Evaluation of a calcium, magnesium and phosphate clinical ordering tool in the emergency department.

OBJECTIVE: We developed a clinical tool comprising patient risk factors for having an abnormal calcium (Ca), magnesium (Mg) or phosphate (PO4) level. We hypothesized that patients without a risk factor do not require testing. This study examined the tool's potential utility for rationalizing Ca, Mg and PO4 ordering in the emergency department (ED). METHODS: We undertook a retrospective observational study in a single metropolitan ED. Patients aged 18 years or more who presented between July and December 2019 were included if they had a Ca, Mg or PO4 test during their ED stay. Demographic and clinical data, including the presence of risk factors, were extracted from the medical record. The primary outcome was a clinically significant abnormal Ca, Mg or PO4 level (>0.2 mmol/l above or below the laboratory reference range). RESULTS: Calcium, Mg and PO4 levels were measured on 1426, 1296 and 1099 patients, respectively. The positive and negative predictive values and likelihood ratios of the tool identifying a patient with a Ca level > 0.2 mmol/l outside the range were 0.05, 0.99, 1.59 and 0.41, respectively. The values for Mg were 0.02, 1.00, 1.44 and 0.35 and those for PO4 were 0.15, 0.93, 1.38 and 0.57, respectively. The majority of patients not identified as having an abnormal level did not receive electrolyte correction treatment. Application of the tool would have resulted in a 35.8% cost reduction. CONCLUSION: The tool failed to predict a very small proportion of patients (approximately 1%) with an abnormal Ca or Mg level and for whom it would have been desirable to have these levels measured. It may help rationalize Ca and Mg ordering and reduce laboratory costs.

Author and journal self-citation in Emergency Medicine original research articles.

OBJECTIVE: To determine author and journal self-citation rates in a sample of original emergency medicine (EM) research articles. METHODS: We undertook a retrospective observational study of original research articles published in 2019 in the top six English language general EM journals. Data comprised the total numbers of articles, citations, authors and self-citations for each author (author self-citations) as well as the number of articles in the reference list that had been previously published in the same journal (journal self-citations). RESULTS: 3213 individual authors and 581 articles were examined. Most authors did not self-cite at all although 62 self-cited five or more times in a single article. The mean (SD) and median (IQR) numbers of individual author self-citations/article/year were 0.6 (1.3) and 0 (0-1), respectively. Overall, author self-citations accounted for 2.4% of all cited articles. There was a weak positive but significant correlation between the number of individual author self-citations/article/year and the number of articles published by the author (r = 0.38, p < 0.001). There was no correlation between the journal impact factor (IF) and the author self-citation rate (r = 0.14, p = 0.79). The journals differed significantly in their author self-citation rates (p < 0.001). Annals of Emergency Medicine had the highest journal self-citation rate at 8.1% (95%CI 7.0%-9.2%) self-citations/100 citations/year, almost twice that of some other journals. There was a large but non-significant positive correlation between the journal IF and journal self-citation rates (r = 0.78, p = 0.07). CONCLUSION: Both author and journal self-citation rates in the articles examined are relatively low compared to other medical and scientific disciplines.

Dr Google in the ED: searching for online health information by adult emergency department patients.

OBJECTIVE: To determine the prevalence, predictors, and characteristics of health-related internet searches by adult emergency department (ED) patients; to examine the effect of searching on the doctor-patient relationship and treatment compliance. DESIGN: A multi-centre, observational, cross-sectional study; a purpose-designed 51-item survey, including tools for assessing e-health literacy (eHEALS) and the effects of internet searching on the doctor-patient relationship (ISMII). Setting, participants: 400 adult patients presenting to two large tertiary referral centre emergency departments in Melbourne, February-May 2017. OUTCOME MEASURES: Descriptive statistics for searching prevalence and characteristics, doctor-patient interaction, and treatment compliance; predictors of searching; effect of searching on doctor-patient interaction. RESULTS: 400 of 1056 patients screened for eligibility were enrolled; their mean age was 47.1 years (SD, 21.1 years); 51.8% were men. 196 (49.0%) regularly searched the internet for health information; 139 (34.8%) had searched regarding their current problem before presenting to the ED. The mean ISMII score was 30.3 (95% CI, 29.6-31.0); searching improved the doctor-patient interaction for 150 respondents (77.3%). Younger age (per 10-year higher age band: odds ratio [OR], 0.74; 95% CI, 0.61-0.91) and greater e-health literacy (per one-point eHEALS increase: OR, 1.11; 95% CI, 1.06-1.17) predicted searching the current problem prior to presentation; e-health literacy predicted ISMII score (estimate, 0.39; 95% CI, 0.20-0.39). Most patients would never or rarely doubt their diagnosis (79%) or change their treatment plan (91%) because of conflicting online information. CONCLUSION: Online health care information was frequently sought before presenting to an ED, especially by younger and e-health literate patients. Searching had a positive impact on the doctor-patient interaction and was unlikely to reduce adherence to treatment.

Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A Randomized Clinical Trial.

STUDY OBJECTIVE: We aim to determine the most efficacious of 3 common medication regimens for the sedation of acutely agitated emergency department (ED) patients. METHODS: We undertook a randomized, controlled, double-blind, triple-dummy, clinical trial in 2 metropolitan EDs between October 2014 and August 2015. Patients aged 18 to 65 years and requiring intravenous medication sedation for acute agitation were enrolled and randomized to an intravenous bolus of midazolam 5 mg-droperidol 5 mg, droperidol 10 mg, or olanzapine 10 mg. Two additional doses were administered, if required: midazolam 5 mg, droperidol 5 mg, or olanzapine 5 mg. The primary outcome was the proportion of patients adequately sedated at 10 minutes. RESULTS: Three hundred forty-nine patients were randomized to the 3 groups. Baseline characteristics were similar across the groups. Ten minutes after the first dose, significantly more patients in the midazolam-droperidol group were adequately sedated compared with the droperidol and olanzapine groups: differences in proportions 25.0% (95% confidence interval [CI] 12.0% to 38.1%) and 25.4% (95% CI 12.7% to 38.3%), respectively. For times to sedation, the differences in medians between the midazolam-droperidol group and the droperidol and olanzapine groups were 6 (95% CI 3 to 8) and 6 (95% CI 3 to 7) minutes, respectively. Patients in the midazolam-droperidol group required fewer additional doses or alternative drugs to achieve adequate sedation. The 3 groups' adverse event rates and lengths of stay did not differ. CONCLUSION: Midazolam-droperidol combination therapy is superior, in the doses studied, to either droperidol or olanzapine monotherapy for intravenous sedation of the acutely agitated ED patient.

Acupuncture for analgesia in the emergency department: a multicentre, randomised, equivalence and non-inferiority trial.

OBJECTIVES: This study aimed to assess analgesia provided by acupuncture, alone or in combination with pharmacotherapy, to patients presenting to emergency departments with acute low back pain, migraine or ankle sprain. DESIGN: A pragmatic, multicentre, randomised, assessor-blinded, equivalence and non-inferiority trial of analgesia, comparing acupuncture alone, acupuncture plus pharmacotherapy, and pharmacotherapy alone for alleviating pain in the emergency department. Setting, participants: Patients presenting to emergency departments in one of four tertiary hospitals in Melbourne with acute low back pain, migraine, or ankle sprain, and with a pain score on a 10-point verbal numerical rating scale (VNRS) of at least 4. MAIN OUTCOME MEASURES: The primary outcome measure was pain at one hour (T1). Clinically relevant pain relief was defined as achieving a VNRS score below 4, and statistically relevant pain relief as a reduction in VNRS score of greater than 2 units. RESULTS: 1964 patients were assessed between January 2010 and December 2011; 528 patients with acute low back pain (270 patients), migraine (92) or ankle sprain (166) were randomised to acupuncture alone (177 patients), acupuncture plus pharmacotherapy (178) or pharmacotherapy alone (173). Equivalence and non-inferiority of treatment groups was found overall and for the low back pain and ankle sprain groups in both intention-to-treat and per protocol (PP) analyses, except in the PP equivalence testing of the ankle sprain group. 15.6% of patients had clinically relevant pain relief and 36.9% had statistically relevant pain relief at T1; there were no between-group differences. CONCLUSION: The effectiveness of acupuncture in providing acute analgesia for patients with back pain and ankle sprain was comparable with that of pharmacotherapy. Acupuncture is a safe and acceptable form of analgesia, but none of the examined therapies provided optimal acute analgesia. More effective options are needed. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12609000989246.

Interobserver and intraobserver variability of glenoid track measurements.

BACKGROUND: A method of assessing combined glenoid and humeral bone loss in traumatic shoulder instability with an associated treatment protocol was recently published. The aim of this study was to investigate its reliability and reproducibility. METHODS: Seventy-one patients with unilateral anteroinferior shoulder instability underwent computed tomography scans, from which 3-dimensional images were derived. En face views of both glenoid fossae and with 3 views of the humeral head were provided to 4 assessors to determine interobserver reliability. From these measurements, the shoulder was assigned a treatment classification. Two observers repeated their assessments 1 month later to determine intraobserver reliability. For each measurement, the mean coefficient of variability was calculated. RESULTS: Assessment of glenoid bone loss showed good interobserver (4 observers agreeing in 90.1% of cases) and also good intraobserver agreement (94% and 96%). There was a poor level of interobserver reliability regarding the on-track or off-track classification (72%). Intraobserver reliability for this measurement was less variable (90% and 80%). There was a poor level of agreement between observers (65%) regarding treatment classification. The coefficient of variability for the Hill-Sachs lesion measured 19.2%, indicating a high level of variability for this measurement compared with <4% for all other measures. CONCLUSION: Linear bone loss on the glenoid can be measured reliably and reproducibly; however, evaluation of Hill-Sachs lesions demonstrates a high level of variability, and poor interobserver reliability.

Variables associated with administration of analgesia, nurse-initiated analgesia and early analgesia in the emergency department.

OBJECTIVE: To determine the patient and clinical variables associated with administration of any analgesia, nurse-initiated analgesia (NIA, prescribed and administered by a nurse) and early analgesia (within 30 min of presentation). METHODS: We undertook a retrospective cohort study of patients who presented to a metropolitan ED in Melbourne, Australia, during July and August, 2013. The ED has an established NIA programme. Patients were included if they were aged 18 years or more and presented with a painful complaint. The study sample was randomly selected from a list of all eligible patients. Data were extracted electronically from the ED records and by explicit extraction from the medical record. Logistic regression models were constructed to assess associations with the three binary study end points. RESULTS: 1289 patients were enrolled. Patients were less likely to receive any analgesia if they presented 08:00-15:59 hours (OR 0.67, 95% CI 0.46 to 0.98) or 16:00-24:00 hours (OR 0.55, 95% CI 0.37 to 0.80) were triage category 5 (OR 0.20, 95% CI 0.08 to 0.49) or required an interpreter (OR 0.34, 95% CI 0.14 to 0.86). Patients were less likely to receive NIA or early analgesia if they were aged 56 years or more (OR 0.70 and 0.63; OR 0.57 and 0.21, respectively) or if they had received ambulance analgesia (OR 0.59, 95% CI 0.36 to 0.95; OR 0.38, 95% CI 0.20 to 0.74, respectively). CONCLUSIONS: Patients who present during the daytime, have a triage category of 5 or require an interpreter are less likely to receive analgesia. Older patients and those who received ambulance analgesia are less likely to receive NIA or early analgesia.

The effect of provision of pain management advice on patient satisfaction with their pain management: a pilot, randomised, controlled trial (pain advice trial).

OBJECTIVE: We aimed to provide pain advice ('The treatment of pain is very important and be sure to tell the staff when you have pain') as an intervention and evaluate its effect upon patient satisfaction. The purpose of this pilot trial was to ensure the design and methods of a future trial are sound, practicable and feasible. METHOD: We undertook a pilot, randomised, controlled, clinical intervention trial in a single ED. The control arm received standard care. The intervention arm received standard care plus pain advice from an independent investigator. All patients and treating ED staff were blinded to patient enrolment. Patient satisfaction with their pain management (six-point ordinal scale) was measured 48 h post-ED discharge, by a blinded researcher. The primary outcome was satisfaction with pain management. RESULTS: Of the 280 and 275 patients randomised to the control and intervention arms, respectively, 196 and 215 had complete data, respectively. 77.6% (152/196) and 88.8% (191/215) of patients reported being provided with pain advice, respectively (difference 11.3% (95% CI 3.6 to 19.0)). The intervention was associated with absolute and relative increases in patient satisfaction of 6.3% and 14.2%, respectively. 91.3% (179/196) and 76.3% (164/215) of patients who were/were not very satisfied reported having received 'pain advice' (difference 15.0% (95% CI 7.6 to 22.5)). CONCLUSIONS: The intervention to provide pain advice resulted in a non-significant increase in patient satisfaction. A larger multicentre trial is feasible and is recommended to further explore the effects of provision of pain advice. TRIAL REGISTRATION NUMBER: ACTRN12615000097549.

Identification of the optimum vagal manoeuvre technique for maximising vagal tone.

OBJECTIVES: This study sought to determine the most effective technique for Valsalva Manoeuvre (VM) and Human Dive Reflex Manoeuvre (HDR) generation of vagal tone. METHODS: We conducted a repeated-measures trial of healthy adult volunteers from a university campus, aged 18-56 years, in sinus rhythm. Participants were randomised to VM (in supine or Trendelenberg postures) and HDR (supine or sitting postures) sequentially. Participants performed three trials of each technique, in random order, with a continuous ECG recording. Single-blinded analysis of ECG data was conducted. Mean differences between premanoeuvre and postmanoeuvre R-R intervals and heart rates were calculated for each posture within and between vagal manoeuvres. RESULTS: Seventy-two participants were enrolled. The difference between VM (supine) and VM (Trendelenberg) was not significant at 0.008 s (-0.023 to 0.038). The difference in mean R-R intervals for HDR (supine) was greater than HDR (sitting) 0.062 (0.031 to 0.093), although this significance was not reflected in a heart-rate change of -0.87 (-3.00 to 1.26). VM supine generated greatest overall mean R-R interval difference, while HDR (sitting) provided the smallest change in R-R interval. The VM (supine) provided a significant maximum effectiveness over the HDR (supine) of 0.102 s (0.071 to 0.132). CONCLUSIONS: This study demonstrates that VM (supine) generates the greatest vagal tone producing the largest transient heart rate decrease in healthy volunteers. No advantage was identified in Trendelenberg posturing for the VM in this study. These results may assist in the standardisation of vagal manoeuvre technique for the range of therapeutic and diagnostic applications.

Prehospital synchronized electrical cardioversion of a poorly perfused SVT patient by paramedics.

Synchronized Direct Current Cardioversion (SDC) is an established therapy for the termination of supraventricular tachycardia (SVT - either atrio-ventricular nodal reentry tachycardia (AVNRT) or atrio-ventricular reentrant tachycardia (AVRT)) with poor perfusion. The evidence is extremely limited with regard to the safety and effectiveness of this therapy. In Australia, half of the eight ambulance services include SDC within their clinical practice guidelines for the management of poorly perfused SVT; however the degree of variation in the application of SDC across these guidelines suggests a need to quantify the practice. This case provides a previously unreported example of the safety and effectiveness of prehospital SDC for SVT (with poor perfusion precipitated by a Valsalva Maneuver) by Victorian paramedics, and discusses the available literature regarding the effectiveness and safety of this practice.

Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest*.

OBJECTIVE: To evaluate the effects on temperature and outcome at hospital discharge of a pre-hospital rapid infusion of large volume, ice-cold intravenous Hartmann's solution in patients with out-of-hospital cardiac arrest and an initial cardiac rhythm of asystole or pulseless electrical activity. DESIGN: Prospective, randomized, controlled clinical trial. SETTING: Pre-hospital emergency medical service and 12 critical care units in Melbourne, Australia. PATIENTS: One hundred and sixty three patients who had been resuscitated from cardiac arrest with an initial cardiac rhythm of asystole or pulseless electrical activity. INTERVENTIONS: : Patients were randomized to either pre-hospital cooling using a rapid infusion of up to two litres ice-cold Hartmann's solution (82 patients) or cooling after hospital admission (81 patients). The planned duration of therapeutic hypothermia (32 °C-34 °C) in both groups was 24 hrs. MEASUREMENTS AND MAIN RESULTS: Patients allocated to pre-hospital cooling received a median of 1500 ml of ice-cold fluid. This resulted in a mean decrease in core temperature of 1.4 °C compared with 0.2 °C in hospital cooled patients (p < .001). The time to therapeutic hypothermia (<34 °C) was 3.2 hrs in the pre-hospital cooled group compared with 4.8 hrs in the hospital cooled group (p = .0328). Both groups received a mean of 15 hrs cooling in the hospital and only 7 patients in each group were cooled for 24 hrs. Overall, there was no difference in outcomes at hospital discharge with favorable outcome (discharge from hospital to home or rehabilitation) in 10 of 82 (12%) in the pre-hospital cooled patients, compared with 7 of 81 (9%) in the hospital cooled patients (p = .50). In the patients with a cardiac cause of the arrest, 8 of 47 patients (17%) who received pre-hospital cooling had a favorable outcome at hospital discharge compared with 3 of 43 (7%) in the hospital cooled group (p = .146). CONCLUSIONS: In adults who have been resuscitated from out-of-hospital cardiac arrest with an initial cardiac rhythm of asystole or pulseless electrical activity, pre-hospital cooling using a rapid infusion of large-volume, ice cold intravenous Hartmann's solution decreases core temperature at hospital arrival and decreases the time to therapeutic hypothermia. In patients with a cardiac cause of the arrest, this treatment may increase the rate of favorable outcome at hospital discharge. Further larger studies should evaluate the effects of pre-hospital cooling when the initial cardiac rhythm is asystole or pulseless electrical activity, particularly in patients with a cardiac cause of the arrest.

Use of the human dive reflex for the management of supraventricular tachycardia: a review of the literature.

BACKGROUND: The human dive reflex (HDR), a physiological phenomenon similar to the bradycardia reflex used by marine mammals during prolonged submersion, can be employed in managing paroxysmal supraventricular tachycardia (PSVT). This review aims to identify a standardised HDR technique for haemodynamically stable PSVT, to determine the effectiveness of the HDR and to define its usefulness in the prehospital setting. METHODS: A review of the Medline, EMBASE and CINAHL databases was conducted. Articles were included if they described the use of the HDR to revert PSVT in the prehospital or emergency medical setting, the nature of the effectiveness of the HDR for PSVT or historically significant developments of HDR techniques for PSVT reversion. Articles not available in English or describing the use of HDR in animal studies only were excluded. RESULTS: 211 articles were identified, of which 21 were found to be relevant. These included 10 studies of HDR effectiveness in PSVT and three physiological studies of HDR effect. No standardised model of performance exists for the HDR. Elements of performance include: a cold stimulus applied to the entire face, a specific temperature of the cold stimulus, application duration, breath holding during HDR and posture assumed to perform the procedure. There are also safety and logistics issues with using the HDR in prehospital care. CONCLUSIONS: The HDR represents an effective method of terminating PSVT in the hospital emergency department. Its usefulness in prehospital care requires further evaluation of the elements of the manoeuvre to determine appropriateness to this setting.

Unicortical fixation does not compromise bony union in the Latarjet procedure.

Background: Fixation of the coracoid during the Latarjet procedure can be performed with either unicortical or bicortical fixation. There is no clear evidence that the number of cortices fixed affects graft union, but in vitro studies suggest bicortical fixation is desirable. The primary aim of the study was to retrospectively review the coracoid union rates in our Latarjet cohort who have undergone either unicortical or bicortical graft fixation. Methods: A retrospective review of Latarjet patients receiving bicortical or unicortical fixation was performed. The rate of coracoid graft union was assessed via radiographs and computed tomography scans at minimum 8 weeks postoperatively. Primary analysis for graft union was performed with Chi-squared and Fisher's exact tests. Results: A total of 184 patients were enrolled (82 bicortical, 102 unicortical) with 20 patients lost to follow-up. There was no significant difference between union rates of bicortical and unicortical groups (union rate: 94% bicortical, 98% unicortical, P = .25). There were no significant differences in rate of instability recurrence (P = .5) or other postoperative complications (P = .83) between the groups. Discussion: At a minimum follow-up of 8 weeks, bicortical fixation was not shown to have a higher rate of union than unicortical fixation. Performing unicortical fixation is an acceptable practice without compromising bony graft union.

Hyperkalaemia in the emergency department: Epidemiology, management and monitoring of treatment outcomes.

OBJECTIVE: To describe the epidemiology, treatment and monitoring of treatment outcomes of patients presenting to the ED with hyperkalaemia. METHODS: We undertook a retrospective observational study in a mixed adult/paediatric ED over five 3-month periods. Consecutive patients were included if they had an initial serum or blood gas potassium ≥6.0 mmol/L. Patients were excluded if their principal diagnosis was diabetic ketoacidosis, their blood sample was haemolysed or the blood gas result was inconsistent with a subsequent serum potassium. Data were extracted from electronic medical records and two senior emergency registrars independently assessed available ECGs. Moderate and severe hyperkalaemia were potassium 6.0-6.4 and ≥6.5 mmol/L, respectively. RESULTS: Overall, 392 patients were included (mean age 73.7 years, triage category 1 or 2 28.3%, admitted 91.3%). Three hundred and twenty-one (81.9%, 95% confidence interval [CI] 77.6-85.5%) patients took one or more medications that predispose to hyperkalaemia and 335 (85.5%, 95% CI 81.5-88.7%) had one or more predisposing comorbidities. Two hundred and seventy-one (69.1%, 95% CI 64.3-73.6%) patients had moderately severe and 121 (30.9%, 95% CI 26.4-35.7%) had severe hyperkalaemia. Two hundred and fifty-nine (66.1%, 95% CI 61.1-70.7%) patients were administered at least one medication in ED to lower the potassium concentration and 51 (13.0%, 95% CI 9.9-16.8%) were dialysed. One hundred and eighty-seven patients received intravenous insulin: 40 (21.4%) had documented biochemical hypoglycaemia, but 45 (24.1%) had no post-insulin blood glucose level documented. Hyperkalaemia-associated ECG changes were uncommon. CONCLUSION: Most ED patients with hyperkalaemia have identifiable clinical and medication-related risk factors. Variations in care were widespread and monitoring for iatrogenic adverse events was suboptimal.

COMBED: Rapid non-invasive Cardiac Output Monitoring Baseline assessment in adult Emergency Department patients with haemodynamic instability.

OBJECTIVE: The application of rapid, non-operator-dependent, non-invasive cardiac output monitoring (COM) may provide early physiological information in ED patients with haemodynamic instability (HI). Our primary objective was to assess the feasibility of measuring pre-intervention (baseline) cardiac index (CI) and associated haemodynamic parameters. METHODS: We performed a prospective observational study of adults shortly after presentation to the ED of a large university hospital with tachycardia or hypotension or both. We applied non-invasive COM for 5 min and recorded CI, mean arterial pressure (MAP), stroke volume index (SVI) and systemic vascular resistance index (SVRI). We assessed for differences between those presenting with hypotension or hypotension and tachycardia with tachycardia alone and between those with or without suspected infection. RESULTS: We obtained haemodynamic parameters in 46 of 49 patients. In patients with hypotension or hypotension and tachycardia (n = 15) rather than tachycardia alone (n = 31), we observed a lower MAP (60.8 vs 87.7, P < 0.0001), CI (2.8 vs 3.9, P = 0.0167) and heart rate (85.5 vs 115.4, P < 0.0001). There was no difference in SVI (33.7 vs 33.4, P = 0.93) or SVRI (1970 vs 2088, P = 0.67). Patients with suspected infection had similar haemodynamic values except for a lower SVRI (1706 vs 2237, P = 0.011). CONCLUSIONS: Rapid, non-operator-dependent, non-invasive COM was possible in >90% of ED patients presenting with HI. Compared with tachycardia alone, patients with hypotension had lower CI, MAP and heart rate, while those with suspected infection had a lower SVRI. This technology provides novel insights into the early state of the circulation in ED patients with HI.

Development of Screening Tools to Predict Medication-Related Problems Across the Continuum of Emergency Department Care: A Prospective, Multicenter Study.

Background: Medication-related problems (MRPs) occur across the continuum of emergency department (ED) care: they may contribute to ED presentation, occur in the ED/short-stay unit (SSU), at hospital admission, or shortly after discharge to the community. This project aimed to determine predictors for MRPs across the continuum of ED care and incorporate these into screening tools (one for use at ED presentation and one at ED/SSU discharge), to identify patients at greatest risk, who could be targeted by ED pharmacists. Methods: A prospective, observational, multicenter study was undertaken in nine EDs, between July 2016 and August 2017. Blocks of ten consecutive adult patients presenting at pre-specified times were identified. Within 1 week of ED discharge, a pharmacist interviewed patients and undertook a medical record review to determine a medication history, patient understanding of treatment, risk factors for MRPs and to manage the MRPs. Logistic regression was undertaken to determine predictor variables. Multivariable regression beta coefficients were used to develop a scoring system for the two screening tools. Results: Of 1,238 patients meeting all inclusion criteria, 904 were recruited. Characteristics predicting MRPs related to ED presentation were: patient self-administers regular medications (OR = 7.95, 95%CI = 3.79-16.65), carer assists with medication administration (OR = 15.46, 95%CI = 6.52-36.67), or health-professional administers (OR = 5.01, 95%CI = 1.77-14.19); medication-related ED presentation (OR = 9.95, 95%CI = 4.92-20.10); age ≥80 years (OR = 3.63, 95%CI = 1.96-6.71), or age 65-79 years (OR = 2.01, 95%CI = 1.17-3.46); potential medication adherence issue (OR = 2.27, 95%CI = 1.38-3.73); medical specialist seen in past 6-months (OR = 2.02, 95%CI = 1.42-2.85); pharmaceutical benefit/pension/concession cardholder (OR = 1.89, 95%CI = 1.28-2.78); inpatient in previous 4-weeks (OR = 1.60, 95%CI = 1.02-2.52); being male (OR = 1.48, 95%CI = 1.05-2.10); and difficulties reading labels (OR = 0.63, 95%CI = 0.40-0.99). Characteristics predicting MRPs related to ED discharge were: potential medication adherence issue (OR = 6.80, 95%CI = 3.97-11.64); stay in ED > 8 h (OR = 3.23, 95%CI = 1.47-7.78); difficulties reading labels (OR = 2.33, 95%CI = 1.30-4.16); and medication regimen changed in ED (OR = 3.91, 95%CI = 2.43-6.30). For ED presentation, the model had a C-statistic of 0.84 (95% CI 0.81-0.86) (sensitivity = 80%, specificity = 70%). For ED discharge, the model had a C-statistic of 0.78 (95% CI 0.73-0.83) (sensitivity = 82%, specificity = 57%). Conclusion: Predictors of MRPs are readily available at the bedside and may be used to screen for patients at greatest risk upon ED presentation and upon ED/SSU discharge to the community. These screening tools now require external validation and implementation studies to evaluate the impact of using such tools on patient care outcomes.

Prescription medication use by emergency department doctors to improve work and academic performance, and to manage stress and anxiety.

OBJECTIVE: To determine medications used by ED doctors to improve work and academic performance, and to manage stress and anxiety. METHODS: We undertook an online, voluntary, anonymous survey of ACEM fellows and trainees. RESULTS: One hundred and thirty-nine (46.5%) respondents used a medication under examination. Sleep aids included melatonin (19.1% of respondents) and benzodiazepines (8.7%). Medications to improve performance included modafinil (4.7%), pseudoephedrine (2.0%), melatonin (2.0%) and beta blockers (1.3%). Some medications were taken prior to shifts. Medications to manage stress and anxiety included benzodiazepines (3.0%) and beta blockers (2.0%). CONCLUSION: Medication use is common and support for some doctors may be required.

Nature and outcomes of sanctioned medical misconduct in six international jurisdictions: a case series.

Objective The aim of this study was to determine the types of medical misconduct, the practitioner, specialities and jurisdictions at risk, patient outcomes and the sanctions imposed. Methods This study was a retrospective case series of 822 adverse medical tribunal determinations in Australia, New Zealand, Canada (Ontario, Alberta), Pennsylvania (USA), Singapore and Hong Kong in 2013-17. Results Inappropriate medical care and illegal or unethical prescribing were the most common types of misconduct. Misconduct varied with practitioner sex, international medical graduate status, speciality and jurisdiction (P<0.05). Cases of inappropriate medical care were more common in Singapore (46.7% of all Singapore cases; 95% confidence interval (CI) 31.9-62.0) and among surgeons (47.6% of all surgeon cases; 95% CI 36.5-58.8). Illegal or unethical prescribing was more common in Australia (31.1%; 95% CI 24.8-38.2) and among general or family practitioners (26.9%; 95% CI 20.0-35.0). Misconduct not related to patients was more common in Pennsylvania (30.3%; 95% CI 25.2-36.0) and among local graduates (20.5%; 95% CI 17.1-24.5). Sexual misconduct was more common in Australia (29.6%; 95% CI 23.4-36.6) and among males (19.6%, 95% CI 16.7-22.8). Healthcare dishonesty was more common in Hong Kong (21.8%; 95% CI 14.0-32.2) and among surgeons (13.4%; 95% CI 7.2-23.2). The most common patient outcomes were patient risk (40.6%; 95% CI 36.1-45.4) and death and actual physical harm combined (31.2%; 95% CI 26.9-35.7). Sanctions were most commonly suspension or deregistration. Deregistration was most common in cases of sexual misconduct. Conclusion Medical misconduct varies widely. Risk factors for particular misconduct types are apparent among jurisdictions and practitioner characteristics. The nature of patient harm varied by type of misconduct, with illegal unethical prescribing commonly leading to drug dependency and sexual misconduct leading to psychiatric injury. What is known about the topic? Medical misconduct is a continuing problem. Tribunals and medical boards sanction misconduct to protect patient safety and public trust. What does this paper add? Tribunals and boards differ in misconduct reporting and permitting public access to determinations. Types of misconduct vary between international jurisdictions, practitioner sex, international graduate status and speciality. Risk and physical injury (including death) are the most common patient outcomes. The nature of patient harm varied by type of misconduct, with illegal unethical prescribing commonly leading to drug dependency and sexual misconduct leading to psychiatric injury. What are the implications for practitioners? Medical colleges should tailor trainee programs to address the common types of misconduct within their specialities. Standardisation of misconduct reporting, and report access, across jurisdictions would facilitate ongoing surveillance and intervention evaluation.

Discordance between patient-reported and actual emergency department pain management.

OBJECTIVE: To determine patient knowledge of the nature of their pain management in the ED. METHODS: This was a planned sub-study of data collected during a randomised, controlled trial of the nature of the informed consent process in a single ED. Patients aged ≥18 years, with a triage pain score of ≥4, were enrolled. Forty-eight hours post-ED discharge, patients were asked if they had declined analgesia or if a range of pain management options had been administered. The primary outcome was discordance between the patient report and the ED report (proportion of cases where these reports differed). RESULTS: Outcome data were collected on 655 patients. There was significant discordance for all variables examined (P < 0.001). Discordance for patients declining analgesia was lowest at 8.9% (95% confidence interval [CI] 6.8-11.4). Discordance for administration of pain management 'other' than analgesia was highest at 32.6% (95% CI 29.0-36.4). Discordance for the administration of oral analgesia or 'any' analgesia was 17.1% (95% CI 14.3-20.3) and 14.4% (95% CI 11.8-17.3), respectively. For both of these outcomes, patients with chest pain and lower triage pain scores were more likely to report discordant responses. With the exception of 'other' pain management, smaller proportions of patients incorrectly reported not receiving management than incorrectly reporting that they did receive it. CONCLUSION: Patients are often unaware of the nature of their pain management. They are most often unaware of management other than analgesia. Patients with chest pain and lower triage pain scores had the least knowledge of their pain management.

Medium-Term Clinical and Radiographic Results of an All-Polyethylene, Pegged, Bone-Ingrowth Glenoid Component: A Concise Follow-up of a Previous Report.

ABSTRACT: We previously reported the mean 4-year outcomes of anatomic total shoulder replacement using an all-polyethylene, pegged, hybrid-fixation (bone ingrowth and cement) glenoid component. In the present study, we report on that patient cohort after another 4 years of follow-up (mean, 101 months; range, 77 to 146 months). At that time, the median American Shoulder and Elbow Surgeons (ASES) score was 92 points (interquartile range [IQR], 81.7 to 98.3) and the median Oxford Shoulder Score was 47 points (IQR, 41 to 48). Osseointegration, demonstrated by bone ingrowth between the flanges on the central peg as seen on coronal computed tomography (CT), was complete in 75% of the shoulders, partial in 21%, and absent in 4%. There were radiolucent lines at the bone-prosthesis interface on CT, with a median Yian score of 1 (IQR, 0 to 2; range, 0 to 18). The conclusion in the present study was that shoulder arthroplasty with an all-polyethylene, hybrid-fixation (bone ingrowth and cement) pegged glenoid component has durable clinical and radiographic outcomes at medium-term follow-up. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.