Quality of in-hospital care in traumatic spinal column and cord injuries (TSC/SCI) in I.R Iran.

PURPOSE: This study aimed to implement the Quality of Care (QoC) Assessment Tool from the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to map the current state of in-hospital QoC of individuals with Traumatic Spinal Column and Cord Injuries (TSCCI). METHODS: The QoC Assessment Tool, developed from a scoping review of the literature, was implemented in NSCIR-IR. We collected the required data from two primary sources. Questions regarding health system structures and care processes were completed by the registrar nurse reviewing the hospital records. Questions regarding patient outcomes were gathered through patient interviews. RESULTS: We registered 2812 patients with TSCCI over six years from eight referral hospitals in NSCIR-IR. The median length of stay in the general hospital and intensive care unit was four and five days, respectively. During hospitalization 4.2% of patients developed pressure ulcers, 83.5% of patients reported satisfactory pain control and none had symptomatic urinary tract infections. 100%, 80%, and 90% of SCI registration centers had 24/7 access to CT scans, MRI scans, and operating rooms, respectively. Only 18.8% of patients who needed surgery underwent a surgical operation in the first 24 h after admission. In-hospital mortality rate for patients with SCI was 19.3%. CONCLUSION: Our study showed that the current in-hospital care of our patients with TSCCI is acceptable in terms of pain control, structure and length of stay and poor regarding in-hospital mortality rate and timeliness. We must continue to work on lowering rates of pressure sores, as well as delays in decompression surgery and fatalities.

Road traffic injuries and associated mortality in the Islamic Republic of Iran.

Background: Road traffic accidents are a major public health problem globally, causing millions of injuries, deaths and disabilities, and a huge loss of financial resources, especially in low- and middle-income countries. Aim: To determine the incidence of road traffic injuries and associated mortality from 1997 to 2020 in the Islamic Republic of Iran. Methods: This retrospective study used data from the Legal Medicine Organization of the Islamic Republic of Iran to estimate the annual rates of road traffic injuries and associated mortality from 21 March 1997 to 20 March 2020. The data were analysed using STATA version 14 and the annual rates are reported per 100 000 population. Results: During the study period, 5 760 835 road traffic injuries and 472 193 deaths were recorded in the Islamic Republic of Iran. The mortality rate increased from 22.4 per 100 000 in 1997 to 40 per 100 000 in 2005 and decreased to 18.4 per 100 000 in 2020. The injury rate increased from 111.1 per 100 000 in 1997 to 394.9 per 100 000 in 2005. It decreased in 2006 and 2007 and increased from then until 2010, finally reaching 331.8 per 100 000 in 2020. The male to female ratio for road traffic mortality was 3.9 in 1997 and 4.6 in 2020. The case fatality rate was highest (20.1%) in 1997 and decreased to 5.6% in 2020. Conclusion: Continuous interventions are needed to reduce the burden of road traffic injuries and associated mortality in the Islamic Republic of Iran.

Modelled economic evaluation of a virtual emergency department in Victoria.

OBJECTIVE: Virtual ED (VED) can potentially alleviate ED overcrowding which has been a public health challenge. The aim of the present study was to conduct a return-on-investment analysis of a VED programme developed in response to changing healthcare needs in Australia. METHODS: An economic model was developed based on initial patient outcome data to assess the healthcare costs, potential costs saved and return on investment (ROI) from the VED. The VED programme operating as part of Alfred Health Emergency Services. The participants were the first 188 patients accessing the Alfred Health VED. VED is the delivery of emergency assessment and management of specific patients virtually via audio-visual teleconferencing. ROI ratios that compare cost savings with intervention costs. RESULTS: The mean total operational cost of VED for 79 days for 188 patients was A$344 117 (95% uncertainty interval [UI] $296 800-$392 088). The VED led to a potential A$286 779 (95% UI $241 688-$330 568) healthcare cost saving from reductions in emergency visits and A$97 569 (95% UI $74 233-$123 117) cost saving in ambulance services. The ROI ratio was estimated at 1.12 (95% UI 0.96-1.32). CONCLUSIONS: The VED was cost neutral in a conservatively modelled scenario but promising if any hospital admission could be saved. Ongoing research examining a larger cohort with community follow up is required to confirm this promising result.

Hospitalisations and in-hospital deaths following moderate to severe traumatic brain injury in Australia, 2015-20: a registry data analysis for the Australian Traumatic Brain Injury National Data (ATBIND) project.

OBJECTIVE: To describe the frequency of hospitalisation and in-hospital death following moderate to severe traumatic brain injury (TBI) in Australia, both overall and by patient demographic characteristics and the nature and severity of the injury. DESIGN, SETTING: Cross-sectional study; analysis of Australia New Zealand Trauma Registry data. PARTICIPANTS: People with moderate to severe TBI (Abbreviated Injury Score [head] greater than 2) who were admitted to or died in one of the twenty-three major Australian trauma services that contributed data to the ATR throughout the study period, 1 July 2015 - 30 June 2020. MAJOR OUTCOME MEASURES: Primary outcome: number of hospitalisations with moderate to severe TBI; secondary outcome: number of deaths in hospital following moderate to severe TBI. RESULTS: During 2015-20, 16 350 people were hospitalised with moderate to severe TBI (mean, 3270 per year), of whom 2437 died in hospital (14.9%; mean, 487 per year). The mean age at admission was 50.5 years (standard deviation [SD], 26.1 years), and 11 644 patients were male (71.2%); the mean age of people who died in hospital was 60.4 years (SD, 25.2 years), and 1686 deaths were of male patients (69.2%). The overall number of hospitalisations did not change during 2015-20 (per year: incidence rate ratio [IRR], 1.00; 95% confidence interval [CI], 0.99-1.02) and death (IRR, 1.00; 95% CI, 0.97-1.03). CONCLUSION: Injury prevention and trauma care interventions for people with moderate to severe TBI in Australia reduced neither the incidence of the condition nor the associated in-hospital mortality during 2015-20. More effective care strategies are required to reduce the burden of TBI, particularly among younger men.

Disposition of patients utilising the virtual emergency department service in southeast region of Melbourne (SERVED-1).

OBJECTIVE: Supported by the state government, three health networks partnered to initiate a virtual ED (VED), as part of a broader roll-out of emergency telehealth services in Victoria. The aim of the present study (Southeast Region Virtual Emergency Department-1 [SERVED-1]) was to report the initial 5-month experience and included all patients assessed through the service over the first 5 months (1 February 2022 to 30 June 2022). METHODS: VED consults occurred after referral from paramedics in the pre-hospital setting. Electronic medical records were retrospectively reviewed for demographic, presenting complaint and outcome data. The primary outcome was the count of VED consultations. The secondary outcome was the proportion of patients where physical ED attendance was avoided within 72 h. The proportion of physical ED attendances avoided sub-grouped by primary presenting complaints were reported. RESULTS: There were 1748 patients who had a VED consultation, of which 1261 (72.1%; 95% confidence interval [CI] 70.0-74.2) patients had physical presentation to an ED avoided in the 72 h following the consult. There was a significant increase in consultations over the 5-month period (incidence rate ratio 1.27; 95% CI 1.23-1.31, P < 0.001) that was consistent in the three health services. The most common presenting complaints were COVID-19 and shortness of breath, and physical presentation was avoided most often among younger patients and those with COVID-19. CONCLUSIONS: Initial experience demonstrated a significant increase in adoption of the service and an overall avoidance of physical ED attendance by a majority of patients. These results support ongoing VED consultations, complemented by follow up and health economic evaluations.

Risk of permanent medical impairment after road traffic crashes: A systematic review.

PURPOSE: To systematically review the risk of permanent disability related to road traffic injuries (RTIs) and to determine the implications for future research regarding permanent impairment following road traffic crashes. METHODS: We conducted this systematic review according to the preferred reporting items for systematic reviews and meta-analysis statement. An extended search of the literature was carried out in 4 major electronic databases for scientific research papers published from January 1980 to February 2020. Two teams include 2 reviewers each, screened independently the titles/abstracts, and after that, reviewed the full text of the included studies. The quality of the studies was assessed using the strengthening the reporting of observational studies in epidemiology (STROBE) checklist. A third reviewer was assessed any discrepancy and all data of included studies were extracted. Finally, the data were systematically analyzed, and the related data were interpreted. RESULTS: Five out of 16 studies were evaluated as high-quality according to the STROBE checklist. Fifteen studies ranked the initial injuries according to the abbreviated injury scale 2005. Five studies reported the total risk of permanent medical impairment following RTIs which varied from 2% to 23% for car occupants and 2.8% to 46% for cyclists. Seven studies reported the risk of permanent medical impairment of the different body regions. Eleven studies stated the most common body region to develop permanent impairment, of which 6 studies demonstrated that injuries of the cervical spine and neck were at the highest risk of becoming permanent injured. CONCLUSION: The finding of this review revealed the necessity of providing a globally validated method to evaluate permanent medical impairment following RTIs across the world. This would facilitate decision-making about traffic injuries and efficient management to reduce the financial and psychological burdens for individuals and communities.

Injury patterns, management and outcomes of retroperitoneal haemorrhage caused by lower intercostal arterial bleeding at a level-1 trauma centre: A 10-year retrospective review.

OBJECTIVE: Haemorrhagic shock is a life-threatening complication of trauma, but remains a preventable cause of death. Early recognition of retroperitoneal haemorrhage (RPH) is crucial in preventing deleterious outcomes including mortality. Injury to the 9-11th intercostal arteries (i.e. arteries of the lower thoracic region) are complicit in RPH. However, the associated injuries, implications and management of such bleeds remain poorly characterised. METHODS: We performed a retrospective review of the medical records of patients diagnosed with RPH who presented to our level-1 trauma centre (2009-2019). We described the associated injuries, management and outcomes relating to RPH of the lower thoracic region (the 9-11th intercostal arteries) from this cohort to identify potential predictors and evaluate the impact of early identification and management of non-cavitary bleeds. RESULTS: Haemorrhage of the lower intercostal arteries (LIA) into the retroperitoneal space is associated with an increased number of posterior lower rib fractures and pneumothorax/haemothorax. A higher proportion of patients in the LIA group required massive transfusion, angioembolisation or surgical ligation when compared to other causes of RPH. CONCLUSION: The present study highlights the importance of injury patterns, particularly posterior lower rib fractures, as predictors for early recognition and management of RPH in the prevention of deleterious patient outcomes. RPH secondary to bleeding of the LIA may require early and aggressive management of haemorrhage through massive transfusion, and angioembolisation or surgical ligation when compared to RPH because of other causes.

A systematic review of acute and emergency care interventions for adolescents and adults with severe acute respiratory infections including COVID-19 in low- and middle-income countries.

Background: Severe acute respiratory infections (SARIs) remain a leading cause of death globally, particularly in low- and middle-income countries (LMICs). Early intervention is critical, considering the potential for rapid decompensation in patients with SARIs. We aimed to evaluate the impact of acute and emergency care interventions on improving clinical outcomes in patients >10 years old with SARIs in LMICs. Methods: A systematic literature search was performed in PubMed, Global Health, and Global Index Medicus databases to identify peer-reviewed studies containing SARI, LMICs, and emergency care interventions. Studies published prior to November 2020 focusing on patients >10 years old were included. A narrative synthesis was performed due to the heterogeneity of identified articles. Risk of bias was assessed using the Risk of Bias 2 and Risk of Bias In Non-Randomized Studies of Interventions tools. Results: 20 223 studies were screened and 58 met the inclusion criteria. Thirty-four studies focused on coronavirus-2019 (COVID-19), 15 on pneumonia, seven on influenza, one study on severe acute respiratory syndrome, and one on undifferentiated SARI. Few COVID-19 studies found a benefit of the tested intervention on clinical status, mortality, or hospital length-of-stay. Little to no benefit was found for azithromycin, convalescent plasma, or zinc, and potential harm was found for hydroxychloroquine/chloroquine. There was mixed evidence for immunomodulators, traditional Chinese medicine, and corticosteroids among COVID-19 studies, with notable confounding due to a lack of consistency of control group treatments. Neuraminidase inhibitor antivirals for influenza had the highest quality of evidence for shortening symptom duration and decreasing disease severity. Conclusions: We found few interventions for SARIs in LMICs with have high-quality evidence for improving clinical outcomes. None of the included studies evaluated non-pharmacologic interventions or were conducted in low-income countries. Further studies evaluating the impact of antivirals, immunomodulators, corticosteroids, and non-pharmacologic interventions for SARIs in LMICs are urgently needed. Registration: PROSPERO registration number: CRD42020216117.

Evaluating the utility of telehealth in emergency medicine.

There has been great interest regarding tele-emergency care (TEC) and its utility following the COVID-19 pandemic. We have seen a roll out of multiple TEC services across Australia, operating in isolation, without coordination and under differing models of care, creating the potential for an uncoordinated, inefficient healthcare system. We outline a potential framework under which TEC services might function as part of the current system, defining potential strategies that may be used to appropriately coordinate the acute care of select patients outside of the ED as well as improve the efficiency of the physical ED itself.

The Australian Traumatic Brain Injury National Data (ATBIND) project: a mixed methods study protocol.

BACKGROUND: Traumatic brain injury (TBI) is the largest contributor to death and disability in people who have experienced physical trauma. There are no national data on outcomes for people with moderate to severe TBI in Australia. OBJECTIVES: To determine the incidence and key determinants of outcomes for patients with moderate to severe TBI, both for Australia and for selected population subgroups, including Aboriginal and Torres Strait Islander Australians. METHODS AND ANALYSIS: The Australian Traumatic Brain Injury National Data (ATBIND) project will analyse Australia New Zealand Trauma Registry (ATR) data and National Coronial Information Service (NCIS) deaths data. The ATR documents the demographic characteristics, injury event description and severity, processes of care, and outcomes for people with major injury, including TBI, assessed and managed at the 27 major trauma services in Australia. We will include data for people with moderate to severe TBI (Abbreviated Injury Scale [AIS] (head) score higher than 2) who had Injury Severity Scores [ISS] higher than 12 or who died in hospital. People will also be included if they died before reaching a major trauma service and the coronial report details were consistent with moderate to severe TBI. The primary research outcome will be survival to discharge. Secondary outcomes will be hospital discharge destination, hospital length of stay, ventilator-free days, and health service cost. ETHICS APPROVAL: The Alfred Ethics Committee approved ATR data extraction (project reference number 670/21). Further ethics approval has been sought from the NCIS and multiple Aboriginal health research ethics committees. The ATBIND project will conform with Indigenous data sovereignty principles. DISSEMINATION OF RESULTS: Our findings will be disseminated by project partners with the aim of informing improvements in equitable system-level care for all people in Australia with moderate to severe TBI. STUDY REGISTRATION: Not applicable.

Emergency department adult presentations from the COVID-19 hotel quarantine program in Victoria, Australia: A retrospective cohort study of admissions and presenting complaints.

OBJECTIVE: The present study aims to describe presentations to the designated ED from the Victorian COVID-19 hotel quarantine program. METHODS: A retrospective cohort study was conducted between 7 December 2020 and 6 June 2021 at The Alfred Emergency and Trauma Centre, a major adult quaternary referral teaching hospital. Participants included adult patients (>18 years old) who were quarantining as part of Victoria's COVID-19 quarantine program. The primary outcome was discharge destination from the ED (admission to hospital vs discharge from ED). RESULTS: Notably, 164 patients presented to The Alfred Emergency and Trauma Centre during the study period. The mean (SD) age was 50.9, with most patients being male (n = 96 [58.5%]). Most patients were referred from a quarantine hotel (n = 83 [50%]). Thirty-four percent (n = 56) of ED presentations were admitted to hospital (31.5% to a ward, 2.5% to intensive care unit). Forty-six percent (n = 75) were discharged to the complex care hotel to be looked after by Alfred Health, with only 16% (n = 26) being discharged to a standard quarantine hotel. The most common presenting complaint categories were: cardiovascular (n = 33 [20%]), miscellaneous (n = 25 [25%]), gastrointestinal (n = 19 [11.5%]) and mental health (n = 18 [11%]). CONCLUSION: The study demonstrates that the number of ED presentations from quarantine was low (<1 presentation/day). COVID Quarantine Victoria and Alfred Health put significant resources into the program to allow most returned international travellers to be safely cared for within a hotel and thus reduce the burden on the public hospital system.

Attitudes and regard for specific medical conditions among Australian emergency medicine clinicians.

OBJECTIVE: To quantify the attitude ED clinicians hold towards patients presenting with different medical conditions, including a novel pandemic condition. METHODS: A cross-sectional study of emergency doctors and nurses utilising the Medical Condition Regard Scale (MCRS); a validated tool used to capture the bias and emotions of clinicians towards individual medical conditions. The five conditions presented to participants each represent a classical medical, complex medical, psychiatric/substance use, somatoform and a novel medical condition. RESULTS: One hundred and ninety-six clinicians were included in the study including 116 nurses and 80 doctors. Concerning each condition, both medical and nursing staff demonstrated the highest regard for a classical medical condition (58 ± 5 and 57 ± 6, respectively). Significantly different from the classical medical condition, the lowest MCRS scores were for the somatoform condition (36 ± 10) for emergency doctors and the substance use condition (39 ± 11) for emergency nurses. Regard for a novel condition (i.e., COVID-19 infection) was comparably high among both cohorts. CONCLUSION: Emergency doctors and nurses generally hold lower regard for complex medical conditions with behavioural components, including substance use disorders and somatoform conditions.

Informing the Alfred Registry for Emergency Care Project: An analysis of presenting complaint documentation in an emergency department.

OBJECTIVE: To assess the feasibility of an ED presenting complaint (PC) tool that categorised all ED PCs into 10 categories. METHODS: A retrospective analysis of 1445 consecutive patient encounters was conducted. The primary outcome was the frequency of use of the 10 PC categories. RESULTS: Of the 1203 patient encounters meeting inclusion criteria, the PC tool was completed by clinicians in 574 (47.7%). When completed, the tool's 10 options were selected for most presentations (72.3%). CONCLUSION: The PC tool captured the majority of presenting complaints in 10 categories. External validation is recommended.

Barriers and factors associated with the use of helmets by Motorcyclists: A scoping review.

Road Traffic Injuries (RTIs) have imposed a great global burden on public health. Motorcyclists and pedestrians comprise the most significant proportion of this burden. Several studies have demonstrated a link between helmet wearing and a decline in the impact of RTIs in motorcyclists. In this study, we aimed to review the barriers to helmet utilization by motorcyclists. This scoping review has been conducted in accordance with the guidelines for the systematic review of observational studies and the PRISMA Checklist. The search was conducted by using related keywords in EMBASE, PubMed, Scopus, and Cochrane Library. Four independent reviewers carried out the screening. The main outcomes of interest were barriers to helmet usage among motorcyclists, drawn from the finally included studies. Fifty-three records were selected for data extraction. According to these reports, the barriers and factors associated with helmet usage among motorcyclists were categorized into five entities as: legislations/enforcement strategies, helmet disadvantages (discomfort, visual/auditory blockage, and thermal dysregulation), risky behaviors (riding while drunk or high on drugs), sex and/or age factors, and the location and time of the injury event (rural vs. urban locations, day vs. night riding). From the perspective of policymakers, the findings of this review are of utmost importance and could be used in addressing the challenge of inadequate compliance with helmet use.

Impact of COVID-19 vaccinations on emergency department presentations.

OBJECTIVE: The aim of the present study was to describe the burden of patients presenting to the ED with symptoms occurring after receiving a COVID-19 vaccination. METHODS: This was a retrospective cohort study performed over a 4-month period across two EDs. Participants were eligible for inclusion if it was documented in the ED triage record that their ED attendance was associated with the receipt of a COVID-19 vaccination. Data regarding the type of vaccine (Comirnaty or ChAdOx1) were subsequently extracted from their electronic medical record. Primary outcome was ED length of stay (LOS) and secondary outcomes included requests for imaging and ED disposition destination. RESULTS: During the study period of 22 February 2021 to 21 June 2021, 632 patients were identified for inclusion in the present study, of which 543 (85.9%) had received the ChAdOx1 vaccination. The highest proportion of COVID-19 vaccine-related attendances occurred in June 2021 and accounted for 21 (8%) of 262 total daily ED attendances. Patients who had an ED presentation related to ChAdOx1 had a longer median ED LOS (253 vs 180 min, P < 0.001) compared to Comirnaty and a higher proportion had haematology tests and imaging requested in the ED. Most patients (n = 588, 88.8%) were discharged home from the ED. CONCLUSION: There was a notable proportion of ED attendances related to recent COVID-19 vaccination administration, many of which were associated with lengthy ED stays and had multiple investigations. In the majority of cases, the patients were able to be discharged home from the ED.

Review article: E-learning in emergency medicine: A systematic review.

E-learning (EL) has been developing as a medical education resource since the arrival of the internet. The COVID-19 pandemic has minimised clinical exposure for medical trainees and forced educators to use EL to replace traditional learning (TL) resources. The aim of this review was to determine the impact of EL versus TL on emergency medicine (EM) learning outcomes of medical trainees. A systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement using articles sourced from CINAHL, Embase, OVID Medline and PubMed. Articles were independently reviewed by two reviewers following strict inclusion and exclusion criteria. Bias was assessed using the Cochrane Risk of Bias tool. The search yielded a total of 1586 non-duplicate studies. A total of 19 studies were included for data extraction. Fifteen of the included studies assessed knowledge gain of participants using multiple-choice questions as an outcome measure. Eleven of the 15 demonstrated no statistically significant difference while two studies favoured EL with statistical significance and two favoured TL with statistical significance. Six of the included studies assessed practical skill gain of participants. Five of the six demonstrated no statistical significance while one study favoured EL with statistical significance. This systematic review suggests that EL may be comparable to TL for the teaching of EM. The authors encourage the integration of EL as an adjunct to face-to-face teaching where possible in EM curricula; however, the overall low quality of evidence precludes definitive conclusions from being drawn.

Preparing for reopening: An emergency care perspective.

Australia is rapidly moving towards 'living with COVID-19', with relaxation of some public health measures. The number of severe cases of COVID-19 may be mitigated by vaccination, but 'living with COVID-19' will be associated with higher number of patients seeking emergency care. This impending impact on the emergency care system requires recognition, monitoring and co-ordinated management. Current challenges include a lack of emergency care monitoring systems, staff shortages and patient flow processes that are quickly overwhelmed by large numbers, particularly in a system already operating at capacity. Effective monitoring systems are required for health systems to proactively detect and respond to stresses. Additional solutions include public health messaging and clinical innovation to facilitate care of the right patient in the right place at the right time. Optimising staff numbers and morale, and efficient patient flow, are integral steps to increasing capacity within the emergency care system.

Establishing determinants and quality indicators for getting home alive following moderate to severe traumatic brain injury: the Australian Traumatic Brain Injury National Data Project.

Moderate to severe traumatic brain injury (TBI) contributes to a significant burden across Australia. However, the data required to inform targeted equitable system-level improvements in emergency TBI care do not exist. The incidence and determinants of outcomes following moderate to severe TBI in Australia remain unknown. The variation in the impact of moderate to severe TBI, according to patient demographics and injury mechanism, is poorly defined. The Australian Traumatic Brain Injury National Data Project will lead to a clear understanding, across Australia and pre-specified subgroups (including Aboriginal and Torres Strait Islander peoples), of the incidence, determinants and impact of priority outcomes following moderate to severe TBI, including survival to discharge home. Furthermore, this project will establish a set of national clinical quality indicators for patients experiencing a moderate to severe TBI. The Australian Traumatic Brain Injury National Data Project will inform where to target emergency care system-wide improvements. Without baseline data, efforts are wasted.