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).

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.

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.

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.

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.

Global health and emergency care: a resuscitation research agenda--part 1.

At the 2013 Academic Emergency Medicine global health consensus conference, a breakout session on a resuscitation research agenda was held. Two articles focusing on cardiac arrest and trauma resuscitation are the result of that discussion. This article describes the burden of disease and outcomes, issues in resuscitation research, and global trends in resuscitation research funding priorities. Globally, cardiovascular disease and trauma cause a high burden of disease that receives a disproportionately smaller research investment. International resuscitation research faces unique ethical challenges. It needs reliable baseline statistics regarding quality of care and outcomes; data linkages between providers; reliable and comparable national databases; and an effective, efficient, and sustainable resuscitation research infrastructure to advance the field. Research in resuscitation in low- and middle-income countries is needed to understand the epidemiology, infrastructure and systems context, level of training needed, and potential for cost-effective care to improve outcomes. Research is needed on low-cost models of population-based research, ways to disseminate information to the developing world, and finding the most cost-effective strategies to improve outcomes.

Can the characteristics of emergency department attendances predict poor hospital outcomes in patients with sepsis?

INTRODUCTION: The emergency department (ED) is often the initial site of identification of patients with sepsis. We aimed to determine the characteristics of ED attendances that predict poor hospital outcomes. METHODS: We conducted a retrospective cohort study of adult patients in eight metropolitan EDs in Perth, Western Australia, from 2001 to 2006. Patients diagnosed with sepsis in the ED were identified using the International Classification of Diseases, 10th Revision-Australian Modification code in the Emergency Department Information System (EDIS) database. The EDIS database was subsequently linked to mortality and hospital morbidity records. The following characteristics were examined: triage category, mode of arrival, source of referral and hospital of presentation. Multivariate logistic regression was performed to identify predictors of hospital mortality, prolonged length of stay, and admission to the intensive care unit (ICU). RESULTS: In the 1,311 patients diagnosed with sepsis in the ED, the hospital mortality and ICU admission rates were 19.5% and 18.5%, respectively. The mean hospital length of stay was 12 ± 15 days. Acute triage categories predicted both hospital mortality and ICU admissions, while mode of arrival by ambulance was a predictor of all poor hospital outcomes (p < 0.001). Patients who presented to non-teaching hospitals had similar hospital outcomes as patients who presented to teaching hospitals. The source of referrals was not a predictor of poor hospital outcomes (p > 0.05). CONCLUSION: Mode of arrival and triage score, which are characteristics unique to the ED, may predict poor hospital outcomes in patients with sepsis.

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.

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.

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.

The effect of age, severity, and mechanism of injury on risk of death from major trauma in Western Australia.

BACKGROUND: We examined the association between age, mechanism of injury, and Injury Severity Score (ISS) on mortality in major trauma. METHODS: We used 9 years of population-based linked major trauma (ISS >15) registry data for Western Australia (N = 4,411). These were categorized using the Sampalis classification of injury severity: survivable (ISS 16-24), probably survivable (ISS 25-49), and nonsurvivable (ISS 50+). Age was categorized as younger than 15 years, 15 to 64 years, and 65 years or older. Multivariable linear logistic regression analysis was used to examine the risk of death. RESULTS: Motor vehicle crashes (MVCs) were most prominent for those younger than 65 years, and falls dominated the 65 years and older group. The median ISS for the three age groups were 20, 25, and 24, respectively (p = 0.001). The proportion of deaths in the three groups were 7.2%, 11.5%, and 30.1%, respectively (p = 0.0001). Falls were the most common cause of death. The inflexion point, above which the risk of death increases exponentially, was age 47 years. For the potentially survivable ISS 25 to 49 group, the inflexion point was age 25 years. After adjusting for age and ISS, falls had the greatest risk for death (odds ratio, 1.62; 95% confidence interval, 1.21-2.18). A lower ISS had a disproportionate effect on the elderly. CONCLUSION: The risk for major trauma death increases as age increases, with the inflexion point at age 47 years. Those younger than 15 years have a significantly lower ISS. The elderly have an increased risk for death following falls. LEVEL OF EVIDENCE: Epidemiologic study, level II.

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.

Accuracy of International classification of diseases, 10th revision codes for identifying severe sepsis in patients admitted from the emergency department.

OBJECTIVE: To determine the accuracy of International classification of diseases, 10th revision, Australian modification (ICD-10-AM) codes in identifying severe sepsis in patients admitted from the emergency department (ED). DESIGN, SETTING AND PARTICIPANTS: A retrospective cohort study of ED patients transferred to the intensive care unit of a tertiary hospital within 24 hours of leaving ED, 2000- 2006. MAIN OUTCOME MEASURES: Clinical diagnosis of severe sepsis compared with diagnosis-based code (DB-C) categories based on ICD-10-AM codes in the Emergency Department Information Systems (EDIS) and Hospital Morbidity Data System (HMDS); sensitivity, specificity, positive predictive value (PPV) and negative predictive value of these databases. RESULTS: In the study period, 1645 patients were transferred to the ICU from the ED, of whom 254 had severe sepsis. Single discharge ICD-10-AM codes recorded in the EDIS and the principal ICD-10-AM codes recorded in the HMDS that fell into D-BC categories for sepsis, pneumonia, viscous perforation, peritonitis, cholecystitis or cholangitis had a PPV of 85.0% (95% CI, 78.4%-91.6%; 96/113) and 88.2% (95%CI, 72.6%-82.6%; 112/127), respectively. The respective sensitivity was 37.8% (95% CI, 31.8%-43.8%) (96/254) and 44.1% (95% CI, 38.0-50.2) (112/254). In contrast, ICD-10-AM codes in the HMDS that code for infection and organ dysfunction had a PPV of 33.5% (95% CI, 30.0%-37.0%; 227/677) and sensitivity of 89.4% (95% CI, 85.6%-93.2%; 227/254). CONCLUSION: ICD-10-AM codes recorded in the EDIS or HMD had limited utility for identifying severe sepsis in patients admitted to ICU from the ED.

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 deaths at Perth secondary hospitals.

OBJECTIVE: Some major trauma (Injury Severity Score [ISS] >15) patients transported to a secondary hospital in Perth do not survive. We sought to describe this cohort and assess preventability. METHODS: A cohort study from a previously developed cohort of trauma deaths in Western Australia from 1 July 1997 to 30 June 2006. A preformatted data sheet was used to collect a range of descriptive, time, physiological, and autopsy data. Trauma scores were calculated. Preventability was assessed using three approaches, based on ISS, Trauma Revised Injury Severity Score (TRISS) and individual case review. RESULTS: There were 74 major trauma deaths, mean age 55.6 ± 26.3 years (range 3-95). Thirty-seven (50%) were motor vehicle crashes. The mean Revised Trauma Score was 3.84 ± 3.09 (0-7.84), median ISS 31 (interquartile range [IQR] 25-51), median TRISS 0.127 (IQR 0.031-0.772) and median time to death was 80 min (IQR 20 min-10 h 8 min). Severe head and chest injuries were the most common. Almost half (36, 48.6%) were receiving CPR on arrival to the hospital. The crude proportion of potentially preventable deaths, based on ISS, TRISS and case review, were 16.2%, 32.4% and 6.7%, respectively. However, these were predominantly elderly patients and a decision against resuscitation was recorded in 54%. CONCLUSIONS: The proportion of potentially preventable major trauma deaths at Perth secondary hospitals is low. The most notable group were the elderly after falls, and trauma system efforts should be focused on this group. Primary prevention of major trauma represents the biggest opportunity for improvements in trauma survival.

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.

Analysis of 22,655 presentations with back pain to Perth emergency departments over five years.

BACKGROUND: Back pain is a significant cause of disability in the community, but the impact on Emergency Departments (EDs) has not been formally studied. Patients with back pain often require significant time and resources in the ED. AIMS: To examine the characteristics of patients presenting with back pain to the ED, including final diagnosis, demographics of those attending and temporal distribution of presentations. METHODS: Emergency presentations in the metropolitan area of Perth, Western Australia, for 2000-2004 were searched using a linked database covering all the major hospitals (Emergency Care Hospitalisation and Outcome Study database). All presentations with the triage code for back pain were extracted and analysed. RESULTS: A total of 22,655 presentations with back pain were identified, representing 1.9% of total presentations. Simple muscular or non-specific back pain accounted for only 43.8% of presentations, with other causes such as renal colic and pyelonephritis accounting for the majority. The young (<15 years old) and elderly (>75 years old) were more likely to have non-muscular causes for their back pain. Muscular back pain presentations occurred mostly between 0800 and 1600, with high proportions presenting on the weekends. Patients with simple muscular back pain spent a mean of 4.4 h in the ED, representing a significant outlay of resources. CONCLUSION: Back pain has a significant impact on EDs, and staff should be alert for another pathology presenting as back pain. There is a need for multidisciplinary back pain teams to be available 7 days a week, but only during the day.