Evaluating the implementation and outcomes of a sepsis pathway in the emergency department.

AIM: Early recognition and timely management, including prompt administration of antibiotics, has been fundamental in improving the mortality related to sepsis. We aimed to study the effect of the Sepsis Pathway Programme, a set of guidelines for sepsis, on the recognition, early investigation and management of septic patients in the emergency department. METHODS: We conducted a comparative prospective cohort study of patients who presented with suspected sepsis pre- and post-implementation of the Sepsis Pathway. Patients where the Sepsis Pathway was used were identified and followed prospectively to analyse outcomes. This group was compared to a pre-intervention control group who were identified retrospectively before the Sepsis Pathway was implemented to determine if there was any difference in outcomes. RESULTS: A total of 109 patients were identified to be septic in the emergency department following the implementation of the Sepsis Pathway. Of these, 52 cases involved the initiation and completion of the Sepsis Pathway. One hundred and fifty-seven cases were identified in the pre-intervention group of which 18 cases were excluded. The time to antibiotic administration decreased from 182 to 75 minutes (p<0.00001). The proportion of cases where antibiotics were given within the hour was higher in the pathway group (36.5% vs 8.6%, OR 6.09, 95% CI 2.69-13.81, p<0.0001). Similarly, the time to lactate measurement decreased from 64 minutes to 54.5 minutes (p=0.0117) and the proportion of cases where lactate was measured improved from 64% to 92.3% (p=0.0005). Blood culture rates improved from 79.1% to 100%. CONCLUSION: The implementation of the Sepsis Pathway improved time taken to perform investigations and manage patients with sepsis. Although it had improved, there was still a delay in recognition of sepsis and initiation of investigations and management, demonstrating that further strategies need to be employed to reduce poor outcomes associated with sepsis. However, it did not affect ICU admissions, length of stay or mortality.

Oxycodone prescribing in the emergency department during the opioid crisis.

OBJECTIVE: Misuse of prescription opioids is a significant public health issue in Australia. There has been a rapid rise in prescription opioid use, with an associated increase in overdose and death. The over-prescribing of oral opioids, especially oxycodone, in the ED has been identified as a contributor to this problem overseas. It is unclear if similar practice occurs in the Australian ED. The primary aim of our study was to identify the incidence of oral oxycodone administration to patients within the ED. The secondary outcome was to identify the incidence of oxycodone prescribed to patients on discharge from the ED into the community. METHODS: Our study was designed as an observational, retrospective data analysis of the incidence of oxycodone prescribed within the three EDs of a large Australian public health service. All immediate-release (IR) and slow-release (SR) oral oxycodone prescribed over a 4-year period (2015-2018) was included. RESULTS: There were 890 557 presentations to the three EDs during the period, which resulted in 288 242 episodes of oxycodone administration within department, equivalent to 324 administrations per 1000 presentations. There were 39 381 prescriptions for oxycodone provided on discharge, resulting in an incidence of 44 prescriptions per 1000 discharged. The most frequently prescribed opioid medication in the ED was oxycodone IR 5 mg, 78.6% of discharge prescriptions generated provided a maximum quantity (20 for IR formulation or 28 for SR) of tablets allowable under the pharmaceutical benefits scheme. CONCLUSIONS: There is a higher incidence of oxycodone prescribing in the Australian ED than previously recognised. An overuse of oxycodone may be contributing to adverse patient outcomes and a public health crisis. Hospitals should consider appropriate steps to reduce the incidence of opioid prescribing and the supply of these medications into the community.

Bilateral vertebral artery dissection and cerebellar stroke: a rare complication of massage.

Dissection of a cervical artery is a well-known cause of stroke, especially in younger patients. We describe the case of a 39-year-old male, who presented to our emergency department after a one-day history of headache and vomiting, with associated sudden onset posterior neck pain and cerebellar signs following a massage. Computed tomography angiogram and brain demonstrated bilateral vertebral artery dissection and cerebellar stroke. He was admitted to hospital for monitoring and conservative management with antiplatelet therapy, resulting in a good outcome. This is the first reported case of bilateral vertebral artery dissection and stroke to be associated with massage. This case also suggests, unlike many reports in the literature, that significant vascular pathology can result from massage even without cervical spine manipulation.

Utility of lumbar puncture after a normal brain computed tomography scan in patients presenting to the emergency department with suspected subarachnoid haemorrhage: A new more rational approach?

OBJECTIVE: The diagnostic approach for patients presenting to EDs with headaches suspicious for subarachnoid haemorrhage (SAH) remains challenging. Modern third-generation computed tomography (CT) has been shown to be extremely sensitive in identifying SAH and may eliminate the need for lumbar puncture (LP) which is an invasive, time-consuming procedure with limited accuracy and complications. The aim of this study is to assess the utility of LP in patients being evaluated for possible SAH in the ED after a negative non-contrast CT scan of the brain, as well as addressing the knowledge gap in regard to rational diagnostics among clinicians. METHODS: We conducted a retrospective data analysis of patients being evaluated for possible SAH between June 2013 and June 2018 across three EDs in Victoria, Australia. A diagnosis of SAH was defined by SAH on CT or an abnormal cerebrospinal fluid result in conjunction with positive results on cerebral angiography. A follow-up period of 6 months was chosen. RESULTS: A total of 4407 patients met inclusion criteria; 397 (9%) patients were diagnosed with SAH on CT. A total of 388 patients underwent LP and 778 were admitted to hospital for further investigations and management. A total of 2613 patients discharged from ED without LP remained well at 6 months from their initial presentation, but 230 cases were lost to follow up. One patient died from haemorrhagic stroke during his third hospitalisation. A single patient demonstrated a true positive LP after a normal CT brain. CONCLUSION: LP is not required in all patients with suspected SAH who have a negative CT scan. There are defining patient characteristics that can be used to risk stratify patients and may eliminate the need for LP.

Prevalence and utility of point-of-care ultrasound in the emergency department: A prospective observational study.

OBJECTIVE: An observational study on the current diagnostic and procedural utility, as well as impact of point-of-care ultrasound (POCUS) in the emergency department (ED). BACKGROUND: Point-of-care ultrasound (POCUS) has been recognised as a useful non-invasive bedside tool in providing valuable information, as well as its utility in procedural guidance for clinicians. However, its current prevalence and utility in ED remain unknown. METHODS: In October 2016, a 31-day prospective observational study was performed in three Monash Health Emergency Departments in Melbourne, Australia. Data regarding patients' presenting complaints, frequency, operators' qualifications and POCUS module were collected and analysed. Factors associated with diagnostic impacts were identified. RESULTS: A total of 390 (2.1%) POCUS examinations were performed among 18,355 presentations in the three Monash Health EDs during the study period. POCUS was performed as a diagnostic tool in 344 (88.2%) and procedural guidance in 46 (11.8%) cases. eFAST/AAA and bedside echocardiography were the two most frequently utilised diagnostic modules. Overall, the majority of diagnostic POCUS cases were indicated for abdominal pain (35.3%), chest pain (14.0%) and trauma mainly traffic accidents (5.8%). Procedural POCUS was most commonly used for vascular access (71.7%), where dyspnoea (21.6%) was the most common presenting complaint. The majority of the cases were performed by FACEMs (Fellows of Australasian College of Emergency Medicine) (66.4%). CONCLUSIONS: Despite known diagnostic and procedural values, the prevalence of POCUS in ED was found to be lower than what was expected. The prevalence was shown to be proportional to the level of clinical expertise among the operators. Training and utility of POCUS among physicians and trainees should be further advocated and supported.

Randomized Placebo-controlled Trial of Droperidol and Ondansetron for Adult Emergency Department Patients With Nausea.

OBJECTIVE: The objective was to separately compare effectiveness of 1.25 mg of intravenous (IV) droperidol and 8 mg of IV ondansetron with 0.9% saline placebo for adult emergency department (ED) patients with nausea. A novel primary outcome measure, expected to aid clinical interpretation of reported results, was employed. METHODS: A randomized controlled trial was conducted at the three EDs of Monash Health, Melbourne, Australia. The design was to demonstrate superiority of the active drugs over placebo. The primary outcome measure of symptom improvement was defined as a visual analog scale (VAS) rating change of -8 mm or more from baseline at 30 minutes posttreatment. Mean VAS changes per group and percentages experiencing the desired treatment effect were also compared. The study was concluded after recruitment of 215 of the planned 378 patients, as interim analysis confirmed that continuation could not result in a finding of superiority. RESULTS: Of 215 patients, 73 (34%), 71 (33%), and 71 (33%) received droperidol, ondansetron, and placebo. Symptom improvement occurred in 75% (95% confidence interval [CI] = 64% to 85%), 80% (95% CI = 69% to 89%), and 76% (95% CI = 64% to 85%), respectively. Mean VAS changes were -29 mm (95% CI = -36 to -23 mm), -34 mm (95% CI = -41 to -28 mm), and -24 mm (95% CI = -29 to -19 mm), respectively. Desired treatment effects were experienced by 77% (95% CI = 65% to 86%), 73% (95% CI = 61% to 83%), and 59% (95% CI = 47% to 71%), respectively. CONCLUSION: For adult ED patients with nausea, superiority was not demonstrated for droperidol or ondansetron over placebo.

Reliability of venous blood gas sodium, potassium and creatinine.

OBJECTIVE: To determine the level of correlation between sodium, potassium and creatinine readings between point-of-care venous blood gas (VBG) and laboratory biochemistry measurements (LBM). METHODS: Data was obtained from three Monash Health (one of the largest health networks in metropolitan Melbourne) emergency departments. 16,527 VBGs were matched with LBM for sodium, 16,437 for potassium and 8,597 for creatinine. Pearson correlation and further subgroup analyses were carried out to explore if acid-base imbalance affected sodium, potassium or creatinine reliability in VBG. RESULTS: The range of VBG values showed more variation in comparison to LBM. There was good correlation (r>0.8, p<0.001) between measured values with the exception of potassium in acidaemia, however, there was consistent and statistically significant difference in measured values. CONCLUSIONS: The small mean differences across all three parameters observed although statistically significant are unlikely to be clinically significant. With minor calibrations, this would be an easily corrected problem. As such, we recommend that sodium, potassium and creatinine measurements can be used interchangeably between the VBG and LBM, with the exception of potassium levels in acidaemia. Potassium levels in acidaemia should be used with caution due to lower correlation.