Predictive performance of the common red flags in emergency department headache patients: a HEAD and HEAD-Colombia study.

OBJECTIVES: Only a small proportion of patients presenting to an ED with headache have a serious cause. The SNNOOP10 criteria, which incorporates red and orange flags for serious causes, has been proposed but not well studied. This project aims to compare the proportion of patients with 10 commonly accepted red flag criteria (singly and in combination) between patients with and without a diagnosis of serious secondary headache in a large, multinational cohort of ED patients presenting with headache. METHODS: Secondary analysis of data obtained in the HEAD and HEAD-Colombia studies. The outcome of interest was serious secondary headache. The predictive performance of 10 red flag criteria from the SNNOOP10 criteria list was estimated individually and in combination. RESULTS: 5293 patients were included, of whom 6.1% (95% CI 5.5% to 6.8%) had a defined serious cause identified. New neurological deficit, history of neoplasm, older age (>50 years) and recent head trauma (2-7 days prior) were independent predictors of a serious secondary headache diagnosis. After adjusting for other predictors, sudden onset, onset during exertion, pregnancy and immune suppression were not associated with a serious headache diagnosis. The combined sensitivity of the red flag criteria overall was 96.5% (95% CI 93.2% to 98.3%) but specificity was low, 5.1% (95% CI 4.3% to 6.0%). Positive predictive value was 9.3% (95% CI 8.2% to 10.5%) with negative predictive value of 93.5% (95% CI 87.6% to 96.8%). CONCLUSION: The sensitivity and specificity of the red flag criteria in this study were lower than previously reported. Regarding clinical practice, this suggests that red flag criteria may be useful to identify patients at higher risk of a serious secondary headache cause, but their low specificity could result in increased rates of CT scanning. TRIAL REGISTRATION NUMBER: ANZCTR376695.

Computed tomography brain scan utilization in patients with headache presenting to emergency departments: a multinational study.

BACKGROUND AND IMPORTANCE: Recommended indications for emergency computed tomography (CT) brain scans are not only complex and evolving, but it is also unknown whether they are being followed in emergency departments (EDs). OBJECTIVE: To determine the CT utilization and diagnostic yield in the ED in patients with headaches across broad geographical regions. DESIGN: Secondary analysis of data from a multinational cross-sectional study of ED headache presentations over one month in 2019. SETTING AND PARTICIPANTS: Hospitals from 10 participating countries were divided into five geographical regions [Australia and New Zealand (ANZ); Colombia; Europe: Belgium, France, UK, and Romania; Hong Kong and Singapore (HKS); and Turkey). Adult patients with nontraumatic headache as the primary presenting complaint were included. Patients were identified from ED management systems. OUTCOME MEASURES AND ANALYSIS: The outcome measures were CT utilization and diagnostic yield. CT utilization was calculated using a multilevel binary logistic regression model to account for clustering of patients within hospitals and regions. Imaging data (CT requests and reports) were sourced from radiology management systems. MAIN RESULTS: The study included 5281 participants. Median (interquartile range) age was 40 (29-55) years, 66% were women. Overall mean CT utilization was 38.5% [95% confidence interval (CI), 30.4-47.4%]. Regional utilization was highest in Europe (46.0%) and lowest in Turkey (28.9%), with HKS (38.0%), ANZ (40.0%), and Colombia (40.8%) in between. Its distribution across hospitals was approximately symmetrical. There was greater variation in CT utilization between hospitals within a region than between regions (hospital variance 0.422, region variance 0.100). Overall mean CT diagnostic yield was 9.9% (95% CI, 8.7-11.3%). Its distribution across hospitals was positively skewed. Regional yield was lower in Europe (5.4%) than in other regions: Colombia (9.1%), HKS (9.7%), Turkey (10.6%), and ANZ (11.2%). There was a weak negative correlation between utilization and diagnostic yield ( r  = -0.248). CONCLUSION: In this international study, there was a high variation (28.9-46.6%) in CT utilization and diagnostic yield (5.4-11.2%) across broad geographic regions. Europe had the highest utilization and the lowest yield. The study findings provide a foundation to address variation in neuroimaging in ED headache presentations.

SOFTLY: Comparison of outcomes of rigid versus soft collar during emergency department investigation for potential cervical spine injury in low-risk blunt trauma patients - A pilot study.

OBJECTIVE: Blunt trauma patients with potential cervical spine injury are traditionally immobilised in rigid collars. Recently, this has been challenged. The present study's objective was comparison of the rate of patient-oriented adverse events in stable, alert, low-risk patients with potential cervical spine injuries immobilised in rigid versus soft collars. METHODS: Unblinded, prospective quasi-randomised clinical trial of neurologically intact, adult, blunt trauma patients assessed as having potential cervical spine injury. Patients were randomised to collar type. All other aspects of care were unchanged. Primary outcome was patient-reported discomfort related to neck immobilisation by collar type. Secondary outcomes included adverse neurological events, agitation and clinically important cervical spine injuries (clinical trial registration number: ACTRN12621000286842). RESULTS: A total of 137 patients were enrolled: 59 patients allocated to a rigid collar and 78 to a soft collar. Most injuries were from a fall <1 m (54%) or a motor vehicle crash (21.9%). Median neck pain score of collar immobilisation was lower in the soft collar group (3.0 [interquartile range 0-6.1] vs 6.0 [interquartile range 3-8.8], P < 0.001). The proportion of patients with clinician-identified agitation was lower in the soft collar group (5% vs 17%, P = 0.04). There were four clinically important cervical spine injuries (two in each group). All were treated conservatively. There were no adverse neurological events. CONCLUSIONS: Use of soft rather than rigid collar immobilisation for low-risk blunt trauma patients with potential cervical spine injury is significantly less painful for patients and results in less agitation. A larger study is needed to determine the safety of this approach or whether collars are required at all.

Outcome of reduction of paediatric forearm fracture by emergency department clinicians.

OBJECTIVES: Paediatric forearm fractures are common. Anecdotally, there is a trend towards ED reduction of selected fractures under procedural sedation. We aimed to determine the rate of subsequent operative intervention for fracture re-displacement. METHODS: Retrospective observational study of children with a forearm/wrist fracture undergoing fracture reduction in ED. Outcome of interest was operative intervention for fracture re-displacement within 6 weeks. RESULTS: Among 176 patients studied, operative intervention occurred in nine patients (5.1%, 95% confidence interval 2.7-9.4%). CONCLUSION: Reduction of paediatric forearm fractures under procedural sedation by ED clinicians is increasingly common and results in a low rate of subsequent operative intervention.

Thunderclap headache syndrome presenting to the emergency department: an international multicentre observational cohort study.

BACKGROUND: Most headache presentations to emergency departments (ED) have benign causes; however, approximately 10% will have serious pathology. International guidelines recommend that patients describing the onset of headache as 'thunderclap' undergo neuroimaging and further investigation. The association of this feature with serious headache cause is unclear. The objective of this study was to determine if patients presenting with thunderclap headache are significantly more likely to have serious underlying pathology than patients with more gradual onset and to determine compliance with guidelines for investigation. METHODS: This was a planned secondary analysis of an international, multicentre, observational study of adult ED patients presenting with a main complaint of headache. Data regarding demographics, investigation strategies and final ED diagnoses were collected. Thunderclap headache was defined as severe headache of immediate or almost immediate onset and peak intensity. Proportion of patients with serious pathology in thunderclap and non-thunderclap groups were compared by χ² test. RESULTS: 644 of 4536 patients presented with thunderclap headache (14.2%). CT brain imaging and lumbar puncture were performed in 62.7% and 10.6% of cases, respectively. Among patients with thunderclap headache, serious pathology was identified in 10.9% (95%CI 8.7% to 13.5%) of cases-significantly higher than the proportion found in patients with a different headache onset (6.6% (95% CI 5.9% to 7.4%), p<0.001.). The incidence of subarachnoid haemorrhage (SAH) was 3.6% (95% CI 2.4% to 5.3%) in those with thunderclap headache vs 0.3% (95% CI 0.2% to 0.5%) in those without (p<0.001). All cases of SAH were diagnosed on CT imaging. Non-serious intracranial pathology was diagnosed in 87.7% of patients with thunderclap headache. CONCLUSIONS: Thunderclap headache presenting to the ED appears be associated with higher risk for serious intracranial pathology, including SAH, although most patients with this type of headache had a benign cause. Neuroimaging rates did not align with international guidelines, suggesting potential need for further work on standardisation.

Migraine in the Emergency Department: A Prospective Multinational Study of Patient Characteristics, Management, and Outcomes.

BACKGROUND AND AIM: Migraine headache is commonly diagnosed in emergency departments (ED). There is relatively little real-world information about the epidemiology, investigation, management, adherence to therapeutic guidelines and disposition of patients treated in ED with a final diagnosis of migraine. The primary aim of the current study is to get a snapshot of assessment and management patterns of acute migraine presentations to the different settings of EDs with a view to raise awareness. METHODS: This is a planned sub-study of a prospective study conducted in 67 health services in 10 countries including Australia, New Zealand, Southeast Asia, Europe, and the UK investigating the epidemiology and outcome of adult patients presenting to ED with nontraumatic headache. Outcomes of interest for this study are demographics, clinical features (including severity), patterns of investigation, treatment, disposition, and outcome of patients diagnosed as having migraine as their final ED diagnosis. RESULTS: The cohort comprises 1,101 patients with a mean age of 39 years (SD ± 13.5; 73.7% [811]) were female. Most patients had had migraine diagnosed previously (77.7%). Neuroimaging was performed in 25.9% with a very low diagnostic yield or significant findings (0.07%). Treatment of mild migraine was in accordance with current guidelines, but few patients with moderate or severe symptoms received recommended treatment. Paracetamol (46.3%) and nonsteroidal anti-inflammatory drugs (42.7%) were the most commonly prescribed agents. Metoclopramide (22.8%), ondansetron (19.2%), chlorpromazine (12.8%), and prochlorperazine (12.8%) were also used. CONCLUSIONS: This study suggests that therapeutic practices are not congruent with current guidelines, especially for patients with severe symptoms. Efforts to improve and sustain compliance with existing management best practices are required.

Chlorhexidine skin cleaning to reduce clean-catch urine contamination in infants: A pilot study.

OBJECTIVE: Clean-catch urine (CCU) samples are frequently contaminated. Our aim was to determine if cleaning with 0.1% chlorhexidine before CCU is a safe and feasible method to reduce contamination. METHODS: Prospective interventional pilot study. Children 1-24 months underwent perigenital skin cleaning with 0.1% chlorhexidine. Primary outcome was contamination rate, and secondary outcomes were parent and clinician satisfaction with the procedure. RESULTS: Twelve of 54 urine samples were contaminated (22%, 95% CI 13-35). Over 90% of parents and clinicians were either 'satisfied' or 'very satisfied'. No adverse events were recorded. CONCLUSION: Cleaning with chlorhexidine solution before CCU is safe and feasible.

Characteristics and outcome of patients transported by police to emergency departments under section 351 of the Mental Health Act 2014 (Vic).

OBJECTIVE: To determine characteristics, precipitating circumstances, clinical care, outcome and disposition of patients brought to the ED under section 351 (s351, police detention and transport) powers of the Mental Health Act 2014 (Vic) (MHAV). METHODS: This is an observational cohort study conducted in two metropolitan teaching hospitals in Victoria. Participants were adult patients brought to ED under s351 of the MHAV. Data collected included demographics, event circumstances, pre-hospital and ED interventions and outcome. Analyses are descriptive. RESULTS: The present study included 438 patient encounters. Median age was 34 years. In 84% of encounters (368/438) patients were co-transported with ambulance. The most common primary reason for detainment was suicide risk/intent (296/438, 67.6%) followed by abnormal behaviour without threat to self or others (92/438, 21%). In ED, parenteral sedation was administered in 11% (48/438). Physical restraint was applied in 17.6% (77/438). Psychiatric admission was required in 23.5% (103/438). In 63 cases, psychiatric admission was involuntary (14.4%). Most patients (297/438, 67.8%) were discharged home. A subset of patients had recurrent s351 presentations. Eighteen (5.6%) patients accounted for 22% (96/438) of all events. CONCLUSION: Most patients brought to ED under s351 of the MHAV had expressed intention to self-harm, did not require medical intervention and were discharged home. It could be questioned whether the current application of s351 is consistent with the least restrictive principles of the MHAV, especially as there is no apparent monitoring or reporting of the use of these powers. There were a concerning number of patients with multiple s351 events over a short period.

Clinical presentation and assessment of older patients presenting with headache to emergency departments: A multicentre observational study.

OBJECTIVE: To describe the characteristics, assessment and management of older emergency department (ED) patients with non-traumatic headache. METHODS: Planned sub-study of a prospective, multicentre, international, observational study, which included adult patients presenting to ED with non-traumatic headache. Patients aged ≥75 years were compared to those aged <75 years. Outcomes of interest were epidemiology, investigations, serious headache diagnosis and outcome. RESULTS: A total of 298 patients (7%) in the parent study were aged ≥75 years. Older patients were less likely to report severe headache pain or subjective fever (both P < 0.001). On examination, older patients were more likely to be confused, have lower Glasgow Coma Scores and to have new neurological deficits (all P < 0.001). Serious secondary headache disorder (composite of headache due to subarachnoid haemorrhage (SAH), intracranial haemorrhage, meningitis, encephalitis, cerebral abscess, neoplasm, hydrocephalus, vascular dissection, stroke, hypertensive crisis, temporal arteritis, idiopathic intracranial hypertension or ventriculoperitoneal shunt complications) was diagnosed in 18% of older patients compared to 6% of younger patients (P < 0.001). Computed tomography brain imaging was performed in 66% of patients ≥75 years compared to 35% of younger patients (P < 0.001). Older patients were less likely to be discharged (43% vs 63%, P < 0.001). CONCLUSIONS: Older patients with headache had different clinical features to the younger cohort and were more likely to have a serious secondary cause of headache than younger adults. There should be a low threshold for investigation in older patients attending ED with non-traumatic headache.

Epidemiology, investigation, management, and outcome of headache in emergency departments (HEAD study)-A multinational observational study.

OBJECTIVE: To describe the epidemiology of nontraumatic headache in adults presenting to emergency departments (EDs). BACKGROUND: Headache is a common reason for presentation to EDs. Little is known about the epidemiology, investigation, and treatment of nontraumatic headache in patients attending EDs internationally. METHODS: An international, multicenter, observational, cross-sectional study was conducted over one calendar month in 2019. Participants were adults (≥18 years) with nontraumatic headache as the main presenting complaint. Exclusion criteria were recent head trauma, missing records, interhospital transfers, re-presentation with same headache as a recent visit, and headache as an associated symptom. Data collected included demographics, clinical assessment, investigation, treatment, and outcome. RESULTS: We enrolled 4536 patients (67 hospitals, 10 countries). "Thunderclap" onset was noted in 14.2% of cases (644/4536). Headache was rated as severe in 27.2% (1235/4536). New neurological examination findings were uncommon (3.2%; 147/4536). Head computed tomography (CT) was performed in 36.6% of patients (1661/4536), of which 9.9% showed clinically important pathology (165/1661). There was substantial variation in CT scan utilization between countries (15.9%-75.0%). More than 30 different diagnoses were made. Presumed nonmigraine benign headache accounted for 45.4% of cases (2058/4536) with another 24.3% classified as migraine (1101/4536). A small subgroup of patients have a serious secondary cause for their headache (7.1%; 323/4536) with subarachnoid hemorrhage (SAH), stroke, neoplasm, non-SAH intracranial hemorrhage/hematoma, and meningitis accounting for about 1% each. Most patients were treated with simple analgesics (paracetamol, aspirin, or nonsteroidal anti-inflammatory agents). Most patients were discharged home (83.8%; 3792/4526). In-hospital mortality was 0.3% (11/4526). CONCLUSION: Diagnosis and management of headache in the ED is challenging. A small group of patients have a serious secondary cause for their symptoms. There is wide variation in the use of neuroimaging and treatments. Further work is needed to understand the variation in practice and to better inform international guidelines regarding emergent neuroimaging and treatment.

The Headache in Emergency Departments study: Opioid prescribing in patients presenting with headache. A multicenter, cross-sectional, observational study.

OBJECTIVE: To describe the patterns of opioid use in patients presenting to the emergency department (ED) with nontraumatic headache by severity and geography. BACKGROUND: International guidelines recognize opioids are ineffective in treating primary headache disorders. Globally, many countries are experiencing an opioid crisis. The ED can be a point of initial exposure leading to tolerance for patients. More geographically diverse data are required to inform practice. METHODS: This was a planned, multicenter, cross-sectional, observational substudy of the international Headache in Emergency Departments (HEAD) study. Participants were prospectively identified throughout March 2019 from 67 hospitals in Europe, Asia, Australia, and New Zealand. Adult patients with nontraumatic headache were included as identified by the local site investigator. RESULTS: Overall, 4536 patients were enrolled in the HEAD study. Opioids were administered in 1072/4536 (23.6%) patients in the ED, and 386/3792 (10.2%) of discharged patients. High opioid use occurred prehospital in Australia (190/1777, 10.7%) and New Zealand (55/593, 9.3%). Opioid use in the ED was highest in these countries (Australia: 586/1777, 33.0%; New Zealand: 221/593, 37.3%). Opioid prescription on discharge was highest in Singapore (125/442, 28.3%) and Hong Kong (12/49, 24.5%). Independent predictors of ED opioid administration included the following: severe headache (OR 4.2, 95% CI 3.1-5.5), pre-ED opioid use (OR 1.42, 95% CI 1.11-1.82), and long-term opioid use (OR 1.80, 95% CI 1.26-2.58). ED opioid administration independently predicted opioid prescription at discharge (OR 8.4, 95% CI 6.3-11.0). CONCLUSION: Opioid prescription for nontraumatic headache in the ED and on discharge varies internationally. Severe headache, prehospital opioid use, and long-term opioid use predicted ED opioid administration. ED opioid administration was a strong predictor of opioid prescription at discharge. These findings support education around policy and guidelines to ensure adherence to evidence-based interventions for headache.

Is COVID-19 the straw that broke the back of the emergency nursing workforce?

OBJECTIVES: To explore the intentions of Australian emergency nurses to remain in or leave emergency nursing after the first year of the SARS-CoV-2 (COVID-19) pandemic. METHODS: Sub-study of a survey of Australian emergency nurses about the impact of COVID-19 on their work, life and career. This sub-study focused on future career intentions, especially intentions to remain in or leave emergency nursing. RESULTS: There were 398 eligible responses. 48.2% of respondents reported that they intended to leave emergency nursing within 5 years. Nurses in EDs who received COVID positive patients were more likely to express an intention to leave ED nursing (P = 0.016). Having directly cared for a COVID positive patient was not statistically associated with intention to leave ED nursing (P = 0.17). Excluding nurses aged >60 years, there was no statistical difference in expressed intention to leave ED nursing between age groups (P = 0.32), nurses with/without a higher qualification (P = 0.32) or number of years in ED nursing (P = 0.54). Intention to leave emergency nursing was associated with not feeling more connected to their emergency nursing colleagues (P = 0.03), the broader ED team (P = 0.008) and their organisation (P = 0.03) since the onset of the pandemic. CONCLUSION: The data suggest that approximately 1 year after the onset of the COVID-19 pandemic in Australia, a high proportion of ED nurses intend to leave ED nursing within 5 years, which will exacerbate pre-existing shortages. Active strategies to address this are urgently needed.

Epidemiology of Headache in Children in a Community Emergency Department: A Scoping Study.

OBJECTIVE: This study aimed to describe the epidemiology of headache in children attending a community mixed adult-pediatric emergency department (ED) in Australia with a view to providing scoping data for future headache-related projects for the pediatric ED research networks. METHODS: This is a retrospective cohort study by medical record review. Participants were children aged 2 to 16 years who presented to the ED between January 1, 2016, and December 31, 2016, with a major symptom of headache. Exclusion criteria were a history of recent head trauma, a ventriculoperitoneal shunt in situ, or known intracranial conditions associated with headache. Data collected included demographics, clinical features, investigations, diagnosis, disposition, and outcome. The primary outcomes of interest were the proportion of children with a serious ED diagnosis, the distribution of ED diagnoses, investigation ordering patterns, treatments provided, and clinical outcome. RESULTS: A total of 225 children were studied, with a median age of 9 years (interquartile range, 6-13 years). The most common associated symptoms were fever (47%) and vomiting (42%). The most common examination feature was fever (21%). Abnormal neurological findings were very uncommon. Few children underwent advanced neuroimaging (7 patients; 3%), and no intracranial abnormalities were detected. Seven children had a serious diagnosis (7/225 [3%]; 95% confidence interval, 2%-6%). Six of these 7 were viral meningitis, and there was 1 case of bacterial meningitis. CONCLUSIONS: In a community teaching hospital cohort of children with headache, intercurrent viral illness is the most common cause. Serious causes were very uncommon. The rate of bacterial meningitis, tumor, or abscess was <1%. This has implications for the planning of research projects.

Epidemiology and outcome of older patients presenting with dyspnoea to emergency departments.

OBJECTIVES: To describe the epidemiology and outcomes of non-traumatic dyspnoea in patients aged 75 years or older presenting to emergency departments (EDs) in the Asia-Pacific region. METHODS: A substudy of a prospective interrupted time series cohort study conducted at three time points in EDs in Australia, New Zealand, Singapore, Hong Kong and Malaysia of patients presenting to the ED with dyspnoea as a main symptom. Data were collected over three 72-h periods and included demographics, co-morbidities, mode of arrival, usual medications, ED investigations and treatment, ED diagnosis and disposition, and outcome. The primary outcomes of interest are the epidemiology and outcome of patients aged 75 years or older presenting to the ED with dyspnoea. RESULTS: 1097 patients were included. Older patients with dyspnoea made up 1.8% [95% confidence interval (CI) 1.7-1.9%] of ED presentations. The most common diagnoses were heart failure (25.3%), lower respiratory tract infection (25.2%) and chronic obstructive pulmonary disease (17.6%). Hospital ward admission was required for 82.6% (95% CI 80.2-84.7%), with 2.5% (95% CI 1.7-3.6%) requiring intensive care unit (ICU) admission. In-hospital mortality was 7.9% (95% CI 6.3-9.7%). Median length of stay was 5 days (interquartile range 2-8 days). CONCLUSION: Older patients with dyspnoea make up a significant proportion of ED case load, and have a high admission rate and significant mortality. Exacerbations or worsening of pre-existing chronic disease account for a large proportion of cases which may be amenable to improved chronic disease management.

Epidemiology, treatment and outcome of patients with lower respiratory tract infection presenting to emergency departments with dyspnoea (AANZDEM and EuroDEM studies).

OBJECTIVE: Lower respiratory tract infection (LRTI) is a frequent cause of dyspnoea in EDs, and is associated with considerable morbidity and mortality. We described and compared the management of this disease in Europe and Oceania/South-East Asia (SEA) cohorts. METHODS: We conducted a prospective cohort study with three time points in Europe and Oceania/SEA. We included in this manuscript patients presenting to EDs with dyspnoea and a diagnosis of LRTI in ED. We collected comorbidities, chronic medication, clinical signs at arrival, laboratory parameters, ED management and patient outcomes. RESULTS: A total of 1389 patients were included, 773 in Europe and 616 in SEA. The European cohort had more comorbidities including chronic heart failure, obesity, chronic obstructive pulmonary disease and smoking. Levels of inflammatory markers were higher in Europe. There were more patients with inflammatory markers in Europe and more hypercapnia in Oceania/SEA. The use of antibiotics was higher in SEA (72.2% vs 61.8%, P < 0.001) whereas intravenous diuretics, non-invasive and invasive ventilation were higher in Europe. Intensive care unit admission rate was 9.9% in Europe cohort and 3.4% in Oceania/SEA cohort. ED mortality was 1% and overall in-hospital mortality was 8.7% with no differences between regions. CONCLUSIONS: More patients with LRTI in Europe presented with cardio-respiratory comorbidities, they received more adjunct therapies and had a higher intensive care unit admission rate than patients from Oceania/SEA, although mortality was similar between the two cohorts.

Development, implementation and evaluation of a process to recognise and reduce aggression and violence in an Australian emergency department.

OBJECTIVE: In 2018, we developed and implemented a novel approach to recognition and response to occupational violence and aggression (OVA). It included routine use of the Brøset Violence Checklist for all ED patients integrated with a score-based notification and response framework. The present study evaluated the impact of the new process on staff knowledge, perceptions and confidence regarding OVA in ED and the rate of security events related to OVA. METHODS: The present study was conducted in a metropolitan hospital ED in Australia. Evaluation was by online before and after survey of nursing staff, point prevalence study of risk classification and comparison of OVA-related events involving security in the year before implementation and the year after the programme was embedded. RESULTS: One percent of patients were assessed as high violence risk with a further 4% at moderate risk. The introduction of the Brøset Violence Checklist increased documentation of violence risk assessment. It also improved staff perception of organisational support and awareness of behaviours associated with the risk of violence. There was a statistically significant reduction in unplanned OVA-related security responses (relative risk 0.75, 95% confidence interval 0.62-0.89). There was also a statistically significant shift to proactive management through early detection and intervention (relative risk 2.22, 95% confidence interval 1.85-2.66). CONCLUSION: A process including routine OVA risk assessment and a notification and response framework reduced unplanned security events due to OVA and increased staff confidence in recognition and management of OVA. This approach may be suitable for use more broadly in ED.

Chronic disease management in emergency department patients presenting with dyspnoea.

OBJECTIVES: Guideline recommended treatments for chronic conditions are thought to reduce ED presentations. METHOD: We used data from 1958 ED patients with dyspnoea to describe medication use in patients with chronic conditions. RESULTS: A total of 1233 (63.5%) patients had one or more of: chronic obstructive pulmonary disease 547 (28%), asthma 454 (23%), atrial fibrillation 368 (19%) or heart failure 401 (21%). Approximately, 70% were prescribed appropriate preventative medication for their chronic condition when they presented to ED with dyspnoea. CONCLUSION: Prescription of guideline recommended therapies for chronic conditions in patients presenting to the ED in Australasia with acute dyspnoea is similar or higher than reported previously.

What is the distribution of Aortic Dissection Detection Risk Score in an undifferentiated emergency department chest pain population?

OBJECTIVE: To determine the distribution of Aortic Dissection Detection Risk Score (ADDRS) in undifferentiated chest pain patients. METHODS: Prospective observational study of adult patients presenting to the ED with non-traumatic chest pain. RESULTS: Of 139 patients studied, more than 75% of patients has an ADDRS ≥1, mainly because of the report of severe pain. There were no aortic dissections. In patients with non-specific chest pain, testing driven by the ADDRS protocol would have seen a 280% increase in d-dimer testing and 2200% increase in computed tomography aortogram rates. CONCLUSION: Widespread use of the ADDRS and its investigation protocol cannot be supported.

External validation of the modified HOPPE score to predict low risk pulmonary embolism suitable for early discharge.

OBJECTIVE: Recently, a novel score for risk stratification of patients with pulmonary embolism (PE)-the HOPPE score-was derived. We aimed to externally validate the HOPPE score in emergency department-diagnosed PE, using SpO2 as a surrogate for PaO2-the modified HOPPE score. METHODS: Retrospective observational study of adult patients with an emergency department diagnosis of PE was performed. Data collected included demographics, co-morbidities, clinical features, electrocardiogram and test results, in-hospital mortality and non-fatal major adverse clinical events (MACE; survived cardiac arrest, cardiogenic shock or thrombolysis administration). The primary outcome of interest was clinical performance of the modified HOPPE score for inhospital mortality and the composite outcome of in-hospital death and MACE. A secondary outcome was comparison of predictive performance between the modified HOPPE score and the simplified Pulmonary Embolism Severity Index score. RESULTS: Two hundred and six patients were studied (median age 61, 55% female). There were no deaths or MACE in patients with a low risk modified HOPPE score of 0 to 6 (0%; 95% confidence interval, 0% to 1.8%). Negative predictive value of a low risk score was 100% (95% confidence interval, 92.2% to 100%) for in-hospital mortality and for the composite of in-hospital mortality or MACE. The modified HOPPE score had similar predictive performance to the simplified Pulmonary Embolism Severity Index score with an area under the curve of 0.88 vs. 0.80 for the composite outcome of in-hospital mortality or MACE (P=0.052). Twenty-eight percent of the patients were classified as low risk and potentially suitable for management as outpatients. CONCLUSION: The modified HOPPE score showed good clinical performance. Prospective validation is warranted.