Spontaneous pneumothorax; a multicentre retrospective analysis of emergency treatment, complications and outcomes.

BACKGROUND: Spontaneous pneumothorax can be managed initially by observation, aspiration or chest drain insertion. AIMS: To determine the clinical features of spontaneous pneumothorax in patients presenting to the emergency department (ED), interventions, outcomes and potential risk factors for poor outcomes after treatment. METHODS: Retrospective chart review from ED of three major referral and two general hospitals in Australia of presentations with primary spontaneous pneumothorax (PSP) or secondary spontaneous pneumothorax (SSP). Main outcomes were prolonged air leak (>5 days) and pneumothorax recurrence within 1 year. RESULTS: We identified 225 people with PSP and 98 with SSP. There were no clinical tension pneumothoraces with hypotension. Hypoxaemia (haemoglobin oxygen saturation measured by pulse oximetry ≤92%) occurred only in SSP and in older patients (age >50 years) with PSP. Drainage was performed in 150 (67%) PSP and 82 (84%) SSP. Prolonged air leak occurred in 16% (95% confidence interval 10-23%) of PSP and 31% (21-42%) of SSP. Independent risk factors for prolonged drainage were non-asthma SSP and pneumothorax size >50%. Complications were recorded in 11% (7.5-16%) of those having drains inserted. Recurrences occurred in 5/91 (5%, 1.8-12%) of those treated without drainage versus 40/232 (17%, 13-23%) of those treated by drainage, of which half occurred in the first month after drainage. CONCLUSION: Pneumothorax drainage is associated with substantial morbidity including prolonged air leak. As PSP appears to be well tolerated in younger people even with large pneumothoraces, conservative treatment in this subgroup may be a viable option to improve patient outcomes, but this needs to be confirmed in a clinical trial.

Pilot study of random finger prick glucose testing as a screening tool for type 2 diabetes mellitus in the emergency department.

BACKGROUND: A study was undertaken to determine the prevalence of undiagnosed hyperglycaemia among patients in the emergency department (ED) and to evaluate the usefulness of random fingerprick plasma glucose (RFPG) screening in the ED with GP follow-up. METHODS: A cross-sectional pilot study of 101 non-diabetic patients in the ED aged > or =45 years was performed. RESULTS: 31 (30.7%) had never had diabetic screening. 67 (66.3%) had plasma glucose levels > or =5.5 mmol/l and were advised to consult their GP; 38 (56.7%) did so and 23 (60.5%) of these had follow-up testing. Nine patients (8.9%) were ultimately diagnosed with impaired glucose metabolism. CONCLUSION: There is considerable potential for diabetic screening in the ED setting.

Complementary and alternative medicines versus prescription drugs: perceptions of emergency department patients.

BACKGROUND: The perceptions of emergency department (ED) patients towards complementary and alternative medicines (CAM) are poorly understood. We assessed these perceptions and compared CAM users with non-users, particularly regarding CAM safety and efficacy. METHODS: This was an analytical, cross sectional survey of ED patients undertaken in a tertiary referral ED. A five point Likert scale evaluated patients' level of agreement with statements relating to CAM and prescription drugs. RESULTS: Of 404 patients who were enrolled (participation rate 97.1%), 275 (68.1%; 95% confidence interval (CI) 63.2 to 72.5) were CAM users (had taken a CAM within the previous 12 months). There were 178 patients (44.1%, 95% CI 39.2 to 49.1) who agreed or strongly agreed that CAM are drug free, and there was no significant difference between CAM users and non-users (p = 0.77). There were 115 patients (28.5%, 95% CI 24.2 to 33.2) who agreed or strongly agreed that CAM are always safe to take with prescription drugs, and there were no significant difference between CAM users and non-users (p = 0.39). Significantly more CAM users agreed or strongly agreed that CAM are safe to take, can prevent people from becoming ill, allow people to be in charge of their own health, can treat the mind, body, and spirit, and are more effective than prescription drugs (p<0.01). Significantly fewer CAM users agreed or strongly agreed that prescription drugs are safe to take (p<0.001). CONCLUSION: Considerable proportions of ED patients are CAM users yet are ignorant of the nature and potential toxicities of CAM. In addition, CAM users have significantly different perceptions of CAM and prescription drugs from non-users. The impact of these perceptions on clinical practice needs evaluation.

A paradigm shift in the nature of care provision in emergency departments.

OBJECTIVES: Access block to acute hospital inpatient beds has pressured emergency departments (EDs) to develop strategies to facilitate the management of patients in the community (new services) and to streamline ED care (facilitative initiatives). The aim of this study was to determine the nature and extent of those strategies introduced into the 17 public hospital EDs in Melbourne, Australia, since 1998. METHODS: This was a cross sectional survey of ED directors and/or nurse unit managers undertaken in November and December, 2002. Face to face or telephone interviews were conducted using a researcher administered questionnaire. RESULTS: All 17 EDs participated. A total of 15 strategies had been introduced into 15 (88.2%) EDs. New services included care coordination teams (12 ED, 70.6%), short stay units (10, 58.8%), psychiatric services (10, 58.8%), chest pain units (7, 41.2%), pharmacy services (3, 17.7%), sexual assault service (1, 5.9%), and hospital in the home within the ED (1, 5.9%). Facilitative initiatives included nurse initiated management (12, 70.6%), fast track processes (10, 58.8%), multidisciplinary triage (4, 23.5%), disposition nurses/communication clerks (3, 17.7%), and day treatment clinics (2, 11.8%). CONCLUSIONS: Melbourne's EDs have adapted rapidly to external pressures of access block and increasing patient numbers. Many traditional inpatient services have now been incorporated into the EDs. These EDs now provide a different and expanded paradigm of care.