The clinical journey of patients with a severe exacerbation of chronic obstructive pulmonary disease (COPD): from the ambulance to the emergency department to the hospital ward.

Background: Exacerbations of chronic obstructive pulmonary disease (COPD) are acute complications that often require emergency management by ambulance, emergency department (ED) and hospital services. Given the high mortality and morbidity of exacerbations, better understanding of the epidemiology of patients with COPD presenting to EDs is needed, as well as identification of predictive factors for adverse outcomes from exacerbations. Methods: This retrospective observational study involved patients who presented to an ED in the state of Queensland and received either an ED or hospital diagnosis of COPD in 2015 and 2016. Administrative data from ambulance, ED, hospital and death registry databases were linked to provide a comprehensive picture of the emergency healthcare pathway for these patients. Results: A total of 16,166 patients (49% female, 51% male) had 29,332 presentations to an ED in Queensland and received either an ED or hospital principal diagnosis of COPD during 2015 and 2016. These patients had a significant comorbidity burden with 54% having two or more comorbidities. Sixty-nine percent of ED presentations involved ambulance transport, and most of these (74%) involved administration of oxygen therapy and/or other medications by paramedics. Prehospital oxygen administration and ≥10 comorbidities were associated with >1 admission [odds ratio (OR) 1.3, 95% confidence interval (CI) 1.1-1.5; OR 4.3, 95% CI: 3.1-5.8, respectively], greater than average lengths of stay (OR 1.5, 95% CI: 1.3-1.6; OR 22.1, 95% CI: 18.1-27.2) and mortality (OR 1.6, 95% CI: 1.5-1.8; OR 5.3, 95% CI: 4.2-6.8). Of the ambulance presentations, 90% were admitted or received ongoing care. Conclusions: COPD places considerable burden on the emergency healthcare pathway including ambulances and EDs in Queensland. Patients with COPD most commonly present to the ED by ambulance and receive extensive pre-hospital management. These patients have significant comorbidity burden and experience high rates of admission and mortality. More research is required to investigate the emergency pathway to further identify reversible factors and enhance healthcare practice and policy for COPD management.

Pre-hospital and emergency department pathways of care for exacerbations of chronic obstructive pulmonary disease (COPD).

Exacerbations are serious complications of chronic obstructive pulmonary disease (COPD) that often require acute care from pre-hospital and emergency department (ED) services. Despite being a frequent cause of emergency presentations, gaps remain in both literature and practice for emergency care pathways of COPD exacerbations. This review seeks to address these gaps and focuses on the literature of pre-hospital and ED systems of care and how these intersect with patients experiencing an exacerbation of COPD. The literature in this area is expanding rapidly; however, more research is required to further understand exacerbations and how they are addressed by emergency medical services worldwide. For the purpose of this review, the pre-hospital domain includes ambulance and other emergency transport services, and encompasses medical interventions delivered prior to arrival at an ED or hospital. The ED domain is defined as the area of a hospital or free-standing centre where patients arrive to receive emergent medical care prior to admission. In many studies there is a significant overlap between these two domains and frequent intersection and collaboration between services. In both of these domains, for the management of COPD exacerbations, several overarching themes have been identified in the literature. These include: the appropriate delivery of oxygen in the emergency setting; strategies to improve the provision of care in accordance with diagnostic and treatment guidelines; strategies to reduce the requirement for emergency presentations; and, technological advances including machine learning which are helping to improve emergency healthcare systems.

Australasian College for Emergency Medicine examiner peer review process: Development and implementation.

INTRODUCTION: In 2005, the Australasian College for Emergency Medicine set out to refine the selection, training and development of examiners. Part of this included development of an examiner peer review process. OBJECTIVES: The objectives of the present study were to observe examiners and seek their opinions on optimal oral examiner techniques, qualities and behaviours, and additionally, to describe how this information was utilized to develop an examiner peer review process. METHODS: A qualitative stepwise method was utilized. This began with development of a list of examiner behaviours based on our direct observation of examiners. This was supplemented by a literature search to develop an examiner technique checklist. The checklist items were then put to the Court of Examiners to be rated on a scale of 1-10 for their perceived importance. A modified Delphi technique was utilized to further develop this checklist as an examiner peer review form with behavioural descriptors. RESULT: An assessment form was developed with similarly themed items grouped together. This form can now be used as the basis for regular feedback to examiners by appointed senior examiners during a peer review process. CONCLUSION: The present article describes the development of a list of optimal examiner attributes, followed by implementation of an examiner peer review process. The authors recommend examiner peer review for high-stakes examinations.

Unintentional falls at home among young and middle-aged New Zealanders resulting in hospital admission or death: context and characteristics.

AIM: This study investigates the characteristics and contexts of unintentional falls at home among young and middle-aged adults. METHOD: We conducted a population-based study of individuals aged 25-59 years resident in Auckland who were admitted to hospital or died following a non-occupational fall at home (July 2005-June 2006). Information was obtained from participant or proxy interviews, and reviews of inpatient records. RESULTS: 344 patients (including 1 death) met the study eligibility criteria representing an overall age-specific incidence rate of 54.0/100,000 (95% CI 48.6-60.1) for the 12-month period. Of the 335 cases (97.4%) interviewed, 36% fell on stairs/steps, 31% fell on the same level, 13% of falls involved ladders/scaffolding, and 11% fell from buildings/structures. Stairs or steps were involved in 43% of falls among females and 28% of falls among males. The majority of falls (81%) occurred in the individual's own home. A quarter (24%) of participants had consumed >or= 2 drinks in the 6 hours preceding the fall, and 24% were on >or= 2 prescription medications. CONCLUSION: While this study was not designed to identify the specific causes of falls, the findings reveal several important contextual factors that can be targeted to prevent fatal and serious non-fatal falls at home among this age group.

Are doctors team players, and do they need to be?

Evidence suggests that teamwork failures contribute to poor outcomes in hospitals and that changes in healthcare delivery have at times worked against the development of effective healthcare teams. Doctors' engagement with the concept of healthcare teams, although variable, has generally been supportive and there have been several successful initiatives. However, lack of evidence on the critical components that improve the performance of healthcare teams impedes growth in our understanding and development of effective teams. In an endeavour to improve the function of healthcare teams through education and systems change, the psychology literature remains a useful framework for studying the critical components of team processes.

The good apprentice in medical education.

This paper targets both current apprentices and their supervisors drawing on current research to answer the following questions. What is apprenticeship and what are the key elements? What is a good apprentice and what can an intern or registrar do to assist their own learning and development? It takes a pragmatic approach and seeks to assist apprentices and their supervisors by attending closely to what is practicable, realistic, expedient and convenient; articulating this and laying it out as clearly as possible.

Maximising learning through effective supervision.

This article targets supervisors and their important role in maximising learning of novice practitioners. The article draws on current research to highlight the importance of clinical supervision and the roles and tasks of the supervisor. Some of the challenges of supervision and how the supervisor can be supported are also discussed. The article has a pragmatic and practical focus to assist the supervisor in one of the most important, challenging but rewarding educational roles.

Atrio-oesophageal fistula: an emergent complication of radiofrequency ablation.

A 72-year-old presented with features of sepsis, neurological sequelae and chest pain after a radiofrequency ablation for AF. Chest CT scan revealed a life-threatening condition not previously reported in emergency medicine journals.

Junior doctor strike model of care: Reduced access block and predominant Fellow of the Australasian College for Emergency Medicine staffing improve emergency department performance.

OBJECTIVE: To describe the response and analyse ED performance during a 5-day junior doctor strike. METHODS: Data were collected via the patient information management computer system. Key performance indicators included percentage seen within maximum waiting times per triage category (TC), ED length of stay, emergency medicine patients who did not wait to be seen, hospital bed occupancy and access block percentage. Comparisons were made for the same 5 days before the strike (BS), during the strike (S) and after the strike. RESULTS: Total doctor's shifts BS were 78.66 with 25% of these shifts being Fellow of the Australasian College for Emergency Medicine (FACEM) shifts. FACEM shifts were more common during the S period at 75% (P < 0.001). Total attendances (BS 631 vs S 596, P = 0.22) and TC percentages (P-values for TC 1, 2, 3, 4, 5, respectively, 1.0, 0.55, 0.88, 0.97, 0.46) in the BS, S and after-the-strike periods were not significantly different. Despite fewer total doctor shifts, the FACEM predominant model of care during the strike resulted in better percentages seen within the maximum waiting times for TC3 (66%), TC4 (78%) and TC5 (86%) (all P < 0.001). There was a reduction in patients who did not wait to be seen (28 BS vs 5 S, P < 0.001), ED length of stay (admissions: BS 451 min vs S 258 min, P < 0.001; discharges: BS 233 min vs S 144 min, P < 0.02) and referrals to inpatient services (P = 0.02). This occurred with reduced bed point occupancy of 66% and a consequent reduction in access block. CONCLUSION: FACEM staffing and reduced access block were significant factors in improved ED performance.

Update on the fellowship exam and its relation to modern educational principles and clinical competency.

The Australasian College for Emergency Medicine is committed to a long term process of quality improvement in the fellowship examination and the training programme leading up to it. The process of quality improvement and the rationale for current and future processes are not always clear to the fellowship as a whole. The present article attempts to update the fellowship on the current thinking with regard to the fellowship exam and the work that is being done surrounding this and relevant areas. This is related to some modern educational assessment principles and terminology. More research is required into the relevance of each component of the fellowship exam and its relation to clinical competency, key competencies and good clinical practice. Any subsequent changes to the exam structure must take into account the evidence and be balanced by what is practicable, reasonable and deliverable.

Antithrombotic therapy in atrial fibrillation: an assessment of compliance with guidelines.

AIM: To assess physician compliance (at South Auckland's Middlemore Hospital) with two international guidelines on the prevention of thromboembolic complications of atrial fibrillation (AF). The two guidelines are The American College of Cardiology/American Heart Association/European Society of Cardiology consensus group (ACC/AHA/ESC guidelines-2001) and the American College of Chest Physicians guidelines (ACCP guidelines-2001). METHOD: A retrospective review of patients who presented to the emergency department with AF between 1 December 2001 and 28 February 2002. Antithrombotic treatment was compared with that recommended by the above stated international guidelines. It was hypothesised that 20% variance from guideline recommended treatment was clinically significant. The incidence of stroke in the study group was followed over a 12-month period. RESULTS: Eighty patients were included in the study. The proportion of patients managed in accordance with the ACC/AHA/ESC and ACCP guidelines was 47.5% (95% CI 36.2-59.0) and 31.2% (95% CI 21.3-42.6) respectively. This was significantly different from that hypothesised (p<0.0001). Only 47.4% (95% CI 34.0-61.0) and 47.3% (95% CI 33.6-61.2) of eligible patients, according to ACC/AHA/ESC and ACCP guidelines respectively, received warfarin. This was also less than hypothesised; p<0.0001. High-risk patients were less likely to be given warfarin if they were older (p<0.03). Four patients had a stroke at follow-up. These patients were not on warfarin, although recommended by the guidelines. CONCLUSION: Warfarin is significantly underutilised in patients with AF at our institution.

Paracetamol poisoning: which nomogram should we use?

OBJECTIVES: To determine the type of paracetamol nomograms used in Australasian EDs. To review the literature to determine the evidence base for existing nomograms. METHODS: A cross sectional descriptive study via postal survey of all Australasian EDs accredited for specialist emergency medicine training by the Australasian College for Emergency Medicine (ACEM). A literature review using Knowledge Finder search engine was employed. RESULTS: The response rate was 87%. The most commonly used nomogram had a four-hour treatment level of 1300 mumol/L (69%). A total of 22% of respondents used a four-hour treatment level of 1000 mumol/L. Two departments (3%) treated all patients above the 660 mumol/L line. Eleven departments (15%) did not have a treatment line below 1300 mumol/L. CONCLUSION: Practice varies in Australasian EDs. Patients with paracetamol levels below the 1300 mumol/L have been reported in the literature to develop hepatotoxicity, and deaths have been documented. N-acetylcysteine is extremely safe when used in the recommended dosages.

Acute gastroenteritis associated with seafood privately imported from the Pacific Islands.

AIMS: To investigate a potential link between consumption of food privately imported from the Pacific Islands and presentation with acute gastroenteritis to Middlemore Hospital Emergency Department. METHODS: This was a three month prospective observational case study that included patients aged greater than fifteen years presenting with acute gastroenteritis and a history of food privately imported from the Pacific Islands. Data included case demographics, symptoms, island of food origin and food type. Stool and blood samples were collected and analysed. RESULTS: Of 358 patients who presented to Middlemore Emergency Department during the study period with gastroenteritis, 34 (9.4%) had a history of consumption of food privately imported from the Pacific Islands. The seafood came from Tonga (23 cases), Samoa (10 cases) or Niue (1 case). The implicated seafood was shellfish (28 cases), jellyfish (2 cases), fish intestine (2 cases), seaweed or seaslug (1 case each). Fourteen patients (41%) provided stool samples; all were culture positive for Vibrio parahaemolyticus (VPH). CONCLUSIONS: This case series confirms a link between acute VPH gastroenteritis and consumption of seafood privately imported from the Pacific Islands. A number of public health initiatives to reduce the burden of VPH gastroenteritis among Auckland's Pacific Islanders have commenced. The Ministries of Health, Agriculture and Forestry are considering tighter controls or banning food privately imported from the Pacific Islands.