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OBJECTIVE: Falls are a leading cause for ED presentations among older adults. Existing secondary falls prevention interventions have not been shown to decrease fall-related ED re-presentation, indicating a need to better understand contributing factors. Our aim was to evaluate risk factors for fall re-presentations among the older patient population presenting to the ED. METHODS: This is a single-centre case-control study. Cases were patients aged ≥65 years with two falls-related ED presentations within 6 months. Age- and sex-matched controls had a corresponding index, but no subsequent ED fall presentation. Data collected included falls risk factors and clinical features of the index presentation. Univariate and multivariate analyses were conducted to assess the relationship between potential exposures and fall re-presentation. RESULTS: A total of 300 patients (mean age 83.8 years) were studied. On univariate analysis, factors significantly associated with ED fall re-presentation included increasing multimorbidity (P < 0.0001), increasing number of medications (P < 0.0001) and residing in residential aged care facility (RACF) (odds ratio [OR] 3.06, P < 0.001). No factors remained significant on multivariate analysis. Post-hoc analyses for the RACF subgroup showed that psychotropic medication use (OR 1.65, P = 0.04) and prior fall within 12 months (OR 2.68, P < 0.001) were significantly associated with re-presentation. Initial presentation with serious musculoskeletal injury was a significant protective factor (OR 0.21, P = 0.02). CONCLUSION: The present study failed to identify factors independently associated with ED fall re-presentation, suggesting that the factors are complex and inter-related. Two high-risk populations were identified - those from RACF and those initially presenting with falls not resulting in serious injury.
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OBJECTIVE: Testicular torsion is an uncommon but time-critical condition in EDs. If the diagnosis is missed or delayed, there are significant medicolegal and patient fertility implications. Scoring tools are advocated for use in children but have limited validation in adults. The aim of the present study was to explore the predictive accuracy of the testicular torsion scoring tools, Testicular Workup for Ischemia and Suspected Torsion (TWIST) and Boettcher Alert Score (BALS), in adult patients with a final ED diagnosis of torsion. METHODS: All patients with an ED working diagnosis of testicular torsion were identified retrospectively. Data collected from digital medical records included demographics, processes of care and clinical information. The outcome of interest was the predictive performance of the scores for a confirmed diagnosis of testicular torsion as adjudicated by an urologist or a surgeon. RESULTS: Fifty-four patients had complete clinical data, of whom 13 had confirmed torsion. The TWIST score had a high area under the receiver operating characteristics curve (AUROC) of 0.89 (95% confidence interval [CI] = 0.78-0.999) with a score of 6-7 corresponding to a positive predictive value (PPV) of 80% (95% CI = 38-96%). The BAL score had an AUROC of 0.79 (95% CI = 0.69-0.92). PPV for a score ≥2 was 38% (95% CI = 22-56%). CONCLUSION: A high TWIST score correlates to a high likelihood of torsion and can inform surgical decision-making in the absence of US.
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BACKGROUND: Several methods exist to reduce the number of arterial blood gases (ABGs). One method, Roche v-TAC, has been evaluated in different patient groups. This paper aggregates data from these studies, in different patient categories using common analysis criteria. RESEARCH DESIGN AND METHODS: We included studies evaluating v-TAC based on paired arterial and peripheral venous blood samples. Bland-Altman analysis compared measured and calculated arterial values of pH, PCO2, and PO2. Subgroup analyses were performed for normal, chronic hypercapnia and chronic base excess, acute hyper- and hypocapnia, and acute and chronic base deficits. RESULTS: 811 samples from 12 studies were included. Bias and limits of agreement for measured and calculated values: pH 0.001 (-0.029 to 0.031), PCO2 -0.08 (-0.65 to 0.49) kPa, and PO2 0.04 (-1.71 to 1.78) kPa, with similar values for all sub-group analyses. CONCLUSION: These data suggest that v-TAC analysis may have a role in replacing ABGs, avoiding arterial puncture. Substantial data exist in patients with chronic hypercapnia and chronic base excess, acute hyper- and hypocapnia, and in patients with relatively normal acid-base status, with similar bias and precision across groups and across study data. Limited data exist for patients with acute and chronic base deficits.
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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.
Subject(s)
Emergency Service, Hospital , Headache , Predictive Value of Tests , Humans , Female , Emergency Service, Hospital/organization & administration , Male , Middle Aged , Adult , Headache/etiology , Headache/diagnosis , Sensitivity and Specificity , AgedABSTRACT
Patients leave ED for a variety of reasons and at all stages of care. In Australian law, clinicians and health services owe a duty of care to people presenting to the ED for care, even if they have not yet entered a treatment space. There is also a positive duty to warn patients of material risks associated with their condition, proposed treatment(s), reasonable alternative treatment options and the likely effect of their healthcare decisions, including refusing treatment. This extends to a decision to leave the ED before care is completed. The form of that warning may vary based on what is known about the patient's condition and the associated risks at the time. Specific documentation of warnings given is essential.
Subject(s)
Duty to Warn , Emergency Service, Hospital , Humans , Emergency Service, Hospital/legislation & jurisprudence , Australia , Duty to Warn/legislation & jurisprudenceABSTRACT
International guidelines and recent research favour a less interventional approach to primary spontaneous pneumothorax (PSP). A retrospective clinical audit of 68 first-episode PSP was undertaken at a major tertiary teaching hospital network in Melbourne, Australia, found that most patients presenting with a moderate to large pneumothorax received initial intercostal catheter insertion (56%), though many (81%) would have met criteria for consideration of conservative management. The results suggest continued deviation from clinical guidelines in the management of PSP.
Subject(s)
Pneumothorax , Humans , Pneumothorax/diagnostic imaging , Pneumothorax/therapy , Australia , Retrospective Studies , Chest Tubes , Hospitals , RecurrenceABSTRACT
Every day in EDs, clinicians are faced with situations where they need to decide whether to detain a patient for assessment and treatment. For patients who meet the relevant criteria, provisions of mental health legislation can be used. For other patients, clinicians often rely on so-called 'duty of care'. This article briefly explores this complex area of law, including the relevant legislation, common law principles and grey areas. It also proposes an approach to decision-making in this area.
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Commitment of Mentally Ill , Mental Health , Humans , Restraint, Physical , Emergency Service, HospitalABSTRACT
What is known about the topic? Anaphylaxis is a rare but inherent risk of treatments and investigational agents. What does this paper add? Using a recent coronial finding in Victoria, this letter explores clinical governance responsibilities of health services and private providers of radiology services with respect to anaphylaxis recognition and management. What are the implications for practitioners? There is a strong case for health service and corporate governance teams (for stand-alone clinics) to ensure that all staff have recent, adequate training to recognise and initiate treatment of anaphylaxis. Reliance on an ambulance response is not enough.
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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 â =â -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.
Subject(s)
Headache , Tomography, X-Ray Computed , Adult , Humans , Female , Middle Aged , Male , Cross-Sectional Studies , Headache/diagnostic imaging , Emergency Service, Hospital , Neuroimaging , BrainABSTRACT
OBJECTIVE: This research aimed to examine the legal and regulatory obligations of authorities and healthcare professionals in the provision of prison emergency health services and to identify problems in the provision of emergency care to prisoners by using case examples from coronial findings. METHODS: Review of legal and regulatory obligations and a search of coronial cases for deaths related to the provision of emergency healthcare in prisons in the past 10 years in Victoria, New South Wales and Queensland. RESULTS: The case review identified several themes - issues with prison authority policies and procedures that delay access to timely healthcare or compromise the quality of care, operational and logistical factors, clinical issues and stigmatic issues including prison staff attitudes to prisoners requesting urgent healthcare assistance. CONCLUSION: Coronial findings and royal commissions have repeatedly identified deficiencies in the emergency healthcare provided to prisoners in Australia. These deficiencies are operational, clinical and stigmatic and not limited to a single prison or jurisdiction. Applying a health quality of care framework focussed on prevention and chronic health management, appropriate assessment and escalation when urgent medical assistance is requested, and a structured audit framework could avoid future preventable deaths in prisons.
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Prisoners , Humans , Prisons , Attitude of Health Personnel , New South Wales , VictoriaABSTRACT
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.
Subject(s)
Neck Injuries , Spinal Injuries , Wounds, Nonpenetrating , Adult , Humans , Pilot Projects , Prospective Studies , Spinal Injuries/therapy , Emergency Service, Hospital , Wounds, Nonpenetrating/complications , Wounds, Nonpenetrating/therapy , Neck Injuries/therapy , Cervical Vertebrae/injuriesABSTRACT
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.
Subject(s)
Forearm Injuries , Radius Fractures , Ulna Fractures , Child , Humans , Radius Fractures/surgery , Ulna Fractures/surgery , Forearm , Forearm Injuries/surgery , Emergency Service, Hospital , Retrospective StudiesABSTRACT
OBJECTIVE: The Snapshot of Suspected ACS Assessment (SSAASY) study aims to describe the assessment processes for patients with suspected acute coronary syndrome (ACS) in Australian EDs, and to compare these processes with the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand (NHFA/CSANZ) guidelines. METHODS: Between March and May 2021, a cross-sectional survey of Australian EDs was undertaken to investigate the assessment strategies used within the ED. All public and private hospitals identified as having dedicated EDs were invited to participate. Respondents provided data on hospital, ED and cardiac service characteristics. They also provided data on the risk stratification process recommended within their department (risk scores, troponin testing, objective testing for coronary artery disease). Awareness of the NHFA/CSANZ guidelines was assessed. RESULTS: Responses were received from 109/162 departments (67%). Most sites (n = 100, 92%) reported using dedicated protocols developed by ED clinicians that included risk stratification scores. Highly sensitive troponin assays were used at 103 (94%) sites. Serial troponin testing was performed over 2 h for low-risk patients in 53 (49%) sites and 2-3 h for intermediate and high-risk patients in 74 (68%) sites. Further investigations included exercise stress tests (48%) and stress echocardiography (38%), with 45% of sites ordering outpatient investigations. CONCLUSIONS: The SSAASY study reported the strategies used to assess suspected ACS. In line with current NHFA/CSANZ guidelines, highly sensitive troponin assays are widely utilised. However, serial sampling intervals were longer than guideline recommendations, suggesting a translational gap between guidelines and clinical practice.
Subject(s)
Acute Coronary Syndrome , Humans , Acute Coronary Syndrome/diagnosis , Cross-Sectional Studies , Risk Assessment , Australia , Troponin , Emergency Service, Hospital , BiomarkersABSTRACT
Aortic dissection (AD) is rare. Missed AD is a common reason for coronial investigations and civil claims for medical negligence. Recommendations include improved education, supervision and information transfer, reminders in chest pain pathways and higher rates of investigation for AD. Higher investigation rates pose risks to patients and the health system which may not be in balance with the likelihood of AD. The appropriate diagnostic yield of investigation to balance risk and benefit has not been defined. The AD detection risk score pathway has been proposed as a useful diagnostic tool but concerns about its derivation, validation and utility remain. In this paper, we try to draw together published literature and local audit data to develop recommendations about what might be done to reduce the number of missed AD cases in EDs and what the impact of higher investigation rates might be.
Subject(s)
Aortic Dissection , Humans , Aortic Dissection/diagnosis , Risk Factors , Chest Pain/diagnosis , Chest Pain/etiologyABSTRACT
Introduction:Headache is a common reason for presentation to emergency departments (ED) around the world. In many countries, ED are not speciality-focussed, however, in Colombia and some other countries, specialist neurological hospitals have ED with a strong neurological focus. For patients presenting with headache, these ED may have different epidemiology, investigation strategies and treatment patterns from general ED. Objective:The objective of this study was to describe the epidemiology of headache presenting to the ED of Instituto Neurológico de Colombia in Medellin, Colombia an ED which is a referral centre for neurological and neurosurgical diseases. Methods:This was an observational study by chart review of adults (aged ≥18) with a main presenting compliant of headache. Demographic, clinical, imaging, diagnoses and outcome data were collected. The primary outcome of interest was the rate of serious secondary intracranial headache cause. Analysis was descriptive. Results:757 patients were studied female 76%, median age 39. Most headache were of gradual onset (85%) and new neurological signs were uncommon (4%). CT was performed in 50% of cases and MRI in 20%. A wide variety of headache causes were identified. Serious secondary intracranial headache was identified in 8.9% (95% CI 7.1-11.1%) of cases. Most patients (89%) were discharged home from ED. Conclusion:Diagnosis of headache in ED is challenging with a very wide range of possible causes. A small proportion of patients (approx. 9%) have a serious cause for their symptoms a proportion similar to that reported in other international emergency department cohorts.
Introdução: A cefaleia é um motivo comum de apresentação aos departamentos de emergência (DE) em todo o mundo. Em muitos países, os PS não são focados em especialidades, no entanto, na Colômbia e em alguns outros países, os hospitais neurológicos especializados têm PS com um forte foco neurológico. Para pacientes que apresentam cefaleia, esses DE podem ter epidemiologia, estratégias de investigação e padrões de tratamento diferentes dos DE geral. Objetivo: O objetivo deste estudo foi descrever a epidemiologia da dor de cabeça apresentada ao pronto-socorro do Instituto Neurológico de Colômbia em Medellín, Colômbia um pronto-socorro que é um centro de referência para doenças neurológicas e neurocirúrgicas. Métodos: Este foi um estudo observacional por meio de revisão de prontuários de adultos (idade ≥18) com apresentação principal complacente de cefaleia. Dados demográficos, clínicos, de imagem, diagnósticos e resultados foram coletados. O desfecho primário de interesse foi a taxa de causa grave de dor de cabeça intracraniana secundária. A análise foi descritiva. Resultados: Foram estudados 757 pacientes 76% do sexo feminino, idade mediana de 39 anos. A maioria das cefaleias foi de início gradual (85%) e os novos sinais neurológicos foram incomuns (4%). A tomografia computadorizada foi realizada em 50% dos casos e a ressonância magnética em 20%. Uma grande variedade de causas de dor de cabeça foi identificada. Cefaleia intracraniana secundária grave foi identificada em 8,9% (IC 95% 7,1-11,1%) dos casos. A maioria dos pacientes (89%) recebeu alta do pronto-socorro. Conclusão: O diagnóstico de cefaleia no DE é desafiador, com uma ampla gama de causas possíveis. Uma pequena proporção de pacientes (aproximadamente 9%) tem uma causa grave para os seus sintomas uma proporção semelhante à relatada em outras coortes internacionais de serviços de emergência.
Subject(s)
Emergency Service, Hospital , Headache , Australia , Headache/drug therapy , Humans , New ZealandABSTRACT
BACKGROUND: Health research often uses health information, a subcategory of personal information, collected during clinical encounters. Conditions under which such health information can be used for the secondary purpose of research are set out in state, national and international law. In Australia, consent is required or the relevant conditions for a waiver of consent must be met and approved by a human research ethics committee (HREC). Consent for use of health information for research is rarely sought at an emergency department (ED) presentation. Research often occurs after the index visit and gaining consent can be difficult. Waiver of consent provisions are frequently used, but acceptability of this approach to patients is unclear. OBJECTIVE: To identify ED patients' knowledge and attitudes towards the use of health information for research, consent preferences and acceptability of waiver of consent. METHODS: An online, anonymous survey of adult patients attending two large EDs in Melbourne, Australia. RESULTS: 103 patients completed the survey. We found that 52% were unaware that health information might be used for research. A majority (77%) felt that HREC approval for use of health information without consent was acceptable. However, 36% would prefer to be contacted regarding consent. CONCLUSION: These findings suggest a lack of awareness that health information can be used for research and that waiver of consent is acceptable, but not necessarily preferred, in most of the ED patient population. Efforts to increase awareness and provide opportunities to express preferences about health information use for research are needed.