Colombia in Medellin, Colombia – an ED which is a referral centre for neurological and neurosurgical diseases. MethodsThis was an observational study by chart review of adults (aged ≥18) with a main presenting compliant of headache. Demographic, clinical, imaging, diagnoses and outcome data were collected. The primary outcome of interest was the rate of serious secondary intracranial headache cause. Analysis was descriptive.ConclusionDiagnosis of headache in ED is challenging with a very wide range of possible causes. A small proportion of patients (approx. 9%) have a serious cause for their symptoms – a proportion similar to that reported in other international emergency department cohorts.
Publisher: Wiley
Date: 05-2009
DOI: 10.1111/J.1465-3362.2009.00029.X
Abstract: In response to concerns about the prevalence of heroin-related morbidity and mortality, overdose response training programs have been implemented in Victoria, with the aim of improving outcomes after heroin overdose. The aim of this study was to examine reported overdose response by current injecting drug users (IDU) during overdose events, in comparison with previous studies. A total of 99 IDU (median age 35 years, 72% male) were administered a questionnaire that collected information on knowledge and experience regarding recognition of heroin overdose and response. The primary outcome measure was the rate of ambulance notification and expired air resuscitation during witnessed heroin overdose. Data were analysed using descriptive statistics and univariate analysis. Sixty participants had overdosed at least once, and 84% had witnessed an overdose. 78% recognised altered consciousness as a sign of heroin overdose, but less were aware of depressed breathing (42%) or cyanosis (61%). Reported overdose interventions included correct positioning (39%), expired air resuscitation (32%), ambulance notification (76%) and staying with the victim (87%). Our study has found improved responses to heroin overdose during witnessed heroin overdose among current IDU, compared with earlier work. However, a lack of knowledge regarding appropriate first-aid response persists, which might improve with the development and implementation of training initiatives in this area, ranging from identification of overdose to the administration of life-saving measures.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2014
Publisher: Wiley
Date: 03-06-2020
Publisher: Wiley
Date: 17-12-2021
Abstract: In 2018, we developed and implemented a novel approach to recognition and response to occupational violence and aggression (OVA). It included routine use of the Brøset Violence Checklist for all ED patients integrated with a score‐based notification and response framework. The present study evaluated the impact of the new process on staff knowledge, perceptions and confidence regarding OVA in ED and the rate of security events related to OVA. The present study was conducted in a metropolitan hospital ED in Australia. Evaluation was by online before and after survey of nursing staff, point prevalence study of risk classification and comparison of OVA‐related events involving security in the year before implementation and the year after the programme was embedded. One percent of patients were assessed as high violence risk with a further 4% at moderate risk. The introduction of the Brøset Violence Checklist increased documentation of violence risk assessment. It also improved staff perception of organisational support and awareness of behaviours associated with the risk of violence. There was a statistically significant reduction in unplanned OVA‐related security responses (relative risk 0.75, 95% confidence interval 0.62–0.89). There was also a statistically significant shift to proactive management through early detection and intervention (relative risk 2.22, 95% confidence interval 1.85–2.66). A process including routine OVA risk assessment and a notification and response framework reduced unplanned security events due to OVA and increased staff confidence in recognition and management of OVA. This approach may be suitable for use more broadly in ED.
Publisher: Elsevier BV
Date: 02-2017
DOI: 10.1016/J.HLC.2017.03.160
Abstract: There is little data on the prevalence of coronary heart disease (CHD) in the young. The study aimed to estimate the prevalence of asymptomatic CHD in siblings of young patients with myocardial infarction (MI) using coronary computed tomography angiography (CCTA). Prospective observational data was collected on siblings of patients aged ≤55 years presenting with acute MI and having coronary stenosis ≥50% on invasive coronary angiography in at least one epicardial coronary artery. Inclusion criteria included ages 30-55 and 30-60 years for males and females respectively. Outcome of interest was obstructive CHD by coronary computer tomography angiography (CCTA), which was defined by either moderate (50-69% stenosis) and/or severe (≥70% stenosis). Fifty participants were studied of whom 20 (40%) were male. Thirty (60%) were current or ex-smokers, 4 (8%) had diabetes, 8 (16%) had hypertension and 26 (52%) had dyslipidaemia. Obstructive CHD by CCTA was detected in 9 (18%, 95% CI 9%-31%) participants and 3 (6%, 95% CI 1%-17%) participants were found to have severe luminal stenosis. The median radiation dose was 3.9 (IQR 0.9) mSv. Approximately a fifth of siblings of young MI patients were found to have asymptomatic but obstructive CHD detected on CCTA of which one third was severe. This is a group in whom screening for CHD warrants further investigation.
Publisher: Wiley
Date: 11-2004
DOI: 10.1111/J.1445-5994.2004.00650.X
Abstract: Standard practice for patients requiring hospital admission with suspected acute coronary syndromes (ACS) is admission to a monitored cardiology bed. The Western Hospital Chest Pain Protocol was developed to identify a subset of these patients who could be safely managed in an unmonitored bed. The objective of this prospective study of chest pain patients classified as 'high' or 'intermediate' risk by the Agency for Health Care Policy and Research/National Health and Medical Research Council guidelines was to further evaluate the safety of this protocol. This study was a prospective, observational, cohort study investigating the outcomes of patients admitted to hospital with suspected ACS. The primary outcome of interest was death or life-threatening arrhythmia within 24 h of hospital admission. If the Western Hospital Chest Pain Protocol had been strictly applied, there would have been one death in the group assigned to unmonitored beds (1/750 0.13%, 95% confidence interval 0.01-0.85%) and no other life-threatening arrhythmias. There is a subgroup of patients with suspected ACS who require hospital admission who can, based on clinical and biochemical features in the emergency department, be safely assigned to unmonitored beds.
Publisher: Wiley
Date: 09-11-2009
DOI: 10.1111/J.1360-0443.2009.02724.X
Abstract: Traditionally, the opiate antagonist naloxone has been administered parenterally however, intranasal (i.n.) administration has the potential to reduce the risk of needlestick injury. This is important when working with populations known to have a high prevalence of blood-borne viruses. Preliminary research suggests that i.n. administration might be effective, but suboptimal naloxone solutions were used. This study compared the effectiveness of concentrated (2 mg/ml) i.n. naloxone to intramuscular (i.m.) naloxone for suspected opiate overdose. This randomized controlled trial included patients treated for suspected opiate overdose in the pre-hospital setting. Patients received 2 mg of either i.n. or i.m. naloxone. The primary outcome was the proportion of patients who responded within 10 minutes of naloxone treatment. Secondary outcomes included time to adequate response and requirement for supplementary naloxone. Data were analysed using multivariate statistical techniques. A total of 172 patients were enrolled into the study. Median age was 29 years and 74% were male. Rates of response within 10 minutes were similar: i.n. naloxone (60/83, 72.3%) compared with i.m. naloxone (69/89, 77.5%) [difference: -5.2%, 95% confidence interval (CI) -18.2 to 7.7]. No difference was observed in mean response time (i.n.: 8.0, i.m.: 7.9 minutes difference 0.1, 95% CI -1.3 to 1.5). Supplementary naloxone was administered to fewer patients who received i.m. naloxone (i.n.: 18.1% i.m.: 4.5%) (difference: 13.6%, 95% CI 4.2-22.9). Concentrated intranasal naloxone reversed heroin overdose successfully in 82% of patients. Time to adequate response was the same for both routes, suggesting that the i.n. route of administration is of similar effectiveness to the i.m. route as a first-line treatment for heroin overdose.
Publisher: Wiley
Date: 29-09-2009
DOI: 10.1111/J.1526-4610.2009.01465.X
Abstract: Ranges of agents are used in the emergency departments to treat migraine headache. Some experts suggest that phenothiazines are among the most effective clinical trials have been small with varied results. We performed a systematic review and meta-analysis to determine the relative effectiveness of phenothiazines compared with placebo and other active agents for the treatment of acute migraine. We searched MEDLINE, EMBASE, CINAHL, Cochrane database, and international clinical trial registers for randomized controlled trials comparing parenteral phenothiazines with placebo or another active parenteral agent for treatment of acute migraine in adults. The primary outcome was relief of headache, and secondary outcome was clinical success. Analysis was for phenothiazines vs placebo, pooled other active agents, and metoclopramide for each outcome. Odds ratios (ORs) were calculated and pooled by using a random effects model (RevMan v5). Thirteen trials were appropriate and had available data. Phenothiazines were compared with placebo in 5 trials and to another active agent in 10 (metoclopramide 4). Phenothiazine was more effective than placebo for headache relief (OR 15.02, 95% confidence interval [CI] 7.57-29.82) and clinical success (OR 8.92, 95% CI 4.08-19.51). Phenothiazines were more effective than other agents combined (OR 2.04, 95% CI 1.25-3.31) and the metoclopramide subgroup (OR 2.25, 95% CI 1.29-3.92) for clinical success, but no differences were found for headache relief. The clinical success rate of phenothiazines was 78% (95% CI 74-82). Phenothiazines are more effective than placebo for the treatment of migraine headache and have higher rates of clinical success than other agents against which they have been compared.
Publisher: Wiley
Date: 08-09-1999
Publisher: Wiley
Date: 05-11-2022
Abstract: The Snapshot of Suspected ACS Assessment (SSAASY) study aims to describe the assessment processes for patients with suspected acute coronary syndrome (ACS) in Australian EDs, and to compare these processes with the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand (NHFA/CSANZ) guidelines. Between March and May 2021, a cross‐sectional survey of Australian EDs was undertaken to investigate the assessment strategies used within the ED. All public and private hospitals identified as having dedicated EDs were invited to participate. Respondents provided data on hospital, ED and cardiac service characteristics. They also provided data on the risk stratification process recommended within their department (risk scores, troponin testing, objective testing for coronary artery disease). Awareness of the NHFA/CSANZ guidelines was assessed. Responses were received from 109/162 departments (67%). Most sites ( n = 100, 92%) reported using dedicated protocols developed by ED clinicians that included risk stratification scores. Highly sensitive troponin assays were used at 103 (94%) sites. Serial troponin testing was performed over 2 h for low‐risk patients in 53 (49%) sites and 2–3 h for intermediate and high‐risk patients in 74 (68%) sites. Further investigations included exercise stress tests (48%) and stress echocardiography (38%), with 45% of sites ordering outpatient investigations. The SSAASY study reported the strategies used to assess suspected ACS. In line with current NHFA/CSANZ guidelines, highly sensitive troponin assays are widely utilised. However, serial s ling intervals were longer than guideline recommendations, suggesting a translational gap between guidelines and clinical practice.
Publisher: Wiley
Date: 19-07-2004
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2009
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2010
Publisher: Wiley
Date: 13-03-2023
Abstract: Blunt trauma patients with potential cervical spine injury are traditionally immobilised in rigid collars. Recently, this has been challenged. The present study's objective was comparison of the rate of patient‐oriented adverse events in stable, alert, low‐risk patients with potential cervical spine injuries immobilised in rigid versus soft collars. Unblinded, prospective quasi‐randomised clinical trial of neurologically intact, adult, blunt trauma patients assessed as having potential cervical spine injury. Patients were randomised to collar type. All other aspects of care were unchanged. Primary outcome was patient‐reported discomfort related to neck immobilisation by collar type. Secondary outcomes included adverse neurological events, agitation and clinically important cervical spine injuries (clinical trial registration number: ACTRN12621000286842). A total of 137 patients were enrolled: 59 patients allocated to a rigid collar and 78 to a soft collar. Most injuries were from a fall m (54%) or a motor vehicle crash (21.9%). Median neck pain score of collar immobilisation was lower in the soft collar group (3.0 [interquartile range 0–6.1] vs 6.0 [interquartile range 3–8.8], P 0.001). The proportion of patients with clinician‐identified agitation was lower in the soft collar group (5% vs 17%, P = 0.04). There were four clinically important cervical spine injuries (two in each group). All were treated conservatively. There were no adverse neurological events. Use of soft rather than rigid collar immobilisation for low‐risk blunt trauma patients with potential cervical spine injury is significantly less painful for patients and results in less agitation. A larger study is needed to determine the safety of this approach or whether collars are required at all.
Publisher: BMJ
Date: 10-02-2012
DOI: 10.1136/EMERMED-2011-200810
Abstract: To determine the rate of major adverse cardiac events (MACE) in patients assessed in an emergency department (ED) for chest pain with a non-ischaemic ECG, Thrombolysis in Myocardial Infarction (TIMI) score of 0 and initial troponin I (TnI) ≤99th centile. This was a sub-study of a prospective observational study of adult patients with potentially cardiac chest pain who underwent evaluation for acute coronary syndrome in an urban teaching hospital. Adult patients with non-traumatic chest pain were eligible for inclusion. Those with ECG evidence of acute ischaemia or an alternative diagnosis were excluded. Data collected included demographic, clinical, ECG, biomarker and outcome data. Low risk was defined as a TIMI risk score of 0 and initial TnI ≤99th centile. Primary outcome of interest was defined as MACE within 7 days. MACE included death, cardiac arrest, revascularisation, cardiogenic shock, arrhythmia, and prevalent (cause of presentation) and incident (occurring within the follow-up period) myocardial infarction (MI). Analysis was by descriptive and clinical performance analyses. 651 patients were studied of whom 215 met the low risk criteria. There was one MACE in this group (0.47%, 95% CI 0.08% to 2.6%)-a revascularisation within 7 days without prevalent MI. Negative predictive value of low risk classification was 99.5% (95% CI 97% to 100%) at both 7 and 30 days. Negative likelihood ratio, weighted by prevalence, was 0.005 at both intervals. Risk stratification for early discharge based on ECG, TIMI score of 0 and presentation TnI ≤99th centile appears to identify a group at very low risk of MACE. Research to prospectively validate this is warranted.
Publisher: Wiley
Date: 06-12-2010
DOI: 10.1111/J.1742-6723.2010.01351.X
Abstract: Several paediatric weight estimation methods have been described for use when direct weight measurement is not possible. A new age-based weight estimation method has recently been proposed. The Luscombe formula, applicable to children aged 1-10 years, is calculated as (3 × age in years) + 7. Our objective was to externally validate this formula using an existing database. Secondary analysis of a prospective observational cohort study. Data collected included height, age, ethnicity and measured weight. The outcome of interest was agreement between estimated weight using the Luscombe formula and measured weight. Secondary outcome was comparison with performance of Argall, APLS and Best Guess formulae. Accuracy of weight estimation methods was compared using mean difference (bias), 95% limits of agreement, root mean square error and proportion with agreement within 10%. Four hundred and ten children were studied. Median age was 4 years 54.4% were boys. Mean body mass index was 17 kg/m(2) and mean measured weight was 21.2 kg. The Luscombe formula had a mean difference of 0.66 kg (95% limits of agreement -9.9 to +11.3 kg root mean square error of 5.44 kg). 45.4% of estimates were within 10% of measured weight. The Best Guess and Luscombe formulae performed better than Argall or APLS formulae. The Luscombe formula is among the more accurate age-based weight estimation formulae. When more accurate methods (e.g. parental estimation or the Broselow tape) are not available, it is an acceptable option for estimating children's weight.
Publisher: Wiley
Date: 24-11-2009
DOI: 10.1111/J.1742-6723.2009.01241.X
Abstract: Access block is the inability of ED patients requiring admission to access appropriate inpatient beds in a timely fashion, defined in Australasia as more than 8 h in the ED. The present study describes changes in prevalence of access block in Australia over a 4 year period. Email, telephone and fax survey of ED on six Mondays at 10.00 hours (31 May, 30 August 2004, 18 June, 3 September 2007, 2 June, 2 September 2008). Data collected included point data on the status of patients in the ED at the index time and of recent ED attendance numbers. Results were collated and analysed by state and hospital role delineation. Forty-eight (60%) of 80 eligible ED answered all six surveys. Presentations to the ED the day before rose 15% (P < 0.0001, paired t-test) in 4 years, and nationally access block patients in the ED rose an average of 27%, and patients waiting to be seen by a doctor 31%. There were differences between states, with hospitals in New South Wales reporting a significant reduction in access block patients (-51%, P= 0.0002), but all other states a significant increase (+45%, P= 0.001). There were differences by role delineation, with non-paediatric major referral hospitals experiencing the greatest access block, but smaller hospitals experiencing the greatest increase in patients waiting. Around one-third of all patients receiving care in these ED surveys were experiencing access block. There is evidence that flow through New South Wales ED has improved. The data suggest that most hospitals have passed the point of efficiency.
Publisher: BMJ
Date: 20-07-2006
Publisher: Wiley
Date: 23-09-2018
Abstract: Research suggests that the presence of instability markers in patients with displaced distal radial fractures is associated with poorer outcome. Our aims were to determine whether the presence of previously defined instability markers could predict the likelihood of successful ED reduction and requirement for a secondary procedure after ED reduction. Retrospective cohort study performed by medical record review. Adult ED patients coded as having an isolated wrist fracture and having fracture reduction in ED were eligible for inclusion. Data collected included demographics, history of osteoporosis, mechanism of injury, radiological features on X-rays and performance of a secondary procedure. Outcomes of interest were the rate of successful fracture reduction in ED (against defined radiological criteria), the rate of secondary procedures and the association between the number of defined instability risk factors and successful reduction and performance of a secondary surgical procedure. Analysis was by χ Three hundred and nineteen patients were studied median age 62 years, 77% female. Sixty-five per cent of patients had satisfactory fracture reduction in ED (95% CI 59%-70%). Eighty-six patients underwent a secondary procedure to reduce/stabilise their fracture (28%, 95% CI 23%-33%). Younger age, lack of satisfactory ED reduction and increased number of instability factors were independently predictive of the performance of a secondary procedure. Instability risk factors are common in patients with wrist fractures requiring reduction in ED. The number of instability factors is not a strong predictor of the performance of secondary procedures.
Publisher: Wiley
Date: 08-2013
Publisher: Elsevier BV
Date: 08-2006
Publisher: Wiley
Date: 06-11-2023
Abstract: Aortic dissection (AD) is rare. Missed AD is a common reason for coronial investigations and civil claims for medical negligence. Recommendations include improved education, supervision and information transfer, reminders in chest pain pathways and higher rates of investigation for AD. Higher investigation rates pose risks to patients and the health system which may not be in balance with the likelihood of AD. The appropriate diagnostic yield of investigation to balance risk and benefit has not been defined. The AD detection risk score pathway has been proposed as a useful diagnostic tool but concerns about its derivation, validation and utility remain. In this paper, we try to draw together published literature and local audit data to develop recommendations about what might be done to reduce the number of missed AD cases in EDs and what the impact of higher investigation rates might be.
Publisher: Wiley
Date: 24-07-2020
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: Wiley
Date: 24-03-2018
DOI: 10.1111/CRJ.12782
Abstract: Shortness of breath is a common presenting symptom to the emergency department (ED) that can arise from a myriad of possible diagnoses. Asthma is one of the major causes. The aim of this study was to describe the demographic features, clinical characteristics, management and outcomes of adults with an ED diagnosis of asthma who presented to an ED in the Asia Pacific region with a principal symptom of dyspnea. Planned sub-study of patients with an ED diagnosis of asthma identified in the Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) study. AANZDEM was a prospective cohort study conducted in 46 EDs in Australia, New Zealand, Singapore, Hong Kong and Malaysia over three 72 hour periods in May, August and October 2014. Primary outcomes were patient epidemiology, clinical features, treatment and outcomes (hospital length of stay (LOS) and mortality). Of the 3044 patients with dyspnea, 387 (12.7%) patients had an ED diagnosis of asthma. The median age was 45 years, 60.1% were female, 16.1% were active or recent smokers and 30.4% arrived by ambulance. Inhaled bronchodilator therapy was initiated in 88.1% of patients, and 66.9% received both inhaled bronchodilators and systemic corticosteroids. After treatment in the ED, 65.4% were discharged. No death was reported. Asthma is common among patients presenting with a principal symptom of dyspnea in the ED of the Asia Pacific region. There was a suboptimal adherence to international guidelines on investigations and treatments of acute asthma exacerbations presenting an opportunity to improve the efficiency of care.
Publisher: Wiley
Date: 13-12-2020
Publisher: Elsevier BV
Date: 02-2005
DOI: 10.1016/J.JEMERMED.2004.08.016
Abstract: The objectives of this before-and-after study of alert, stable adult patients presenting to the Emergency Department of Western Hospital with potential neck injuries who were immobilized in hard cervical collars were to determine the impact of implementation of the Canadian C-spine rule on x-ray ordering rates and whether implementation of the rule reduced time in hard collars for patients with potential neck injury. Data collected included demographics, mechanism of injury, x-ray rate, and time in hard collar. Data analysis was by chi-square test for proportions and Mann-Whitney U test for continuous variables. There were 211 patients studied. The x-ray ordering rate decreased from 67% to 50% (25% relative reduction, p = 0.0187). Time in hard collar was also reduced from a median of 128 min to a median of 103 min (effect size 25.5 min), but this did not reach statistical significance. Implementation of the Canadian C-spine rule reduced x-ray ordering by 25%.
Publisher: Wiley
Date: 30-05-2019
Abstract: To determine the accuracy of using parental estimate of a child's weight compared to actual weight in a paediatric emergency setting. Prospective, observational study. Age, weight and height data were collected from children aged 1 month up to 11 years with an Australian Triage score of 3 or higher. This was compared with a parent weight estimate. Analysis is descriptive. A total of 450 children were studied with a mean age of 4 years 4 months. A total of 85.3% of parents were willing to provide a weight estimate (n = 384). The mean difference between the parent estimate (where provided) and the actual weight was 0.33 kg (measured weight > estimated 95% confidence interval [CI] -6.9 kg to +7.6 kg). There was 75% agreement within 10% of the measured weight (95% CI 71-79%) and 92% agreement within 20% of the measured weight (95% CI 89-95%). Weight was more commonly underestimated than overestimated. Children of Polynesian/Pacific ethnicity were less likely to have an accurate parental weight estimation. Parent estimate is an accurate weight estimation method when parents are willing to give an estimate. There is ethnic variation in accuracy that should be taken into account when applying this method.
Publisher: Elsevier BV
Date: 2015
Publisher: Wiley
Date: 03-2001
DOI: 10.1046/J.1442-2026.2001.00179.X
Abstract: The aim of this study was to define the degree of change on a visual analogue scale that corresponded to a clinically meaningful reduction in the level of pain reported by patients experiencing acute pain. Secondary analysis of data was performed from prospective, descriptive studies of 152 adults and 73 children presenting to emergency departments with acute pain. At presentation and at 20 min intervals to a maximum of three measurements, patients marked the level of their pain on a 100 mm, non-hatched visual analogue scale. At each follow up, they also gave a verbal rating of their pain as 'a lot better', 'a little better', 'much the same', 'a little worse' or 'much worse'. Data from the groups reporting that pain was 'a lot better' and 'about the same' were analysed for mean and median absolute change in visual analogue scale and compared. Of 559 pain comparisons, 60 were rated as 'a lot better' and 257 as 'about the same'. The mean absolute change in visual analogue scale for the group reporting that pain was 'a lot better' was 24 mm (median = 19 mm, 95% confidence interval = 17-31 mm). For the group reporting that pain was 'about the same', the mean visual analogue scale change was 0 mm (median = 0 mm, 95% confidence interval = -1 to 1 mm). When evaluating treatments for acute pain, a difference in visual analogue scale pain score of less than about 20 mm is unlikely to be clinically meaningful. Studies should be designed and reported relative to this benchmark rather than the minimum clinically significant difference in visual analogue scale pain score.
Publisher: Springer Science and Business Media LLC
Date: 22-09-2016
Publisher: BMJ
Date: 10-2006
Publisher: Wiley
Date: 26-04-2022
Abstract: Pregnancy is defined as a ‘red flag’ in headache assessment. We aimed to describe the prevalence and causes of serious secondary headache in pregnant ED patients. Unplanned secondary analysis of HEAD Study/HEAD Colombia data. 3.2% (117/3643) of ED headache patients aged 18–50 years were pregnant, of whom six (5.1%) had a serious secondary cause identified. The proportion of patients with serious headache causes was not significantly different between pregnant female, non‐pregnant female and male patient subgroups ( P = 0.89). Inclusion of pregnancy as a ‘red flag’ in ED headache assessment is not supported by these data.
Publisher: Wiley
Date: 06-2001
DOI: 10.1046/J.1442-2026.2001.00216.X
Abstract: To characterize the prerequisite experience and training undertaken by nurses for the role of triage in emergency departments in Australasia. Postal survey of charge nurses/unit nurse managers of all Australasian emergency departments accredited for specialist emergency physician training by the Australasian College for Emergency Medicine. The response rate was 89%. The most common duration of prerequisite experience was 12-18 months. Most programmes use a combination of educational activities, with self-directed learning packages, lectures and mentored experience being the most common. Three hospitals reported no preparation for triage. In Australasia, there is wide variability in required training and experience before triage duties are performed. Strategies to set suggested minimum standards in these areas and to make training activities more accessible are recommended.
Publisher: BMJ
Date: 11-2007
Publisher: Wiley
Date: 12-01-2015
Publisher: Wiley
Date: 22-07-2007
DOI: 10.1111/J.1742-6723.2007.00997.X
Abstract: In 1993 Emergency Medicine Australasia (then Emergency Medicine [Fremantle]) published a therapeutic review on the management of spontaneous pneumothorax. That review found a lack of high-quality evidence on which to base management decisions and a variety of therapeutic options without clear superiority one over another. Now, almost 15 years later, the present paper aims to revisit the evidence base to see if management choices are clearer.
Publisher: Wiley
Date: 09-2020
DOI: 10.1111/IMJ.14808
Publisher: Elsevier BV
Date: 05-2010
DOI: 10.1016/J.AJEM.2009.03.005
Abstract: Serial electrocardiographic and biomarker data are used to rule out acute coronary syndrome (ACS) in emergency department (ED) patients with chest pain. These do not identify coronary artery disease (CAD). Functional tests are often used but have limitations. Multislice computed tomography coronary angiography (MSCT-CA) is evolving rapidly, raising the possibility of fast, accurate, and relatively noninvasive anatomical testing for CAD. We aimed to quantify the proportion of ED rule-out ACS patients suitable for MSCT-CA. This retrospective cohort study (by explicit record review) included adult patients who underwent a rule-out ACS process in ED-associated short-stay units. Data collected included demographics, electrocardiographic and biomarker data, contraindications/factors likely to make MSCT-CA unsuccessful or difficult to interpret including irregular heart rhythm, high pulse rate (with rate control contraindicated), renal or thyroid disease, contrast allergy, metformin use, pregnancy, and already confirmed CAD. Outcome of interest was the proportion of patients suitable for MSCT-CA. Data analysis is by descriptive statistics. Four hundred sixty patients were studied (63% male median age, 63 years). Forty-nine percent (224/460 95% confidence interval, 44%-53%) were suitable for MSCT-CA. One hundred eighty-one (39%) already had known CAD. Reasons for unsuitability of the remainder were metformin use 18 (6%), irregular heart rhythm 15 (5%), renal dysfunction 12 (4%), high pulse rate with contraindications to rate control 8 (3%), thyroid disease 7 (3%), and contrast allergy 2 (0.7%). Approximately half of ED patients with chest pain who have underwent ACS rule-out were potentially suitable for MSCT-CA to identify CAD. The best use of MSCT-CA in the investigation of patients with chest pain requires further clarification.
Publisher: Elsevier BV
Date: 07-2003
DOI: 10.1067/MEM.2003.207
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2013
Publisher: Wiley
Date: 31-07-2017
Publisher: BMJ
Date: 04-2010
Abstract: 'Normal' range for cardiac troponin I (TnI) has changed with more sensitive tests, but the validity of low-level elevations is contentious. We aimed to describe the characteristics and outcome of patients with an initial TnI level 1-5 times the upper limit of normal. Retrospective study of patients assessed for ACS with initial TnI level between 0.05-0.19 ng/ml. Data collected included demographics, clinical data, TnI levels and outcome. Primary outcome was the proportion of patients who had a serial TnI rise consistent with ACS. 72 patients were studied median age 71, median TIMI score 3, 66.7% male. 35 patients (48.6%) had a TnI rise consistent with ACS. Approximately half of patients with initial TnI between 0.05-0.19 ng/ml had a TnI rise consistent with ACS. An initial TnI in this range is not, of itself, indicative of ACS. Clinical decision-making should be guided by clinical features and serial TnI measurement.
Publisher: Wiley
Date: 06-2002
DOI: 10.1046/J.1442-2026.2002.00308.X
Abstract: To determine whether, for patients with moderate or severe asthma presenting to emergency departments, there is a difference in need for hospitalization between those with a duration of symptoms less than 6 h and those with a longer duration of symptoms. This prospective, observational study investigated a s le of patients presenting with acute asthma between 21 August and the 3 September 2000, attending study emergency departments and classified as having moderate or severe asthma according to the National Asthma Guidelines. Data collected included duration of symptoms (less than 6 h or greater than 6 h) and disposition following emergency department treatment (home, ward, intensive care unit, high dependency unit, transfer). Data analysis was by Chi square analysis. Of 381 eligible patients, 348 had sufficient data for entry into this study (33 had missing data). Patients with duration of symptoms more than 6 h were more likely to require hospital admission (P < 0.0001). The relative risk for hospital admission or transfer as opposed to discharge from the emergency department for the group with a duration of symptoms of more than 6 h was 2.2. Patients presenting with moderate or severe asthma and a duration of symptoms of more than 6 h are more likely to require hospital admission or transfer for further treatment than patients with a shorter duration of symptoms. This has implications for decision making regarding asthma management and disposition in the emergency department.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2013
Publisher: Elsevier BV
Date: 07-2014
DOI: 10.1016/J.IJLP.2014.02.013
Abstract: The aim of this study is to describe the characteristics and outcome of patients brought to an emergency department by police under Section 10 of Mental Health Act (Victoria, Australia). Retrospective medical record review. Patients referred under Section 10 provisions treated in calendar year 2009 were identified from ED database. Data collected included demographics, incident details, patient management, final diagnosis and disposition. Primary outcomes of interest were ED diagnosis and disposition. Secondary outcomes were length of stay in ED and use of restraint or sedation. One hundred and ninety seven presentations by 164 patients were identified. Patients were predominantly male (58%) with median age of 35 years (IQR 22-44, range 16-69). The most common presenting complaint (65%) was threat of self harm. No sedation or restraint was used in 61%. Sixty seven percent were deemed safe for discharge home while 26% were admitted to a psychiatric ward (equally ided between voluntary and involuntary admission). The predominant discharge diagnosis was self harm ideation or intent (35%). Median ED length of stay was 156 min (inter-quartile range 79-416). Most patients brought to ED by police under Section 10 provisions were for threat of self harm and did not require sedation or restraint. The majority are discharged home. Further work exploring less restrictive or traumatic processes to facilitate psychiatric assessment of this group of patients is warranted.
Publisher: Elsevier BV
Date: 10-2001
DOI: 10.1016/S0736-4679(01)00374-2
Abstract: This prospective, observational study evaluated the safety of the Western Hospital admission protocol for patients with suspected acute coronary syndromes. The study included all patients admitted from the Emergency Department with an admission diagnosis of unstable angina, post infarct angina, atypical chest pain, or chest pain for evaluation. Data collected included demographic data, admission diagnosis, location of admission (bed with or without cardiac monitoring), past medical history and presenting chest pain history to determine Agency for Health Care Policy (AHCPR) and Western Hospital (WH) protocol classifications, cardiac enzyme assays, electrocardiogram analysis, adverse outcomes [death, myocardial infarction (MI), dysrhythmia, acute pulmonary edema, recurrent pain], diagnosis at hospital discharge, and length of stay-(LOS). There were 508 patients with a mean age of 63.7 years enrolled in the study. Three hundred nineteen (62.8%) were admitted to beds without any cardiac monitoring. There was one unexpected death in the unmonitored group, an 85 year-old patient who suffered a presumed dysrhythmia and whom the treating physician had decided was not for resuscitation. Twelve patients suffered nonfatal MI, and none suffered pulmonary edema. All MI patients made an uneventful recovery, and none required thrombolysis. If all patients had been admitted to an area of care based on AHCPR guidelines, an additional 310 admissions to monitored beds would have been required. The results of this study suggest that selected patients with suspected acute coronary syndromes can be safely managed in beds without continuous cardiac monitoring.
Publisher: Elsevier BV
Date: 2008
DOI: 10.1016/J.AJEM.2007.06.026
Abstract: Capillary refill time (CRT) has been taught as a rapid indicator of circulatory status. The aim of this study was to define normal CRT in the Australian context and the environmental, patient, and drug factors that influence it. This prospective observational study included healthy adults at hospital clinics, workplaces, universities, and community groups. Volunteer participants provided their age, sex, ethnic group, and use of hypertensive or cardiac medications. Capillary refill time, ambient temperature, and patient temperature were recorded in a standard manner. Data were analyzed using descriptive statistics and regression analyses. The 95th percentile was used to define the upper limit of normal. One thousand participants were included 57% were women, 90% were white, and 21% were taking cardiac medications. The median CRT was 1.9 seconds (95th percentile, 3.5 seconds). The CRT increased 3.3% for each additional decade of age. The CRT was also on average 7% lower in men than in women. The CRT decreased by 1.2% per degree-Celsius rise of ambient temperature, independently of patient's temperature, and decreased by 5% for each degree-Celsius rise in patient temperature, independently of ambient temperature. On multivariant analysis, age, sex, ambient temperature, and patient temperature were statistically significant predictors of CRT, but together explain only 8% of the observed variability. Capillary refill time varies with environmental and patient factors, but these account for only a small proportion of the variability observed. Its suitability as a reliable clinical test is doubtful.
Publisher: Wiley
Date: 18-05-2006
DOI: 10.1111/J.1742-6723.2006.00846.X
Abstract: Several guidelines have been developed to direct the ordering of head computed tomography (CT) for patients, but most are clinical presentation-specific. Recently, an integrated guideline for ordering emergent head CT for patients who present to the ED of Western Hospital, Footscray, Victoria, Australia, was developed in response to concerns raised regarding perceived over-utilization of head CT for ED patients. Our aim was to determine compliance with the guideline. This was an explicit retrospective medical record review of patients who presented to the ED of Western Hospital between 1/04/2004 and 17/6/2004 and had a head CT as part of their assessment. Clinical information for these cases was compared with guideline recommendations. Data are described by descriptive statistics. Of the 231 cases that were included in the study, 65 (28.1%, 95% confidence interval 23-35%) had abnormal CT findings. Guidelines were adhered to in 217 (93.9%, 95% confidence interval 91-97%) cases. For the cases where the guidelines were not adhered to (14 [6.1%]), there was only one abnormal scan the clinical significance of which is not clear. The study found that compliance with head CT guideline was high. This suggests that the guideline is both clinically relevant and supported by ED doctors or conversely that the guideline is concordant with existing ordering practices of the ED.
Publisher: Wiley
Date: 06-2002
Publisher: Wiley
Date: 11-01-2023
Publisher: Wiley
Date: 25-02-2019
Abstract: Asthma exacerbations are common presentations to ED. Key guideline recommendations for management include administration of inhaled bronchodilators, systemic corticosteroids and titrated oxygen therapy. Our aim was to compare management and outcomes between patients treated for asthma in Europe (EUR) and South East Asia/Australasia (SEA) and compliance with international guidelines. In each region, prospective, interrupted time series studies were performed including adult (age >18 years) patients presenting to ED with the main complaint of dyspnoea during three 72 h periods. This was a planned sub-study that included those with an ED primary diagnosis of asthma. Data was collected on demographics, clinical features, treatment in ED, diagnosis, disposition and in-hospital outcome. The results of interest were differences in treatment and outcome between EUR and SEA cohorts. Five hundred and eighty-four patients were identified from 112 EDs (66 EUR and 46 SEA). The cohorts had similar demographics and co-morbidity patterns, with 89% of the cohort having a previous diagnosis of asthma. There were no significant differences in treatment between EUR and SEA patients - inhaled beta-agonists were administered in 86% of cases, systemic corticosteroids in 66%, oxygen therapy in 44% and antibiotics in 20%. Two thirds of patients were discharged home from the ED. The data suggests that compliance with guideline-recommended therapy in both regions, particularly corticosteroid administration, is sub-optimal. It also suggests over-use of antibiotics.
Publisher: Wiley
Date: 28-08-2023
Abstract: Every day in EDs, clinicians are faced with situations where they need to decide whether to detain a patient for assessment and treatment. For patients who meet the relevant criteria, provisions of mental health legislation can be used. For other patients, clinicians often rely on so‐called ‘duty of care’. This article briefly explores this complex area of law, including the relevant legislation, common law principles and grey areas. It also proposes an approach to decision‐making in this area.
Publisher: Wiley
Date: 12-1999
Publisher: Elsevier BV
Date: 10-2006
DOI: 10.1016/J.RESUSCITATION.2006.02.007
Abstract: To determine emergency department (ED) staff preference for one- or two-handed paediatric chest compressions and to determine if there was a difference in compression rates delivered and fatigability between the techniques. This was a randomised, cross-over observational study of paediatric CPR performed on a standard paediatric manikin by ED staff. Consenting, eligible staff [ED doctors and nurses] performed CPR in pairs with chest compressions delivered using a one- and two-handed technique. The outcomes of interest were compression rates for one- and two-handed CPR, decrease in compression rate over time for each technique and staff preference for technique. Data was analysed using descriptive statistics, Chi Square test and Mann-Whitney U-test as appropriate. Sixty-two ED staff participated in the study. Compression rates with both techniques were similar and higher than guidelines recommend (133.6 min(-1) for one-handed and 135.7 min(-1) for two-handed respectively). The compression rate slowed by 6.9 compressions/min over 1 min in one-handed compressions compared with 2.6 compressions/min in two-handed compressions (p = 0.0264). 65.6% of participants reported that they preferred the two-handed compression technique. This study showed that CPR compression rate is similar with one- and two-handed compression techniques, but compression rate decreased more quickly with the one-handed technique. The majority of staff preferred the two-handed compression technique for reasons of ease, control and uniformity with other CPR techniques.
Publisher: Wiley
Date: 08-11-2013
Publisher: BMJ
Date: 08-11-2012
DOI: 10.1136/EMERMED-2012-201783
Abstract: Hospital emergency departments (EDs) treat a high proportion of older people, many as a direct consequence of falling. To develop and externally validate a fall risk screening tool for use in hospital EDs and to compare the tool's predictive ability to existing screening tools. This prospective cohort study involved two hospital EDs in Sydney, Australia. Potential participants were people aged 70+ years who presented to the ED after falling or with a history of 2+ falls in the previous year and were subsequently discharged. 219 people participated in the tool development study and 178 people participated in the external validation study. Study measures included number of fallers during the 6-month follow-up period, and physical status, medical history, fall history and community service use. 31% and 35% of participants fell in the development and external validation s les, respectively. The developed two-item screening tool included: 2+ falls in the past year (OR 4.18, 95% CI 2.61 to 6.68) and taking 6+ medications (OR 1.89, CI 1.18 to 3.04). The area under the receiver operating characteristic curve (AUC) was 0.70 (0.64-0.76). This represents significantly better predictive ability than the measure of 2+ previous falls alone (AUC 0.67, 0.62-0.72, p=0.02) and similar predictive ability to the FROP-Com (AUC 0.73, 0.67-0.79, p=0.25) and PROFET screens (AUC 0.70, 0.62-0.78, p=0.5). A simple, two-item screening tool demonstrated good external validity and accurately discriminated between fallers and non-fallers. This tool could identify high risk in iduals who may benefit from onward referral or intervention after ED discharge.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2012
Publisher: Elsevier BV
Date: 11-2008
Abstract: International guidelines for the management of primary spontaneous pneumothorax (PSP) vary, and there is growing opinion that more patients could be successfully managed with observation alone. There is little published evidence detailing the outcomes of emergency department (ED) patients who have been treated for PSP. The aim of this study was to describe the clinical outcomes for patients with PSP. This was a retrospective cohort study that was conducted by explicit medical record review that investigated adult patients with PSP who had been treated at two urban teaching hospital EDs from 1996 to 2005. The data collected included demographics, clinical data at presentation, and outcome data. The outcome of interest was the proportion of patients who were successfully treated with the initial management strategy (ie, conservative, aspiration, and tube thoracostomy). Data analysis was performed using descriptive statistics. A total of 203 episodes of PSP in 154 patients (70% male median age, 24 years) was identified. PSP size ranged from 5 to 100%. Ninety-one PSP patients (45%) were treated with outpatient observation, 48 patients (24%) were treated with aspiration, and 64 patients (31%) were treated with tube thoracostomy. In total, the conditions of 79% of patients (82 of 91 patients) who were treated with observation resolved without additional intervention. Aspiration was successful in 50% of cases (24 of 48 cases) where it was attempted the conditions of 73% of PSP patients who were treated with tube thoracostomy (47 of 64) resolved without additional intervention. These data suggest that observation alone is an effective initial treatment strategy for selected patients with PSP. They support the inclusion of an observation arm in planned prospective studies comparing different management approaches.
Publisher: Wiley
Date: 02-2007
DOI: 10.1111/J.1742-6723.2006.00929.X
Abstract: The present paper describes the process, outcomes and lessons learned from a federally funded, multicentre action research project aimed at improving discharge practices for asthma patients who attend ED and are discharged home. Thirty-two ED participated and worked locally to improve discharge practices using previously published best-practice guidelines. Although they achieved some improvements, major barriers to best-practice discharge outside ED control were identified, including access to GP, hospital policies regarding supply of medications and access to appropriate asthma education. The ED developed some useful tools to assist with improving asthma management that have been compiled as a toolkit and are available online.
Publisher: Wiley
Date: 29-07-2009
Publisher: Elsevier BV
Date: 08-2006
DOI: 10.1016/J.RMED.2005.11.022
Abstract: To compare the estimated size of spontaneous pneumothoraces using the established Rhea inter-pleural distances method with the CT-derived Collins method. Adult patients with spontaneous pneumothorax treated conservatively were identified from the ED databases. X-rays were reviewed independently by two researchers and measured according to the methods described by Rhea and Collins. Estimates of size derived by the two methods were compared using bias plot analysis techniques. A total of 156 X-rays in 57 patients were identified. A total of 82% were male with a median age of 22 years. Pneumothoraces varied in size from 4% to 88%. The average difference between methods was 4% (Collins method estimating larger size) with 95% limits of agreement -3.8% to 11.7%. Agreement was very close for small pneumothoraces but deteriorated with increasing pneumothorax size (Collins methods estimated larger pneumothorax size). The Rhea method for estimating pneumothorax size is acceptably accurate for smaller pneumothoraces but may significantly under-estimate the size of larger pneumothoraces.
Publisher: Wiley
Date: 14-07-2022
Publisher: Elsevier BV
Date: 10-2008
DOI: 10.1016/J.IJCARD.2007.06.095
Abstract: Anomalous coronary arteries with an inter-arterial course are associated with sudden cardiac death. We reported a study comparing the accuracy of fluoroscopic coronary angiography (FCA) with that of multi-slice computed tomography (MSCT) coronary angiography in determining the proximal course of anomalous coronary arteries. Twelve patients with thirteen anomalous coronary arteries had both FCA and MSCT coronary angiography were included in this study. Twelve cardiologists in idually reviewed FCAs of anomalous coronary arteries and determined the proximal course of anomalous coronary arteries as retro-aortic, inter-arterial or ante-pulmonary. Their diagnoses were compared with MSCT coronary angiography which was regarded as the reference standard in this study. On MSCT coronary angiography, there were six anomalous left circumflex arteries with a retro-aortic course, five anomalous right coronary arteries and one anomalous left anterior descending artery with inter-arterial courses, and a single anomalous left main artery with an ante-pulmonary course. The percentage of correct diagnosis made by 12 cardiologists based on FCA findings was 93/156 or 60%. None of the cardiologists was correct in determining the proximal course of all anomalous coronary arteries. The median number of anomalous coronary arteries with their proximal courses correctly identified by the cardiologists was 7.5 (range 3-12). In conclusion, FCA was limited in delineating the proximal course of anomalous coronary arteries in comparison with MSCT coronary angiography.
Publisher: Wiley
Date: 10-11-2014
Abstract: Subarachnoid haemorrhage (SAH) is an uncommon but important cause of sudden-onset headache. Three clinical decision rules (CDRs) for investigation in sudden headache have been proposed, but concerns were raised about the generalisability of some variables. Our aim was to determine what proportion of patients with confirmed SAH has the identified high-risk factors and the sensitivity of the proposed CDR in an Australasian cohort. This is a retrospective cohort study of alert and neurologically intact adult patients with confirmed SAH attending two community teaching hospitals between 2000 and 2011. The outcomes of interest were the proportion of patients with each high-risk criterion (descriptive statistics) and sensitivity of each proposed CDR (%, interquartile range [IQR]). There were 59 confirmed SAH that met the inclusion criteria. Sensitivity of proposed CDR 1 was 96.6% (95% confidence interval [CI] 88.5-99.1%), sensitivity of proposed CDR 2 was 100% (95% CI 93.9-100%) and sensitivity of proposed CDR 3 was 89.8% (95% CI 79.5-95.3%). The addition of vomiting to the criteria in CDRs 1 and 3 increased the sensitivity of both these CDRs to 100%. CDR 2, or the refinement of CDRs 1 and 3 with the inclusion of at least one episode of vomiting as a criterion, has very high sensitivity. Although unlikely to reduce CT scan rates for patients in whom there is a clinical suspicion of SAH, they might be useful in guiding which patients require further testing (e.g. lumbar puncture) after a negative CT scan.
Publisher: Wiley
Date: 24-11-2009
Publisher: SAGE Publications
Date: 30-12-2009
Abstract: Background. Clinical decision rules can benefit clinicians, patients, and health systems, but they involve considerable up-front development costs and must be acceptable to the target audience. No existing instrument measures the acceptability of a rule. The current study validated such an instrument. Methods. The authors administered the Ottawa Acceptability of Decision Rules Instrument (OADRI) via postal survey to emergency physicians from 4 regions (Australasia, Canada, United Kingdom, and United States), in the context of 2 recently developed rules, the Canadian C-Spine Rule (C-Spine) and the Canadian CT Head Rule (CT-Head). Construct validity of the 12-item instrument was evaluated by hypothesis testing. Results. As predicted by a priori hypotheses, OADRI scores were 1) higher among rule users than nonusers, 2) higher among those using the rule ‘‘all of the time’’ v. ‘‘most of the time’’ v. ‘‘some of the time,’’ and 3) higher among rule nonusers who would consider using a rule v. those who would not. We also examined explicit reasons given by respondents who said they would not use these rules. Items in the OADRI accounted for 85.5% (C- Spine) and 90.2% (CT-Head) of the reasons given for not considering a rule acceptable. Conclusions. The OADRI is a simple, 12-item instrument that evaluates rule acceptability among clinicians. Potential uses include comparing multiple ‘‘protorules’’ during development, examining acceptability of a rule to a new audience prior to implementation, indicating barriers to rule use addressable by knowledge translation interventions, and potentially serving as a proxy measure for future rule use.
Publisher: Wiley
Date: 06-04-2022
DOI: 10.5694/MJA2.51477
Publisher: Wiley
Date: 03-01-2022
Publisher: Wiley
Date: 09-2003
DOI: 10.1046/J.1445-5994.2003.00469.X
Abstract: Abstract Aims: To characterize presentations due to acute asthma at Australian emergency departments (ED), including their severity, treatment and disposition. Methods: This prospective, observational study involved 38 departments of emergency medicine throughout Australia participating in the Snapshot of Asthma Study Group project 2000 and 2001. Data were collected for patients presenting with acute asthma between 21 August 2000 and 3 September 2000, and 20 August 2001 and 2 September 2001 and included demographics, severity classification, treatment and disposition. Results: There were 1340 acute asthma presentations in the study periods. Of these presentations, 67% were for children aged years. Asthma severity (according to the Australian National Asthma Guidelines classification) was ‘mild’ in 49% of cases ‘moderate’ in 45% of cases and ‘severe’ in 6% of cases. Treatment administered included: (i) salbutamol to 90%, (ii) ipratropium bromide to 59% and (iii) corticosteroids to 71%. Only six patients received aminophylline. Spacer use for salbutamol was rare (1%) in adults and only moderate (43%) in children. Sixty‐five percent of patients were discharged home from the ED. Less than 1% of patients required ventilatory assistance, of which half was provided non‐invasively. One percent of patients were admitted to the intensive‐care unit or high‐dependency unit. Conclusion: Overall adherence to treatment guidelines was good. There appears to be underuse of spacers and corticosteroids in some groups and overuse of ipratropium bromide. The majority of patients are treated and discharged from the ED. (Intern Med J 2003 33: 406−413)
Publisher: Open Exploration Publishing
Date: 31-08-2021
Abstract: Acute aortic syndromes, including aortic dissection (AD), are rare. The AD detection risk score (ADDRS) and associated investigation pathway were developed to reduce missed diagnosis of AD. The methodology for its development was sub-optimal and it has not been robustly validated in the emergency department chest pain population. Recent research suggests that it will drive over-investigation and that the risks of missed diagnosis may not be in balance with the risks of the testing strategy. There are serious doubts about whether the score and investigation pathway are fit for purpose.
Publisher: Wiley
Date: 12-2001
DOI: 10.1046/J.1035-6851.2001.00262.X
Abstract: The aims of the present study were to determine the publication rate of abstracts presented by Australasian emergency physicians at major emergency medicine meetings and to identify the site of publication of papers. All free paper abstracts presented (oral and poster) by Australasian emergency physicians and trainees at five Australasian College for Emergency Medicine/Australasian Society for Emergency Medicine and International Conference on Emergency Medicine meetings between 1995 and 1998 were identified retrospectively from conference programmes. In order to determine whether or not the abstract had been published, the PubMed database (www4.ncbi.nlm.nih.gov/PubMed/) was searched using the presenter's name and key words from the abstract. In addition, a hand search of the non-abstracted journal Emergency Medicine was conducted. Of the 207 free paper abstracts identified, 73 (35%) had been published as full articles. Papers were published in a variety of journals however, Emergency Medicine accounted for almost half the published papers. The mean time between presentation and publication was 12.6 months (median 11 months). The abstract to publication rate for papers presented by Australasian emergency physicians and trainees at Australasian College for Emergency Medicine/Australasian Society for Emergency Medicine and International Conference on Emergency Medicine meetings is 35%, which is lower than that reported by some other established specialities, but comparable to rates reported for US-based national and international emergency medicine meetings. Future research should look at barriers to the publication of findings and ways to assist the publication process.
Publisher: Wiley
Date: 10-01-2017
Publisher: Wiley
Date: 02-2003
DOI: 10.1046/J.1442-2026.2003.00408.X
Abstract: To determine the level of agreement in classification of the severity of acute asthma at presentation to the emergency department, between emergency physician global assessment and severity classification according to the National Asthma Council Guidelines, Australia 1998 (NACG). Prospective observational study in emergency departments throughout Australia, participating in the Asthma Snapshot 2000 project. Patients between the ages of one and 60 years presenting to participating emergency departments with acute asthma between 21 August and 3 September 2000 were included. Data collected were emergency physician global assessment of asthma severity and severity classification according to the National Asthma Council Guidelines and disposition. Five hundred and five subjects had completed data for emergency physician assessment of severity and for calculation of severity classification according to the National Asthma Council Guidelines. Weighted kappa for agreement in classification was 0.48 (95% confidence interval: 0.40, 0.56). Emergency physicians assess asthma as less severe compared to the National Asthma Council Guidelines assessment. Agreement between physician assessment of severity of acute asthma and severity classification according to National Asthma Council Guidelines is only moderate. This may have implications in treatment and disposition. This also suggests that emergency physicians may be using other methods to classify acute asthma than the National Asthma Council Guidelines classification.
Publisher: Wiley
Date: 02-2009
DOI: 10.1111/J.1742-6723.2008.01145.X
Abstract: The impact of ED overcrowding on delay to analgesia has not been well studied. Our objective was to determine if ED workload influenced time to analgesia (TTA). An observational, retrospective study (May 2006 to March 2007) was conducted. Adult patients with diagnoses of acute biliary pain, renal colic, wrist and femoral neck fractures were identified and assigned to an ED workload group based on total patient care time--a validated measure of ED workload. The groups were defined by low, middle and high quartiles of total patient care time. The high quartile was defined as overcrowded--equating to average ED occupancy/24 h of 85-140%. Data collected included demographics, pain score and analgesia data. The primary outcome was comparison of TTA between workload groups. Data were analysed using Cox regression and multivariate analyses. S le size required was 50 per group. A total of 254 patients were studied (52% male median age 57 years). Demographics were similar between groups. Ninety-three per cent received analgesia with median TTA of 53 min (interquartile range 30.5-114.5). No significant association was found between workload and TTA (hazard ratio [HR] 1.02, 95% CI 0.99-1.02). On multivariate analysis, factors associated with delay to analgesia included advanced age (HR 0.35, P= 0.006), language other than English (HR 0.55, P= 0.010), lower triage acuity (HR 0.20, P= 0.000) and delay to pain assessment (HR 0.16, P= 0.000). Those with higher pain scores received analgesia more quickly (HR 1.12, P= 0.003). No relationship between workload and TTA was observed however, there were delays to analgesia associated with age, non-English-speaking background and delay to pain assessment.
Publisher: Wiley
Date: 19-07-2019
Abstract: The aims of this study were to establish the bias (mean difference) and 95% limits of agreement (LoA) between electrolyte values (sodium and potassium) and haemoglobin between whole blood analysed by the ED resuscitation room blood gas analyser and specimens analysed using standard techniques in the central hospital laboratory and to determine the proportion of analyses falling outside defined clinically acceptable LoA and pathology expert defined standards. Prospective cohort study. Paired blood gas analyser and laboratory s les taken no more than 10 min apart were included. The primary outcome of interest was bias and 95% LoA by Bland-Altman analysis. Subgroup analyses for values outside the normal range were also conducted. Three hundred and fifty-two s le pairs were included in the analysis. For sodium concentration the bias was 0.6 mmol/L (95% LoA -3.3 to 4.6 mmol/L). For potassium concentration the bias was 0.21 mmol/L (95% LoA -0.36 to 0.79 mmol/L). For haemoglobin concentration the bias was -1.6 g/dL (95% LoA -10.2 to 6.9 g/dL). For sodium and haemoglobin concentrations, >95% of results fell within the defined clinically acceptable limits. For potassium concentration, >90% of results fell within the defined clinically acceptable limits. In general, serum sodium and potassium concentrations were slightly higher than blood gas levels and for haemoglobin serum levels were slightly lower. Agreement between blood gas analysis and laboratory analysis for sodium, potassium and haemoglobin concentrations shows acceptable agreement for use in time critical clinical decision-making in ED.
Publisher: Wiley
Date: 04-10-2016
Abstract: We investigated and compared the importance of the considerations and discussions when withdrawing and withholding life-sustaining healthcare between emergency physicians (EP) and emergency registrars (ER). This was a sub-study of a prospective cross-sectional questionnaire-based case series conducted in six EDs. Primary outcomes were, which of the discussion and considerations, were rated most important by EP and ER in the decision-making process. We studied responses relating to the care of 320 patients, of which 49.4% were women and the median age was 83 (interquartile range [IQR] 72-88). EP and ER were sole decision-makers in 185 (39.7%) and 135 (30.0%) of cases, respectively. Treatment was withdrawn or withheld in 72.0 and 90.6% of all deaths by EP and ER, respectively (P < 0.001). EP and ER provided full treatment in 88 (34%) and 19 (12.7%) of cases, respectively (P < 0.05). The consideration rated most important was prognosis: 165 (90.2%, confidence interval: 85.0-93.7) and 121 (90.3%, confidence interval: 84.1-94.2) for EP and ER, respectively. ER rated co-morbidities and age more important than did EP (P < 0.05). Both rated discussions with family as very important. EP and ER referred 6.0% versus 11.9% patients to palliative care services, respectively. The proportion of patients taking longer than 24 h to die was higher for ER compared with that for EP (14.1% vs 4.9%, P < 0.05). We found that ER were more likely to withdraw/withhold life-sustaining healthcare, provide partial treatment, rate different considerations as important and their patients took longer to die than that of EP. Focused education and training might improve decision-making consistency between physicians and training registrars.
Publisher: SAGE Publications
Date: 07-05-2020
Abstract: Nonsteroidal anti-inflammatory drugs (NSAIDs) are the recommended agents for treatment of renal colic pain. Some clinicians express concern about their prescription when renal function in unknown. This study aimed to determine the prevalence of renal impairment in patients presenting to emergency departments (ED) with a clinical diagnosis of renal colic. This retrospective observational study included patients with an ED diagnosis of renal colic. Exclusions were patients younger than 18, previous inclusion and missing medical records. The primary outcome of interest was the proportion of patients with abnormal estimated glomerular filtration rate (eGFR), stratified by eGFR group. A total of 1805 patients were studied: median age 46 years and 72% male. In the population overall, the proportion with eGFR less than 45 was 2.6% (95% confidence interval (CI) 2–3.4%). In the subgroup without known renal impairment, the proportion with eGFR less than 45 was 1.7% (95% CI 1.2–2.4%). On multivariate analysis, the only variable predictive of eGFR less than 45 in patients without known renal impairment was age 60 years or older (odds ratio 1.09, 95% CI 1.06–1.12). The proportion of patients with clinical renal colic who have an eGFR less than 45 at ED presentation is very low ( %). This evidence supports administration of NSAIDs for pain relief in patients without known renal impairment before eGFR is known. Not applicable for this multicentre audit.
Publisher: Wiley
Date: 08-09-1999
Publisher: Wiley
Date: 04-2007
DOI: 10.1111/J.1742-6723.2006.00917.X
Abstract: The present pilot study aimed to assess the practicality, safety and accuracy of performing CT coronary angiography (CT-CA) in the evaluation of acute chest pain of patients with low thrombolysis in myocardial infarction (TIMI) risk scores. The present prospective observational study was undertaken in a university teaching hospital between November 2004 and December 2005. Participants were a convenience s le of patients admitted to hospital for investigation of chest pain with TIMI risk scores <3. Consenting patients underwent CT-CA within 48 h of presentation. Outcomes of interest were practicality (proportion of diagnostic quality scans obtained and preparation time for CT-CA), rate of serious adverse events, and accuracy at the patient level using selective coronary angiography as the reference standard. Thirty-four patients were recruited. Diagnostic quality scans were obtained in 26/34 or 76% of patients (four failed CT-CA and four non-diagnostic scans). The median CT preparation time was 1.9 h (range 0.17-4.0). No serious adverse events were found. Fourteen of those 26 patients with diagnostic CT-CA subsequently had selective coronary angiography, of which nine were positive. The sensitivity and specificity of CT-CA in identifying patients with significant coronary artery disease were 9/9 (100% 95% confidence interval 72-100%) and 4/5 (80% 95% confidence interval 28-100%), respectively. The majority of acute chest pain patients with low TIMI risk scores were successfully scanned with a 16-slice CT to produce CT-CA studies with good diagnostic quality and accuracy. No major adverse events were found. The place of CT-CA in diagnostic workup for chest pain remains to be defined.
Publisher: Wiley
Date: 03-09-2014
No related grants have been discovered for Anne-Maree Kelly.