Risk scores and accelerated diagnostic protocols can identify chest pain patients with low risk of major adverse cardiac event who could be discharged early from the ED, saving time and costs. We aimed to derive and validate a chest pain score and accelerated diagnostic protocol (ADP) that could safely increase the proportion of patients suitable for early discharge. Logistic regression identified statistical predictors for major adverse cardiac events in a derivation cohort. Statistical coefficients were converted to whole numbers to create a score. Clinician feedback was used to improve the clinical plausibility and the usability of the final score (Emergency Department Assessment of Chest pain Score [EDACS]). EDACS was combined with electrocardiogram results and troponin results at 0 and 2 h to develop an ADP (EDACS-ADP). The score and EDACS-ADP were validated and tested for reproducibility in separate cohorts of patients. In the derivation (n = 1974) and validation (n = 608) cohorts, the EDACS-ADP classified 42.2% (sensitivity 99.0%, specificity 49.9%) and 51.3% (sensitivity 100.0%, specificity 59.0%) as low risk of major adverse cardiac events, respectively. The intra-class correlation coefficient for categorisation of patients as low risk was 0.87. The EDACS-ADP identified approximately half of the patients presenting to the ED with possible cardiac chest pain as having low risk of short-term major adverse cardiac events, with high sensitivity. This is a significant improvement on similar, previously reported protocols. The EDACS-ADP is reproducible and has the potential to make considerable cost reductions to health systems
ObjectiveWorkplace violence (WPV) is an increasingly concerning occupational hazard within the ED. The aim of the present study was to evaluate the incidence and characteristics of WPV in an adult ED. MethodsA retrospective cohort study was conducted to identify the incidence of ED WPV in an adult metropolitan ED. Data were obtained from the activity records of security staff from 1 January 2013 to 31 December 2015 for all incidents of patient-perpetrated violence. Data on patients identified from these records as requiring security staff intervention for violence in the ED were collected through an explicit chart review. Data on patient illicit drug or alcohol exposure and acute psychiatric diagnoses were also collected. ResultsThere were 1853 episodes of patient-perpetrated WPV identified over the study period. The incidence of WPV over the 3years was 103 (95% CI: 98-108) per 10000 of the presenting population, with a significant increase from 2013 to 2015 (IRR 1.07; 95%CI: 1.04-1.10; P<0.01). Drug and/or alcohol exposure was observed in 1145 (61.8%) patients. Among the drug- and/or alcohol-affected violent population, three quarters (840/1145= 73.4%) did not have a concurrent psychiatric diagnosis that required assessment during the violent presentation. ConclusionThe rate of WPV was increasing within this Australian ED during the study period. The majority of violent patients were affected by drugs and/or alcohol in the absence of a psychiatric diagnosis. Interventions to reduce access to and misuse of alcohol and illicit drugs could have a substantial impact on the concerning increase of violence in the ED.
Clinical staff in EDs are subject to a range of stressors. The objective of this study was to describe and compare clinical staff perceptions of their ED's working environment across two different Australian EDs. Methods This was a cross-sectional, descriptive, research design that included distribution of three survey tools to clinical staff in two Australian EDs in 2016. Descriptive statistics were reported to characterise workplace stressors, coping styles and the ED environment. These data were compared by hospital and the employee's clinical role (nurse or physician). Results In total, 146 ED nurses and doctors completed the survey (response rate: 67%). Despite geographical variation, the staff at the two locations had similar demographic profiles in terms of age, sex and years of experience. Staff reported moderate levels of workload and self-realisation but low levels of conflict or nervousness in the workplace. Nurses and physicians reported similar perceptions of the work environment, although nurses reported slightly higher median levels of workload. Staff rated the death or sexual abuse of a child as most stressful, followed by workplace violence and heavy workload. Staff used a large range of coping strategies, and these were similar across both sites. Conclusion These findings are the first multi-site and multidisciplinary examinations of Australian ED staff perceptions, improving our understanding of staff stressors and coping strategies and highlighting similarities across different EDs. These data support the development and implementation of strategies to improve ED working environments to help ensure professional longevity of ED staff.
Time-out protocols have reportedly improved team dynamics and patients' safety in various clinical settings - particularly in the operating room. In 2016, the World Health Organization (WHO) introduced a Trauma Care checklist, which outlines steps to follow immediately after the primary and secondary surveys and prior to the team leaving the patient. The WHO Trauma Care checklist's main perceived benefit is the prompting of clinicians to complete trauma admissions as per evidence-based guidelines. The WHO Trauma Care checklist, while likely to be successful in reducing errors of omission related to hospital admission, may be limited in its ability to reduce errors that occur in the initial 30 min of trauma reception - when most of the life-saving decisions are made. To address this limitation a Trauma Team Time-out protocol is proposed for initial trauma resuscitation, targeting the critical first 30 min of hospital reception.
Patients with supraventricular tachycardia commonly present to the ED. There is a lack of consensus regarding assessment of these patients. Our aim was to determine the utility of troponin and four other investigations (full blood examination, electrolyte levels, thyroid function tests and chest X‐rays) commonly requested for these patients. MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (January 1992–March 2017) were searched for randomised controlled trials and observational studies (of sample size greater than 10). Our search strategy yielded no randomised controlled trials and seven observational studies with significant statistical heterogeneity among selected studies ( I 2 87.3%, P < 0.001). Included studies investigated a total of 1155 patients. All studies reported on the utility of troponin testing in this patient population. The pooled proportion of patients investigated with troponin was 0.66 (95% confidence interval 0.44–0.88). The pooled proportion of positive troponin tests was 0.32 (95% confidence interval 0.23–0.41). Only one study reported on the utility of the remaining four investigations with abnormal results as follows: thyroid stimulating hormone 14%, haemoglobin 6%, white cell count 19% and chest X‐ray 22%. Investigations are commonly requested for patients presenting with supraventricular tachycardia. Troponin testing is commonly performed with a high proportion of positive findings although these results did not appear to be associated with major adverse cardiac events. Heterogeneity among studies and low levels of evidence precluded conclusions on full blood examinations, electrolyte levels, thyroid testing and utility of chest X‐rays in this patient population.
Musculoskeletal injuries are a common presentation to the ED, with significant costs involved in the management of these injuries, variances in care within the ED and associated morbidity. A series of rapid review papers were completed to guide best practice for the assessment and management of common musculoskeletal injuries presenting to the ED. This paper presents the methodology used across the rapid reviews. PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites, were searched in 2015. The search was repeated consistently for each topic area (injuries of the foot and ankle, knee, hand and wrist, elbow, shoulder, lumbar spine and cervical spine). English-language primary studies, systematic reviews and guidelines that were published in the last 10 years and addressed acute musculoskeletal injury management were considered for inclusion. Data extraction of each included article was conducted, followed by a quality appraisal. The extracted data from each article was synthesised to group similar evidence together. For each rapid review, the evidence has been organised in a way that a clinician can direct their attention to a specific component of the clinical cycle of care in the ED, such as the assessment, diagnostic tests, management and follow-up considerations from ED. The series of rapid reviews are designed to foster evidence-based practice within the ED, targeting the injuries most commonly presenting. The reviews provide clinicians in EDs with rapid access to the best current evidence, which has been synthesised and organised to assist decision-making.
The role of serum troponin testing in patients presenting to the ED after syncope is unclear. The aim of this systematic review was to examine the practice and utility of troponin testing among patients presenting to the ED after syncope. We conducted a search of MEDLINE, Embase, Cochrane Library, Web of Science and Scopus databases from 1990 to February 2017 using keyword and subject headings for syncope and troponin testing. Design and results of the included studies are extracted. Studies were assessed for heterogeneity and the pooled proportion of measured troponin and positive troponin result described. There were nine studies included for analysis. Significant statistical heterogeneity among studies was observed ( P < 0.001). Using the random effects model, the pooled proportion of patients presenting to the ED after syncope who had troponin measured was 0.64 (95% CI 0.46–0.82). Among patients who had been troponin tested, the pooled proportion who had a positive result was 0.19 (95% CI 0.13–0.26). Variability among reported outcomes prevented further meta‐analysis. Troponin testing was commonly performed for the assessment of patients with syncope with a substantial proportion returning positive results. The correlation between raised troponin and patient outcomes was not adequately reported. It is possible that an elevated troponin may indicate serious illness, rather than myocardial damage alone.
The Australian health system is generally well prepared for mass casualty events. Fortunately, there have been very few terrorist attacks and these have involved low numbers of casualties compared with events overseas. Nevertheless, Australian health professionals need to be prepared to treat mass casualties with blast and ballistic trauma. The US military and its allies including Australia have had extensive experience with mass casualty management in the Middle East and Afghanistan wars for more than a decade. To define their experience, they developed the Tactical Combat Casualty Care Guidelines that have saved many lives. It is now prudent to incorporate this knowledge and experience into civilian practice in Australia.
Background There are currently no studies assessing effectiveness of sub-dissociative intranasal (IN) ketamine as the initial analgesic for adult patients in the ED. Objective The study aims to examine the effectiveness of sub-dissociative IN ketamine as a primary analgesic agent for adult patients in the ED. Method This is a prospective, observational study of adult ED patients presenting with severe pain (6 on 11-point scale at triage). IN ketamine dose was 0.7mg/kg, with secondary dose of 0.5mg/kg at 15min if pain did not improve. After 6 months, initial dose was increased to 1.0mg/kg with the same optional secondary dose. Primary outcomes The primary outcomes are change in VAS rating at 30min; percentage of patients reporting clinically significant reduction in VAS (20mm) at 30min; dose resulting in clinically significant pain reduction. Results Of the 72 patients available for analysis, median age was 34.5 years and 64% were men. Median initial VAS rating was 76mm (interquartile range [IQR]: 65-82). Median total dose of IN ketamine for all patients was 0.98mg/kg (IQR: 0.75-1.15, range: 0.59-1.57). Median reduction in VAS rating at 30min was 24mm (IQR: 2-45). Forty (56%, 95% CI: 44.0-66.7) reported VAS reduction 20mm, these patients having had a total median ketamine dose of 0.94mg/kg (IQR: 0.72-1.04). Conclusion IN ketamine, at a dose of about 1mg/kg, was an effective analgesic agent in 56% of study patients. The place of IN ketamine in analgesic guidelines for adults requires further investigation.
Objective: To determine patient expectations of antiemetic treatment in the ED. Methods: Survey of adult ED patients with nausea. Primary outcome: expectation of antiemetic treatment as symptoms being 'totally gone', 'a lot less', 'a little less' and 'the same'. Secondary outcomes' comparison between expectations and symptom change when expectations were met; general views on indications for treatment, treatment satisfaction and reasons for additional medication use. Results: Of 176 surveyed, treatment expectation was recorded by 165 (94%). These were: 'totally gone', 'a lot less' or 'a little less' for 60 (36%), 84 (51%) and 21 (13%), respectively. This pre-treatment nomination, was matched or exceeded by the reported level of symptom reduction at 30 min, for 43/87 (49%, 95% CI: 39-60) whose expectations were met, and 6/33 (18%, 95% CI: 7-35) whose were not. The majority (117/176, 66%) believed treatment should be reserved for moderate or severe nausea; 158/176 (90%) would accept treatment if offered; 130/165 (79%) expected a treatment effect by 30 min. Treatment satisfaction findings were similar to expectations being met. Further drug treatment at 30 min was desired by 29/120 (24%) who received an antiemetic drug. Most were improved, but believed additional drugs might help more. Of the 91 not wanting more treatment, most were improved and thought no more drugs were necessary. Conclusion: Most patients expected antiemetic treatment to make symptoms at least 'a lot less'. Most also believe treatment should be reserved for moderate or severe nausea, and should take effect by 30 min.
Emergency medicine was once exclusively provided in public hospitals in Australia, but now over half a million consultations per annum are in private (7% total emergency consultations). Private EDs have excess capacity and are staffed by senior doctors (majority FACEM) with open access to investigations and broad specialist inpatient services. Public EDs struggle with rising attendances and overcapacity. Private hospitals have high levels of patient satisfaction and aim to optimise service provision. A major barrier to private ED attendances is out-of-pocket costs. Insurers deem private EDs outpatient services and therefore do not contribute any funding to these attendances. Additionally state governments provide no funding while Medicare items cover only 10-15% of costs. Out-of-pocket consultation costs to patients vary nationally ($110-$480) but never cover the full cost of providing services. Patients may also pay out-of-pocket costs for investigations. Private EDs can provide many benefits to patients and the community. Patients can see senior doctors immediately (at less cost per patient than public EDs). Demand can be directed away from resource-poor public EDs. Private EDs could also provide extra surge capacity during disasters. There is a need for further strong advocacy for private emergency medicine at many levels, particularly regarding the lack of funding. Stakeholder relationships should be strengthened. Research and education about decision-making in the choice between public and private ED attendance should be encouraged, particularly regarding paramedic advice to patients. Finally, patients who have purchased private insurance should be able to utilise it during evaluation of an acute illness.
There are a number of cardiac output (CO) monitors that could potentially be used in the ED. Two of the most promising methods, thoracic electrical bioimpedance and suprasternal Doppler, have not been directly compared. The aim of this study was to investigate the feasibility of CO monitoring using suprasternal Doppler and bioimpedance in emergency care and compare haemodynamic data obtained from both monitors. Haemodynamic measurements were made on the same group of patients using bioimpedance (Niccomo, Medis, Germany) and suprasternal Doppler (USCOM, Sydney, Australia). Usable CO data were obtained in 97% of patients by suprasternal Doppler and 87% by bioimpedance. The median CO obtained by Doppler was 3.4 L/min lower than bioimpedance. The stroke volume median was lower by 51 mL in Doppler. These two methods of non-invasive cardiac monitoring are not interchangeable. The results suggest that the choice of non-invasive cardiac monitor is important, but the grounds on which to make this choice are not currently clear.
Objective: Endotracheal intubation requires laryngoscopy followed by passage of the endotracheal tube (ETT). Tube passage can be difficult, but there is little evidence to support which adjunct for tube passage is most effective. Methods: The four tube passage adjuncts tested were the naked ETT, stylet ETT, railroaded bougie and preloaded bougie. Participants completed pre-and post-test surveys identifying demographics, experience and method preference. After instruction, participants completed eight intubations on manikins with 'easy' and 'difficult' airways. Results: One hundred and seventeen practitioners who were experienced emergency medicine physicians, anaesthesiologists and out-of-hospital providers completed 936 total ETT attempts. For the 'difficult' airway, the percentage first pass success (95% confidence interval [CI]) for the naked ETT was 30.8% (23.1-39.7%). This was significantly lower than the stylet ETT (95.7% [86.6-100%]), the railroaded bougie (75.2% [63.8-86.6%]), or the preloaded bougie (89.7% [79.7-99.7%]). On difficult airways, the median (interquartile range [IQR]) time-to-intubation was fastest in the stylet ETT (25.0 s [20.9-32.2 s]) with the railroaded bougie being the slowest (43.2 s [36.5-56.2 s]). Seventynine per cent of participants stated that they would change their practice based on participating in this study. Participants increased their preference for the preloaded bougie from 30.6% to 69.4%. Conclusion: The data show that tube passage with a stylet ETT or a preloaded bougie is superior in terms of higher first pass success, faster time-to-intubation and higher posttest preference. The naked ETT is clearly inferior to other methods. This research supports the recommendation to use a stylet ETT or bougie for every predicted difficult intubation.