Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.

Utstein-style guidelines contribute to improved public health internationally by providing a structured framework with which to compare emergency medical services systems. Advances in resuscitation science, new insights into important predictors of outcome from out-of-hospital cardiac arrest, and lessons learned from methodological research prompted this review and update of the 2004 Utstein guidelines. Representatives of the International Liaison Committee on Resuscitation developed an updated Utstein reporting framework iteratively by meeting face to face, by teleconference, and by Web survey during 2012 through 2014. Herein are recommendations for reporting out-of-hospital cardiac arrest. Data elements were grouped by system factors, dispatch/recognition, patient variables, resuscitation/postresuscitation processes, and outcomes. Elements were classified as core or supplemental using a modified Delphi process primarily based on respondents' assessment of the evidence-based importance of capturing those elements, tempered by the challenges to collect them. New or modified elements reflected consensus on the need to account for emergency medical services system factors, increasing availability of automated external defibrillators, data collection processes, epidemiology trends, increasing use of dispatcher-assisted cardiopulmonary resuscitation, emerging field treatments, postresuscitation care, prognostication tools, and trends in organ recovery. A standard reporting template is recommended to promote standardized reporting. This template facilitates reporting of the bystander-witnessed, shockable rhythm as a measure of emergency medical services system efficacy and all emergency medical services system-treated arrests as a measure of system effectiveness. Several additional important subgroups are identified that enable an estimate of the specific contribution of rhythm and bystander actions that are key determinants of outcome.

Characteristics and Outcomes of MI Patients with and without Chest Pain: A Cohort Study.

INTRODUCTION: There are conflicting data on patient characteristics and outcomes of myocardial infarction (MI) patients presenting with and without the symptom of chest pain. OBJECTIVES: Compare the characteristics and survival of patients stratified by the symptom chest pain. METHODS: This retrospective cohort study identified patients with an emergency department discharge diagnosis of MI, who arrived by ambulance at a teaching hospital in Perth, Western Australia, between January 2008 to October 2009. The cohort was linked to hospital data and the state-based death register; clinical data were extracted by medical record review. Patient characteristics were compared using logistic regression models and survival analysis using Kaplan-Meier curves and Cox regression models. RESULTS: Of 382 patients, 26% presented without chest pain. The odds of presenting without chest pain were increased if aged 80+ (OR 7.54; 95%CI 2.81-20.3) and aged 70-79 years (OR 4.33; 95% CI 1.50-12.5), and female (OR 1.67; 95%CI 0.99-2.82). The adjusted hazard (median follow-up time 2.2 years) of presenting without chest pain was not significantly associated with survival (HR 1.03; 95%CI 0.71-1.48). CONCLUSION: Characteristics differed between patients with and without chest pain. However, the symptom of chest pain was not associated with survival.

Symptoms of myocardial infarction: concordance between paramedic and hospital records.

INTRODUCTION: To further reduce time to definitive therapy for acute myocardial infarction (MI) patients, the focus of research needs to be on better understanding prehospital delay in recognition and response to symptoms. Paramedic clinical records can serve as a convenient source of data for such studies, but their accuracy needs to be established. OBJECTIVES: This study aimed to determine the concordance of the symptoms and symptom-onset time recorded in the paramedic patient care record (PCR) with those recorded in the hospital medical record for MI patients. METHODS: A retrospective review of paramedic and hospital medical records was undertaken between January 1, 2008 and October 31, 2009 for all patients with an emergency department (ED) discharge diagnosis of MI at a single teaching hospital in Perth, Western Australia. The symptoms of MI and onset times documented in the paramedic PCR were compared with those recorded in the hospital medical record, which was considered the "gold standard." The study assessed differences in documentation using McNemar's tests, and concordance was described by kappa and adjusted kappa statistics, sensitivity, specificity, and positive and negative predictive value (PPV, NPV). RESULTS: Of 810 patients with an ED discharge diagnosis of MI, 584 (71%) patients arrived by ambulance and 509 patients had a paramedic PCR. After exclusions, 400 patients had both paramedic PCR and hospital medical records available for review. Of 21 documented MI symptoms, the majority (71.4%) had adjusted kappa statistics greater than 0.75, and observed agreement greater than 90%. For the symptom of chest pain, sensitivity, specificity, PPV, and NPV were all over 85%. Where recorded in both records (n = 196, 49%) the symptom-onset time agreed exactly for 118 (60.2%) records, differed by 1-15 minutes for 24 (12.2%) records, and differed by 16-30 minutes for 22 (11.2%) records. CONCLUSION: Our study demonstrated that documentation of the common symptoms of MI and symptom-onset time was similar between the paramedic and hospital records, justifying the use of paramedic PCRs as a source of data for research in prehospital MI patient delay. Further research is required to investigate why symptom-onset time was not routinely documented for all patients with chest pain.

Myocardial infarction: sex differences in symptoms reported to emergency dispatch.

BACKGROUND: Emergency management of myocardial infarction (MI) is time-critical, because improved patient outcomes are associated with reduced time from symptom onset to definitive care. Previous studies have identified that women are less likely to present with chest pain. OBJECTIVE: We sought to measure the effect of sex on symptoms reported to the ambulance dispatch and ambulance times for MI patients. METHODS: The Western Australia Emergency Department Information System (EDIS) was used to identify patients with emergency department (ED) diagnoses of MI (ST-segment elevation MI and non-ST-segment elevation MI) who arrived by ambulance between January 1, 2008, and October 31, 2009. Their emergency telephone calls to the ambulance service were transcribed to identify presenting symptoms. Ambulance data were used to examine ambulance times. Sex differences were analyzed using descriptive and age-adjusted regression analysis. RESULTS: Of 3,329 MI patients who presented to Perth EDs, 2,100 (63.1%) arrived by ambulance. After predefined exclusions, 1,681 emergency calls were analyzed. The women (n = 621; 36.9%) were older than the men (p < 0.001) and, even after age adjustment, were less likely to report chest pain (odds ratio [OR] = 0.70; 95% confidence interval [CI] 0.57, 0.88). After age adjustment, ambulance times did not differ between the male and female patients with chest pain. The women with chest pain were less likely than the men with chest pain to be allocated a "priority 1" (lights and sirens) ambulance response (men 98.3% vs. women 95.5%; OR = 0.39; 95% CI 0.18, 0.87). CONCLUSION: Ambulance dispatch officers (and paramedics) need to be aware of potential sex differences in MI presentation in order to ensure appropriate ambulance response.

Prehospital continuous positive airway pressure for acute respiratory failure: a systematic review and meta-analysis.

INTRODUCTION: Acute respiratory failure (ARF) is a common problem encountered by emergency medical services and is associated with significant morbidity, mortality, and health care costs. Continuous positive airway pressure (CPAP) is an integral part of the hospital treatment of acute ARF, predominantly because of congestive heart failure. Intuitively, better patient outcomes may be achieved when CPAP is applied early in the prehospital setting, but there are few outcome studies to validate its use in this setting. OBJECTIVE: This systematic review and meta-analysis aimed to examine the effectiveness of CPAP in the prehospital setting for patients with ARF. METHODS: A literature review of bibliographic databases and secondary sources was conducted and potential papers were assessed by two independent reviewers. Included studies were those that compared CPAP therapy (and usual care) with no CPAP for ARF in the prehospital setting. Studies of other methods of noninvasive ventilation were not included. Methodologic quality was assessed using guidelines from the Cochrane Collaboration. Outcomes included the number of intubations, mortality, physiologic parameters, and dyspnea score. Forrest plots were constructed to estimate the pooled effect of CPAP on outcomes. RESULTS: Five studies (1,002 patients) met the selection criteria--three randomized controlled trials (RCTs), a nonrandomized comparative study, and a retrospective comparative study using chart review. Forty-seven percent of the patients were allocated to the CPAP group. Baseline characteristics were similar between groups. The pooled estimates demonstrated significantly fewer intubations (odds ratio [OR] 0.31; 95% confidence interval [CI] 0.19-0.51) and lower mortality (OR 0.41; 95% CI 0.19-0.87) in the CPAP group. CONCLUSION: The studies included in this review showed a reduction in the number of intubations and mortality in patients with ARF who received CPAP in the prehospital setting. The results may not be applicable to other health care contexts because of the inherent differences in the organization and staffing of the EMS systems. Information from large RCTs on the efficacy of CPAP initiated early in the prehospital setting is critical to establishing the evidence base underpinning this therapy before ambulance services incorporate CPAP as routine clinical practice.

Paramedic identification of acute pulmonary edema in a metropolitan ambulance service.

INTRODUCTION: Acute pulmonary edema (APE) is a common cause of acute dyspnea. In the prehospital setting, it is often difficult to differentiate APE from other causes of shortness of breath (SOB). Radiography and echocardiography aid in the identification of APE but are often not available. There is little information on how accurately ambulance paramedics identify patients with APE. Objectives. This study aimed to 1) describe the prehospital clinical presentation and management of patients with a clinical diagnosis of APE and 2) compare the accuracy of coding of APE by paramedics against the emergency department (ED) medical discharge diagnosis. METHODS: This study included a retrospective cohort of all patients who had episodes identified as APE by ambulance paramedics and were transported to a metropolitan hospital ED in 2011. Two databases were used: an ambulance database and the Emergency Department Information System. The ED medical discharge diagnosis (using International Statistical Classification of Diseases and Related Problems, 10th Revision, Australian Modification [ICD-10-AM] codes) was used as the comparator with paramedic-assigned problem codes for APE. The outcomes for the study were the positive predictive value, i.e., the proportion of patients identified as having APE in the ambulance database who also had an ED discharge diagnosis of APE, and the sensitivity of paramedic identification of APE, i.e., the proportion of patients with an ED discharge diagnosis of APE that were correctly identified as APE by the ambulance paramedics. RESULTS: Four hundred ninety-five patients were transported to an ED with APE identified by the paramedics as the primary problem code. Shortness of breath, crepitations, high systolic blood pressure, and chest pain were the most common presenting signs and symptoms. Pink frothy sputum was rare (3% of patient episodes of APE). One hundred eighty-six patients received an ED discharge diagnosis of APE, i.e., a positive predictive value of 41%. Of 631 ED presentations with APE, paramedics identified 186, i.e., a sensitivity of 29%. CONCLUSION: Acute pulmonary edema is difficult to identify in the prehospital setting because of the variability in the signs and symptoms associated with this condition. Improved identification of APE is essential in the initiation of appropriate and timely care. Ambulance paramedics need to be aware of such variability when considering patients who may be suffering from APE. Key words: pulmonary edema; acute pulmonary edema; emergency medical services; ambulance; paramedics.

Evidence-based paramedic models of care to reduce unnecessary emergency department attendance--feasibility and safety.

BACKGROUND: As demand for Emergency Department (ED) services continues to exceed increases explained by population growth, strategies to reduce ED presentations are being explored. The concept of ambulance paramedics providing an alternative model of care to the current default 'see and transport to ED' has intuitive appeal and has been implemented in several locations around the world. The premise is that for certain non-critically ill patients, the Extended Care Paramedic (ECP) can either 'see and treat' or 'see and refer' to another primary or community care practitioner, rather than transport to hospital. However, there has been little rigorous investigation of which types of patients can be safely identified and managed in the community, or the impact of ECPs on ED attendance. METHODS/DESIGN: St John Ambulance Western Australia paramedics will indicate on the electronic patient care record (e-PCR) of patients attended in the Perth metropolitan area if they consider them to be suitable to be managed in the community. 'Follow-up' will examine these patients using ED data to determine the patient's disposition from the ED. A clinical panel will then develop a protocol to identify those patients who can be safely managed in the community. Paramedics will then assess patients against the derived ECP protocols and identify those deemed suitable to 'see and treat' or 'see and refer'. The ED disposition (and other clinical outcomes) of these 'ECP protocol identified' patients will enable us to assess whether it would have been appropriate to manage these patients in the community. We will also 'track' re-presentations to EDs within seven days of the initial presentation. This is a 'virtual experiment' with no direct involvement of patients or changes in clinical practice. A systems modelling approach will be used to assess the likely impact on ED crowding. DISCUSSION: To date the efficacy, cost-effectiveness and safety of alternative community-based models of emergency care have not been rigorously investigated. This study will inform the development of ECP protocols through the identification of types of patient presentation that can be considered both safe and appropriate for paramedics to manage in the community.

Reducing time to analgesia in the emergency department using a nurse-initiated pain protocol: a before-and-after study.

Suboptimal management of pain in emergency departments (EDs) remains a problem, despite having been first described over two decades ago. A 'before-and-after' intervention study (with a historical control) was undertaken in one Western Australian tertiary hospital ED to test the effect of a 'nurse-initiated pain protocol' (NIPP) intervention. A total of 889 adult patients were included: 144 in the control group and 745 in the intervention group. Patients in the intervention group were: More likely to have a pain score recorded than those in the control group; have reduced median time to the first pain score; and reduced time to analgesia. The statistically significant reduction in both time to pain score and time to analgesia remained, even when adjusted by age and sex. Whilst we demonstrated the safety and efficacy of a NIPP in ED, an unacceptable proportion of patients continued to have inadequate pain relief.

Major trauma patients transferred from rural and remote Western Australia by the Royal Flying Doctor Service.

BACKGROUND: The "golden hour" of trauma care is irrelevant in rural areas. We studied the effect of distance and remoteness on major trauma patients transferred by the Royal Flying Doctor Service from rural and remote Western Australia. METHODS: The Royal Flying Doctor Service retrieval and Trauma Registry databases were linked for the period of July 1, 1997, to June 30, 2006. Major trauma was defined as Injury Severity Score (ISS) >15. Remoteness was quantified using the Accessibility/Remoteness Index of Australia (ARIA) classes: inner regional, outer regional, remote, and very remote. The primary outcome was death. RESULTS: Among 1328 major trauma transfers to Perth, mean age was 34.2 years ± 18.3 years (range, 0-87 years) and 979 (73.7%) were male. Over half were motor vehicle crashes. Mean transfer time was 11.6 hours (95% confidence interval [CI], 11.2-12.1). The median ISS was 25 (interquartile range [IQR], 18-29), and there were no differences within the ARIA classes for cause and injury patterns. After adjusting for ISS, age, and time, the risk of death increases as remoteness increases: outer regional odds ratio (OR), 2.25 (95% CI, 0.58-8.79); remote, 4.03 (95% CI 1.04-15.62); and very remote, 4.69 (95% CI, 1.23-17.84). Risk increases by 87% for each 1,000 km (OR, 1.87; 95% CI, 1.007-3.48; p = 0.05) flown. Despite long retrieval times, there were no deaths in flight. CONCLUSION: There is an excess of a fourfold increase in the risk of major trauma death in patients transferred to Perth from remote and very remote Western Australia. Remoteness, as measured by the ARIA, is more important than distance, in the risk of death.

Use of emergency departments by older people from residential care: a population based study.

OBJECTIVE: to investigate the differences between emergency department (ED) presentations of older people who do and do not live in residential care facilities (RCFs). DESIGN: a population-based retrospective cohort study. ED records linked to ambulance and hospital morbidity records. SETTING: public EDs in Perth, Western Australia. SUBJECTS: all patients 65 years and older who presented to EDs between 1 January 2003 and 31 December 2006 (n = 97,161). MEASUREMENTS: patient demographic and clinical characteristics. Logistic regression was used to model the effect of living in RCFs on the likelihood of a particular ED diagnosis, hospital admission and in-hospital death. RESULTS: the age-sex standardised rate of ED presentation for those living in RCFs was 1.69 times that of community dwellers. Compared to community dwellers, people from RCFs were older (mean age 84.7 years vs. 76.0 years, P < 0.001) and a lower proportion were male (28.7% vs. 46.7%, P < 0.001). Adjusting for age and sex revealed that people from RCFs were more likely to be diagnosed with pneumonia/influenza [odds ratio (OR) 1.94, 95% confidence interval (CI) = 1.72-2.19], urinary tract infections (OR 1.72, 95% CI 1.49-1.98) or hip fractures (OR 1.16, 95% CI 1.03-1.32); less likely to be diagnosed with circulatory system diseases (OR 0.69, 95% CI 0.64-0.75) or neoplasms (OR 0.47, 95% CI 0.31-0.72); more likely to be admitted (OR 1.13, 95% CI 1.06-1.20) and to die in hospital (OR 1.57, 95% CI 1.40-1.75). CONCLUSION: there are different patterns of ED presentations and hospital admissions of older people who do and do not live in RCFs. The appropriateness of these differences is uncertain.

The relationship between remoteness and trauma deaths in Western Australia.

BACKGROUND: Mortality from trauma in rural areas is increased compared with the urban environment. We aimed to describe the relationship between trauma deaths and various categories of remoteness in rural areas, in Western Australia (WA). METHODS: We used Death Registry data from July 1, 1997 to June 30, 2006. Deaths were allocated to one of the five Remoteness Areas classified by the Accessibility/ Remoteness Index of Australia: Major Cities, Inner Regional, Outer Regional, Remote, and Very Remote. Population data were obtained from the Australian Bureau of Statistics 2001 census. RESULTS: There were 4,937 deaths (3,543, 71.8% men; mean age 43.4 years +/- 24.3 years). The least number of deaths occurred in Remote WA, and the age at which death occurred decreased as remoteness increased. Falls occur predominantly in the elderly in the major city. Transport injuries are the leading cause of death (43.3%) outside the major city, where self harm is the leading cause of death (31.2%). The relative risk for death in very remote WA compared with the major city is 4.28 (95% CI 3.93-4.68). The standardized age-specific death rates ranged from 24.09 per 100,000 person-years in the major city, to 103.30 per 100,000 person-years in very remote WA. CONCLUSIONS: We have quantified the direct relationship between remoteness and trauma deaths. In particular, the death rate in very remote areas is over four times the rate in major cities. Such data should be useful for the planning of trauma systems in these areas.

Acute upper respiratory infections in Western Australian emergency departments, 2000-2003.

OBJECTIVE: To describe the epidemiological and other characteristics of emergency department (ED) presentations diagnosed with acute upper respiratory infection (URI). DESIGN AND SETTING: A retrospective study of patients given an ED diagnosis of acute URI from July 2000 to July 2003 at any of the four metropolitan teaching hospitals in Perth, Western Australia. RESULTS: Acute URI accounted for 3.6% (95% CI, 3.5-3.7) of ED presentations, and 80.7% (95% CI, 80.1-81.3) of these were aged less than 15 years. The most common diagnosis was acute upper respiratory infections of multiple and unspecified sites, followed by croup and acute tonsillitis. Of those with croup, 76.0% (95% CI, 74.7-77.3) presented at night, 67.6% (95% CI, 66.2-69.0) were male and the number of presentations with croup was highest in June 2002. The number of diagnoses of acute tonsillitis did not display a great deal of variation from month to month. Overall, hospital admission was 12.3% (95% CI, 11.8-12.8), with a median length of hospital stay of 1 day (IQR 1.0-2.0). An increase in comorbidity, residing in the most disadvantaged areas, and being a re-presentation increased the odds of being admitted. CONCLUSION: Further investigation is needed into whether alternative medical care services would be appropriate and acceptable for patients with less severe acute URIs.

Outcomes in patients with an emergency department diagnosis of fever of unknown origin.

OBJECTIVE: To describe the outcomes in patients given an ED diagnosis of fever of unknown origin (FUO). METHODS: A retrospective analysis of ED records linked to hospital morbidity, mortality and microbiology records of patients presenting to Western Australia's teaching hospitals from July 2000 to July 2003. RESULTS: There were 3218 presentations diagnosed with FUO, 2049 (63.7%) children (median age 1.8 years) and 1169 (36.3%) adults (median age 56.0 years). FUO accounted for 0.3% of adult and 1.5% of paediatric ED presentations. Overall, 1997 (62.1%, 95% confidence interval 60.4-63.8%) were admitted (82% adults vs 50.7% children; P < 0.001). Adults had a longer median length of stay than children (4 days vs 2 days; P < 0.001) and a higher proportion of positive blood cultures (admissions 15.1%vs 4.9%; P < 0.001) commonly with Escherichia coli. Streptococcus pneumoniae was the most common organism isolated from children. Of 3053 FUO index presentations, 338 (11.1%, 95% confidence interval 10.0-12.2%) re-presented. Children were more likely to re-present than adults (13.5% of 1959 vs 6.8% of 1094; P < 0.001). CONCLUSIONS: Fever of unknown origin is diagnosed less frequently in adults than in children. Adult patients are more likely to be admitted, have longer lengths of stay and have positive blood cultures. Although FUO is diagnosed infrequently in the ED, blood cultures remain useful in the evaluation of unexplained fever, particularly in adults as age increases.

An observational study of bispectral index monitoring for out of hospital cardiac arrest.

Cerebral resuscitation is the most important goal of advanced life support. Currently, there are no objective monitoring methods available to gauge the effectiveness of advanced life support on cerebral resuscitation. We assessed the utility of bispectral index (BIS) monitoring during cardiopulmonary resuscitation as a marker of cerebral resuscitation. Twenty one patients with out of hospital cardiac arrest had a BIS monitor applied during the resuscitation, in addition to standard advanced life support. The BIS monitor was also applied to a cadaver to assess the role of artefact. Illustrative data are presented, outlining the process of evaluation undertaken. A major component of the BIS tracing during external chest compressions appears to be due to movement artefact. Our pilot data indicate that with current technology, BIS monitoring is not a clinically reliable marker of the efficacy of external chest compressions.

Community senior first aid training in Western Australia: its extent and effect on knowledge and skills.

OBJECTIVE: To define the extent of Senior First Aid training in a sample of the Western Australian community, and to evaluate the effect of previous training on first aid knowledge and skills. METHODS: A telephone survey of a random sample from suburban Perth and rural Western Australia; and practical assessment of first aid skills in a subsample of those surveyed. RESULTS: 30.4% of respondents had completed a Senior First Aid certificate. Trained individuals performed consistently better in theoretical tests (p=0.0001) and practical management of snakebite (p=0.021) than untrained. However, many volunteers, both trained and untrained, demonstrated poor skills in applying pressure immobilisation bandaging and splinting the limb adequately despite electing to do so in theory. CONCLUSIONS AND IMPLICATIONS: Overall knowledge and performance of first aid skills by the community are poor, but are improved by first aid training courses.

Pre-hospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug administration In Cardiac arrest (PARAMEDIC-2): Trial protocol.

Despite its use since the 1960s, the safety or effectiveness of adrenaline as a treatment for cardiac arrest has never been comprehensively evaluated in a clinical trial. Although most studies have found that adrenaline increases the chance of return of spontaneous circulation for short periods, many studies found harmful effects on the brain and raise concern that adrenaline may reduce overall survival and/or good neurological outcome. The PARAMEDIC-2 trial seeks to determine if adrenaline is safe and effective in out-of-hospital cardiac arrest. This is a pragmatic, individually randomised, double blind, controlled trial with a parallel economic evaluation. Participants will be eligible if they are in cardiac arrest in the out-of-hospital environment and advanced life support is initiated. Exclusions are cardiac arrest as a result of anaphylaxis or life threatening asthma, and patient known or appearing to be under 16 or pregnant. 8000 participants treated by 5 UK ambulance services will be randomised between December 2014 and August 2017 to adrenaline (intervention) or placebo (control) through opening pre-randomised drug packs. Clinical outcomes are survival to 30 days (primary outcome), hospital discharge, 3, 6 and 12 months, health related quality of life, and neurological and cognitive outcomes (secondary outcomes). Trial registration (ISRCTN73485024).

Reducing hospital presentations for opioid overdose in patients treated with sustained release naltrexone implants.

BACKGROUND: Non-fatal overdoses represent a significant morbidity for regular heroin users. Naltrexone is an opioid antagonist capable of blocking the effects of heroin, thereby preventing accidental overdose. However, treatment with oral naltrexone is often associated with non-compliance. An alternative is the use of a sustained release preparation of naltrexone. The aim of this study was to assess the change in number of opioid and other drug overdoses in a large cohort of heroin dependent persons (n=361; 218 males) before and after treatment with a sustained release naltrexone implant. A sub-group of this cohort (n=146; 83 males) had previously received treatment with oral naltrexone, which also allowed a comparison of overdoses pre- and post-oral and also post-implant treatments. METHOD: We used a pre-post design, with data prospectively collected via the West Australian Health Services Research Linked Database, and the Emergency Department Information System. Participants were treated under the Australian Therapeutic Goods Administration's special access guidelines. RESULTS: Most (336, 93%) of the cohort was in one or both databases. We identified 21 opioid overdoses involving 20 persons in the 6 months pre-treatment that required emergency department presentation or hospital admission: none were observed in the 6 months post-treatment. This is consistent with the existing pharmacokinetic data on this implant, which indicates maintenance of blood naltrexone levels at or above 2 ng/ml for approximately 6 months. A reduced number of opioid overdoses were also observed 7-12 months post-implant. The study found a significant increase in sedative "overdoses", some of which occurred in the 10 days following implant treatment and were likely associated with opioid withdrawal and/or implant treatment. For those previously treated with oral naltrexone, more opioid overdoses occurred in both the 6-months prior to and after oral compared to the 6-months post-implant treatment. CONCLUSIONS: The findings support the clinical efficacy of this sustained release naltrexone implant in preventing opioid overdose. However, given the high prevalence of poly-substance use among dependent heroin users, programs offering this type of treatment should also focus on preventing, detecting and managing poly-substance use.

Patient delay and use of ambulance by patients with chest pain.

OBJECTIVE: To identify the reasons why patients with chest pain delay in seeking hospital medical care and do or do not use an ambulance. METHODS: One hundred and fifty-one patients with an ED diagnosis of acute myocardial infarction or angina were interviewed about demographic characteristics, medical history, symptom onset, time taken before deciding to call an ambulance or go to hospital (delay time) and transport used. Multiple logistic regression determined independent predictors of late presentation (delay time>30 min) and ambulance use. RESULTS: One hundred and twelve (74.2%, 95% CI 67.0-81.0%) patients delayed more than 30 min. Independent predictors of late presentation were: seeing a general practitioner (GP) (P=0.001), having prior heart problems (P=0.009) and symptoms occurring at night (P=0.036). Eighty-one (54.7%, 95% CI 47.0-63.0%) patients used an ambulance. Predictors of ambulance use were increased age (P=0.025) and having ambulance insurance (P=0.018), although there was interaction between these variables. CONCLUSIONS: Education programmes should continue to emphasize that chest pain is a potential medical emergency and an ambulance should be called. GPs should consider developing an action plan to manage patients presenting with chest pain.