Summer alcohol-related emergency department workload and occupancy in Australasia 2019-2022.

OBJECTIVE: Alcohol is a major public health issue and the ACEM funds regular 'snapshot' surveys of the prevalence of alcohol-related presentations in EDs. The present study uses these data to investigate ED occupancy and alcohol- and methamphetamine-related presentations at the time of the COVID-19 pandemic. METHODS: Survey-based point prevalence study of EDs in Australia and New Zealand conducted at 02:00 hours local time on the Saturday of the weekend before Christmas in 2019-2022. Primary outcomes were ED occupancy, the number of alcohol-related presentations and methamphetamine-related presentations in each ED at the time of survey. RESULTS: Seventy eight of a possible 152 hospitals answered all four surveys (51%, 95% confidence interval 43-59, individual yearly response rates ranged from 70.5% to 83.3%). The mean number of alcohol-related presentations in EDs at the snapshot time was 4.2 (95% confidence interval 3.2-5.2) in the 2019 survey and 3.8 (3.1-4.6) in 2022 with no significant variation over time. There was also no change in methamphetamine-related presentations which occurred at a lower level. There was a major increase in reported total ED occupancy - from 31.4 to 43.5 in Australia (P < 0.0001, paired t test) and from 22.8 to 38.7 in New Zealand (P = 0.0001). Subgroup analysis showed that both the number being treated and the number waiting to be seen increased, with little change in the number in observation units. CONCLUSIONS: The present study demonstrates that the COVID-19 pandemic did not affect summer alcohol-related ED presentations in Australasia but was associated with an unsustainable increase in ED crowding.

A multicentre case series of analytically confirmed gamma-hydroxybutyrate intoxications in Western Australian emergency departments: Pre-hospital circumstances, co-detections and clinical outcomes.

INTRODUCTION: Gamma-hydroxybutyrate (GHB) use is associated with high risk of accidental overdose. This study examined the pre-hospital circumstances, demographic characteristics and clinical outcomes of analytically confirmed GHB emergency department (ED) presentations in Western Australia (WA). METHODS: This case series was conducted across three WA EDs involved in the Emerging Drugs Network of Australia, from April 2020 to July 2022. Patient demographics, pre-hospital drug exposure circumstances and ED presentation and outcome characteristics were collected from ambulance and hospital medical records of GHB-confirmed cases. RESULTS: GHB was detected in 45 ED presentations. The median age was 34 years and 53.3% (n = 24) were female. Most patients arrived at the ED by ambulance (n = 37, 85.7%) and required immediate emergency care (Australasian Triage Score 1 or 2 = 97.8%). One-third of patients were admitted to intensive care (n = 14, 31.1%). Methylamphetamine was co-detected in 37 (82.2%) GHB-confirmed cases. Reduced conscious state was indicated by first recorded Glasgow Coma Scale of ≤8 (n = 29, 64.4%) and observations of patients becoming, or being found, 'unresponsive' and 'unconscious' in various pre-hospital settings (n = 28, 62.2%). 'Agitated' and/or 'erratic' mental state and behavioural observations were recorded in 20 (44.4%) cases. DISCUSSION AND CONCLUSIONS: Analytically verified data from ED presentations with acute toxicity provides an objective information source on drug use trends and emerging public health threats. In our study, patients presenting to WA EDs with GHB intoxication were acutely unwell, often requiring intensive care treatment. The unexpectedly high proportion of female GHB intoxications and methylamphetamine co-ingestion warrants further exploration.

Assessing the utility of night-time presentations as a proxy for alcohol-related harm among young emergency department trauma patients.

OBJECTIVE: To assess the usefulness of night-time presentations to measure alcohol-related harm (ARH) in young trauma patients, aged 12-24 years, attending Western Australian EDs. METHODS: A retrospective longitudinal study examined alcohol-related ED presentations in Western Australia (WA; 2002-2016) among 12- to 24-year-olds. Data from the Emergency Department Data Collection, WA State Trauma Registry Database and Hospital Morbidity Data Collection were used to identify ARH through specific codes and text searches. These were compared to ARH estimates based on presentation time. Statistical analysis involved sensitivity and specificity calculations and Cox proportional hazards modelling. RESULTS: We identified 2644 (17.8%) night-time presentations as a proxy measure of ARH among the 14 887 presentations of patients aged 12-24 years. This closely matched the 3064 (20.6%) identified as ARH through coding methods. The highest risk for an ARH presentation occurred during the night hours between 00.00 and 04.59 hours. During these hours, the risk was 4.4-5.1 times higher compared to presentations at midday (between 12.00 and 12.59 hours). However, when looking at individual patients, we observed that night-time presentations were not a strong predictor of ARH (sensitivity: 0.39; positive predictive value: 0.46). CONCLUSIONS: Implementing targeted interventions during night hours could be beneficial in addressing ARH presentations. However, relying solely on the time of presentation as a proxy for ARH is unlikely to effectively identify ARH in young individuals. Instead, the present study emphasises the importance of implementing mandatory data collection strategies in EDs to ensure accurate measurement of ARH cases.

Incidence, Management, and Hospital Costs of Orthopaedic Injuries of E-Scooter Riders in Western Australia.

The use of electric scooters (e-scooters) is increasing in Australia and internationally. The increasing availability of e-scooters has led to a rise in the number of injuries, with most patients sustaining orthopaedic injuries. This retrospective case series describes the incidence, management, and hospital costs of the orthopaedic injuries, which presented to the emergency department (ED) of the major trauma center in Western Australia. Data on demographics, ED dispatch destination, management, follow-up clinics, and hospital costs were collected between 2017 and 2022. Since June 2020, there have been 61 e-scooter crashes, which resulted in orthopaedic injuries, with more than half of the crashes occurring after the introduction of regional e-scooter sharing schemes. Thirty-two patients (52%) were admitted to the hospital. The most common orthopaedic fracture was to the upper limb (44%), followed by the lower limb (41%) and the axial skeleton (15%). Fourteen (23%) patients sustained more than one fracture. Twenty-two patients (36%) required operative management. The median number of outpatient clinic attendances per patient was 3 (interquartile range (IQR): 1-5), with inpatients requiring twice the number of clinics as compared to those discharged from the ED. The median cost per presentation was AU$5880.60 (IQR: AU$1283.10-AU$21,150.90) with inpatient costs exceeding those discharged from the ED. The range of the total costs was AU$413.80 to AU$100,239.80. The rise in the accessibility of e-scooters in Western Australia has led to a rise in ED presentations with orthopaedic injuries. Considering the recent implementation of e-scooter sharing schemes in metropolitan areas, ongoing surveillance of e-scooter injuries by clinicians and policy makers is warranted to inform harm minimization strategies.

Western Australian State Trauma Registry analysis of incidence and injury patterns associated with e-Scooter injuries: 5-year retrospective case series.

BACKGROUND: Electric scooters (e-Scooters) are a form of motorized vehicle that offers cheap, efficient and environmentally friendly transportation. Increased e-Scooter utilization has been accompanied by increases in e-Scooter related injuries in multiple countries. This project describes the incidence, injury pattern, injury severity and patient factors associated with e-Scooter use from the Western Australian State Trauma Registry. METHODS: Retrospective cohort of all trauma patients captured by the Western Australian State Trauma Registry between 01 July 2017 and 30 June 2022 were analysed. Patient demographics, helmet use, reported drug use, and injury details (including principal and additional diagnoses, ISS) were collected. RESULTS: Eighty-one patients sustained e-Scooter related injuries between 2017 and 2022. Fifty-four (66%) of hospital admissions were recorded in 2021-2022, an annual percent change of 385.7% from the previous year. Most patients were male (80%). Median age was 40 years (IQR: 32-50). Helmet use was reported in 43% of patients. Helmet use was associated with a significantly lower odds of head injury (OR = 4.42, CI: 1.38-14.21; P = 0.01). Thirty-five percent of patients were intoxicated with either alcohol or drugs. Forty-four (54%) patients required surgery. CONCLUSION: E-Scooter crashes are a new mechanism of injury affecting patients captured by the Western Australian State Trauma Registry. Helmet use correlated with a reduced risk of head injury.

Analytically confirmed illicit and novel psychoactive drug use in Western Australian emergency departments: initial results from the Emerging Drugs Network of Australia (EDNA).

INTRODUCTION: The burden of acute illicit drug use in Australia is largely unknown. Establishing a prospective drug surveillance system in emergency departments using analytical confirmation may facilitate the early identification of emerging drugs. We describe demographic data and acute toxicity patterns, stratified by analytical confirmation of illicit drugs and novel psychoactive substances, to emergency departments in Western Australia. METHODS: Patients presenting with severe and/or unusual clinical features consistent with recreational drug toxicity were identified across five Western Australian emergency departments participating in the Emerging Drugs Network of Australia between April 2020 and December 2021. Demographic and toxicology patterns in patients with and without analytically confirmed illicit drugs/novel psychoactive substances from blood samples were collected during the emergency department presentation. RESULTS: The cohort included 434 severe and/or unusual toxicology presentations; median age 33 years (first and third quartiles 25-40 years), 268 (61.8%) males. Any substance (illicit, novel psychoactive substance, pharmaceutical) was detected in 405 (93.3%) presentations. Illicit drugs/novel psychoactive substances were detected in 257 (59.2%) presentations, including 73 (28.3%) with more than one confirmed illicit drug/novel psychoactive substance. Frequent illicit drugs identified were metamfetamine (n = 201, 77.9%) and gamma-hydroxybutyrate (n = 30, 11.6%). Forty-eight novel psychoactive substances were detected within 43 (16.7%) presentations. Novel benzodiazepines were most frequently detected (n = 29, 60.4%). Frequent pharmaceuticals detected included diazepam (n = 100, 26.1%) and clonazepam (n = 40, 10.4%). One hundred and fifty-five (35.7%) presentations were discharged home and 56 (12.9%) were admitted to intensive care. Presentations with detected illicit drugs/novel psychoactive substances had a lower median intensive care length of stay compared to presentations without detected illicit drugs/novel psychoactive substances (32.6 h versus 50.8 h respectively, P < 0.001). CONCLUSIONS: Integration of clinical and analytic data in patients with severe and/or unusual toxicology presentations via the Emerging Drugs Network of Australia provides insight into illicit drug/novel psychoactive substance use responsible for acute harm across Western Australian emergency departments.

Impact of art and reflective practice on medical education in the emergency department.

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

Genes involved in platelet aggregation and activation are downregulated during acute anaphylaxis in humans.

Objective: Mechanisms underlying the anaphylactic reaction in humans are not fully understood. Here, we aimed at improving our understanding of anaphylaxis by investigating gene expression changes. Methods: Microarray data set GSE69063 was analysed, describing emergency department (ED) patients with severe anaphylaxis (n = 12), moderate anaphylaxis (n = 6), sepsis (n = 20) and trauma (n = 11). Samples were taken at ED presentation (T0) and 1 h later (T1). Healthy controls were age and sex matched to ED patient groups. Gene expression changes were determined using limma, and pathway analysis applied. Differentially expressed genes were validated in an independent cohort of anaphylaxis patients (n = 31) and matched healthy controls (n = 10), using quantitative reverse transcription-polymerase chain reaction. Results: Platelet aggregation was dysregulated in severe anaphylaxis at T0, but not in moderate anaphylaxis, sepsis or trauma. Dysregulation was not observed in patients who received adrenaline before T0. Seven genes (GATA1 (adjusted P-value = 5.57 × 10-4), TLN1 (adjusted P-value = 9.40 × 10-4), GP1BA (adjusted P-value = 2.15 × 10-2), SELP (adjusted P-value = 2.29 × 10-2), MPL (adjusted P-value = 1.20 × 10-2), F13A1 (adjusted P-value = 1.39 × 10-2) and SPARC (adjusted P-value = 4.06 × 10-2)) were significantly downregulated in severe anaphylaxis patients who did not receive adrenaline before ED arrival, compared with healthy controls. One gene (TLN1 (adjusted P-value = 1.29 × 10-2)) was significantly downregulated in moderate anaphylaxis patients who did not receive adrenaline before ED arrival, compared with healthy controls. Conclusion: Downregulation of genes involved in platelet aggregation and activation is a unique feature of the early anaphylactic reaction not previously reported and may be associated with reaction severity.

'Trial by fire': An online survey exploring confidence of junior doctors in managing toxicology presentations to the emergency department.

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

Influenza epidemiology in patients admitted to sentinel Australian hospitals in 2019: the Influenza Complications Alert Network (FluCAN).

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

Surveillance for severe influenza and COVID-19 in patients admitted to sentinel Australian hospitals in 2020: the Influenza Complications Alert Network (FluCAN).

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

Prehospital continuous positive airway pressure (CPAP) for acute respiratory distress: a randomised controlled trial.

OBJECTIVE: To compare the efficacy of continuous positive airway pressure (CPAP) versus usual care for prehospital patients with severe respiratory distress. METHODS: We conducted a parallel group, individual patient, non-blinded randomised controlled trial in Western Australia between March 2016 and December 2018. Eligible patients were aged ≥40 years with acute severe respiratory distress of non-traumatic origin and unresponsive to initial treatments by emergency medical service (EMS) paramedics. Patients were randomised (1:1) to usual care or usual care plus CPAP. The primary outcomes were change in dyspnoea score and change in RR at ED arrival, and hospital length of stay. RESULTS: 708 patients were randomly assigned (opaque sealed envelope) to usual care (n=346) or CPAP (n=362). Compared with usual care, patients randomised to CPAP had a greater reduction in dyspnoea scores (usual care -1.0, IQR -3.0 to 0.0 vs CPAP -3.5, IQR -5.2 to -2.0), median difference -2.0 (95% CI -2.5 to -1.6); and RR (usual care -4.0, IQR -9.0 to 0.0 min-1 vs CPAP -8.0, IQR -14.0 to -4.0 min-1), median difference -4.0 (95% CI -5.0 to -4.0) min-1. There was no difference in hospital length of stay (usual care 4.2, IQR 2.1 to 7.8 days vs CPAP 4.8, IQR 2.5 to 7.9 days) for the n=624 cases admitted to hospital, median difference 0.36 (95% CI -0.17 to 0.90). CONCLUSIONS: The use of prehospital CPAP by EMS paramedics reduced dyspnoea and tachypnoea in patients with acute respiratory distress but did not impact hospital length of stay. TRIAL REGISTRATION NUMBER: ACTRN12615001180505.

The Emerging Drugs Network of Australia: A toxicosurveillance system of illicit and emerging drugs in the emergency department.

OBJECTIVE: The unprecedented rise in synthetic drugs, many containing unknown toxic agents, has made timely analytical diagnosis more difficult, and has reduced the confidence of clinicians providing ED management to this population of patients. This has also impacted the quality of evidence informing harm reduction responses. The Emerging Drugs Network of Australia (EDNA) brings together emergency physicians, toxicologists and forensic laboratories to establish a standardised ED toxicosurveillance system in Australia. METHODS: Blood analysis of intoxicated patients will be conducted by forensic laboratories to enable precise identification of the substances causing acute toxicity. This will be linked with clinical data collected at the time of ED presentation to enable analysis of the clinical effects and outcomes associated with different illicit and emerging drugs. Toxicological and clinical data collected across sentinel sites will align with a nationally endorsed minimum dataset. RESULTS: EDNA's collaborative network will establish a national system of surveillance and reporting of illicit and emerging drugs causing acute toxicity. Standardisation of data collection recorded in a national clinical registry will provide more robust data on epidemiology and associated harms. This will facilitate the translation of clinical and toxicological evidence into timely, appropriate harm reduction and policy. CONCLUSION: Our work represents a collaborative response to calls for more sophisticated data on emerging drug trends in Australia. EDNA will improve coordination between clinicians and analytical services by way of its standardised approach to surveillance and reporting.

Small nucleolar RNA networks are up-regulated during human anaphylaxis.

BACKGROUND: Anaphylaxis is a severe, potentially life-threatening allergic reaction driven primarily by the activation of mast cells. We still fail to understand factors underlying reaction severity. Furthermore, there is currently no reliable diagnostic test to confirm anaphylaxis in the emergency department (ED). OBJECTIVE: This study sought to explore gene expression changes associated with anaphylaxis severity in peripheral blood leucocytes and evaluate biomarker potential. METHODS: Microarray analysis (total RNA) was performed using peripheral blood samples from ED patients with moderate (n = 6) or severe (n = 12) anaphylaxis and sepsis (n = 20) at presentation (T0) and one hour later (T1). Results were compared between groups and healthy controls (n = 10 and n = 11 matched to anaphylaxis and sepsis patients, respectively). Changes in gene expression were determined using R programming language, and pathway analysis applied to explore biological processes and pathways associated with genes. Differentially expressed genes were validated in an independent cohort of anaphylaxis (n = 30) and sepsis (n = 20) patients, and healthy controls (n = 10), using quantitative reverse transcription-polymerase chain reaction (qRT-PCR). RESULTS: Significant up-regulation of small nucleolar RNAs (snoRNAs) was demonstrated in anaphylaxis compared to sepsis patients in the microarray cohort, at T0 and T1. qRT-PCR analysis of the validation cohort showed five genes: SNORD61, SNORD8, SNORD69, SNORD119 and HIST1H1D to be significantly up-regulated (adjusted p < 0.05) in severe anaphylaxis compared to sepsis. Seven genes (SNORD61, SNORD8, SCARNA21, SNORD69, SNORD110, SNORD119 and SNORD59A) were significantly up-regulated (adjusted p < 0.05) in severe anaphylaxis compared to healthy controls. CONCLUSION: This study demonstrates for the first time the unique involvement of snoRNAs in the pathogenesis of anaphylaxis and suggests they are not a general feature of systemic inflammation. Further investigation of snoRNA expression in anaphylaxis could provide insights into disease pathogenesis. CLINICAL RELEVANCE: SnoRNAs are up-regulated during acute anaphylaxis in humans and could potentially be used as biomarkers of severe anaphylaxis.

Is a nudge all we need to promote deliberate clinical inertia and thoughtful clinical decision making?

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

Single high-sensitivity troponin levels to assess patients with potential acute coronary syndromes.

OBJECTIVE: We tested the hypothesis that patients with a potential acute coronary syndrome (ACS) and very low levels of high-sensitivity cardiac troponin I can be efficiently and safely discharged from the emergency department after a single troponin measurement. METHODS: This prospective cohort study recruited 2255 consecutive patients aged ≥18 years presenting to the Emergency Department, Royal Perth Hospital, Western Australia, with chest pain without high-risk features but requiring the exclusion of ACS. Patients were managed using a guideline-recommended pathway or our novel Single Troponin Accelerated Triage (STAT) pathway. The primary outcome was the percentage of patients discharged in <3 hours. Secondary outcomes included the duration of observation and death or acute myocardial infarction in the next 30 days. RESULTS: The study enrolled 1131 patients to the standard cohort and 1124 to the STAT cohort. Thirty-eight per cent of the standard cohort were discharged directly from emergency department compared with 63% of the STAT cohort (p<0.001). The median duration of observation was 4.3 (IQR 3.3-7.1) hours in the standard cohort and 3.6 (2.6-5.4) hours in the STAT cohort (p<0.001), with 21% and 38% discharged in <3 hours, respectively (p<0.001). No patients discharged directly from the emergency department died or suffered an acute myocardial infarction within 30 days in either cohort. CONCLUSIONS: Among low-risk patients with a potential ACS, a pathway which incorporates early discharge based on a single very low level of high-sensitivity cardiac troponin increases the proportion of patients discharged directly from the emergency department, reduces length of stay and is safe. TRIAL REGISTRATION NUMBER: ACTRN12618000797279.

Research, kindness and the antifragility of emergency medicine.

Antifragility is a property of things that benefit from shocks, randomness and uncertainty and love adventure and risk. This describes emergency medicine. Improving evidence-based medicine requires a learning health system, where the whole system is constructed to advance patient care via research driven excellence. So we need to develop our own evidence base by embedding research into everyday practice. Clinical research is messy but the repeated stress testing of clinical practice via research enhances our antifragility. This is even more important because our world is complex, as are humans. Unfortunately, the human brain is hard wired for simplicity, making us disinclined to challenge the status quo. Yet probably <10% of our practice is supported by high-level evidence. Research is altruistic and a form of kindness for our patients, which includes having a culture of research within a learning health system, so that we can be thoughtful!

"Sorry, what did you say?" Communicating defibrillator retrieval and use in OHCA emergency calls.

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

Impact of the Four-Hour Rule policy on emergency medical services delays in Australian EDs: a longitudinal cohort study.

INTRODUCTION: Delayed handover of emergency medical services (EMS) patients to EDs is a major issue with hospital crowding considered a primary cause. We explore the impact of the 4-hour rule (the Policy) in Australia, focusing on ambulance and ED delays. METHODS: EMS (ambulance), ED and hospital data of adult patients presenting to 14 EDs from 2002 to 2013 in three jurisdictions were linked. Interrupted time series 'Before-and-After' trend analysis was used for assessing the Policy's impact. Random effects meta-regression analysis was examined for associations between ambulance delays and Policy-associated ED intake, throughput and output changes. RESULTS: Before the Policy, the proportion of ED ambulances delayed increased between 1.1% and 1.7% per quarter across jurisdictions. After Policy introduction, Western Australia's increasing trend continued but Queensland decreased by 5.1% per quarter. In New South Wales, ambulance delay decreased 7.1% in the first quarter after Policy introduction. ED intake (triage delay) improved only in New South Wales and Queensland. Each 1% ambulance delay reduction was significantly associated with a 0.91% reduction in triage delay (p=0.014) but not ED length of stay ≤4 hours (p=0.307) or access-block/boarding (p=0.605) suggesting only partial improvement in ambulance delay overall. CONCLUSION: The Policy was associated with reduced ambulance delays over time in Queensland and only the immediate period in New South Wales. Associations may be due to local jurisdictional initiatives to improve ambulance performance. Strategies to alleviate ambulance delay may need to focus on the ED intake component. These should be re-examined with longer periods of post-Policy data.