Improving the safety of anticoagulation initiation in patients discharged from the emergency department.

OBJECTIVE: To improve the safety of anticoagulation initiation by increasing the proportion of patients reviewed by a pharmacist. METHODS: An electronic intervention was developed to ensure all patients prescribed anticoagulation on discharge were reviewed by an ED pharmacist. Safe anticoagulation initiation was compared for patients seen and not seen. RESULTS: The intervention increased the number of patients seen by an ED pharmacist. Pre-intervention (n = 238) 84.5% of patients were reviewed by a pharmacist. Post-intervention (n = 253) 99.6% of patients were reviewed by a pharmacist. Of the 38 patients not reviewed by a pharmacist, 20 (52.6%) had safe anticoagulation initiation and in a sample of 40 patients reviewed by a pharmacist, all 40 (100%) had safe anticoagulation initiation (52.6% vs 100%, P < 0.001). CONCLUSION: The real-time electronic intervention improved the number of patients reviewed by a pharmacist. ED pharmacist reviewed patients were more likely to have safe anticoagulation initiation.

Evaluation of a calcium, magnesium and phosphate clinical ordering tool in the emergency department.

OBJECTIVE: We developed a clinical tool comprising patient risk factors for having an abnormal calcium (Ca), magnesium (Mg) or phosphate (PO4) level. We hypothesized that patients without a risk factor do not require testing. This study examined the tool's potential utility for rationalizing Ca, Mg and PO4 ordering in the emergency department (ED). METHODS: We undertook a retrospective observational study in a single metropolitan ED. Patients aged 18 years or more who presented between July and December 2019 were included if they had a Ca, Mg or PO4 test during their ED stay. Demographic and clinical data, including the presence of risk factors, were extracted from the medical record. The primary outcome was a clinically significant abnormal Ca, Mg or PO4 level (>0.2 mmol/l above or below the laboratory reference range). RESULTS: Calcium, Mg and PO4 levels were measured on 1426, 1296 and 1099 patients, respectively. The positive and negative predictive values and likelihood ratios of the tool identifying a patient with a Ca level > 0.2 mmol/l outside the range were 0.05, 0.99, 1.59 and 0.41, respectively. The values for Mg were 0.02, 1.00, 1.44 and 0.35 and those for PO4 were 0.15, 0.93, 1.38 and 0.57, respectively. The majority of patients not identified as having an abnormal level did not receive electrolyte correction treatment. Application of the tool would have resulted in a 35.8% cost reduction. CONCLUSION: The tool failed to predict a very small proportion of patients (approximately 1%) with an abnormal Ca or Mg level and for whom it would have been desirable to have these levels measured. It may help rationalize Ca and Mg ordering and reduce laboratory costs.

Cardiopulmonary resuscitation and endotracheal intubation decisions for adults with advance care directive and resuscitation plans in the emergency department.

BACKGROUND: Emergency departments routinely offer cardiopulmonary resuscitation and endotracheal intubation to patients in resuscitative states. With increasing longevity and prevalence of chronic conditions in Australia, there has been growing need to uptake and implement advance care directives and resuscitation plans. This study investigates the frequency of the presence of advance care directives and resuscitation plans and its utilisation in cardiopulmonary and endotracheal intubation decision making. METHODS: Retrospective audit of electronic patients' medical records aged ≥65 years presenting over a 3-month period. Data collected included demographics, triage categories, advance care directive and/or resuscitation plans/orders status. RESULTS: A total of 6439 patients were included representing 29% of the total patient population during the study period. Participants were randomly selected (N = 300); mean age was 78.7 (±8.1) years. An advance care directive was present in only 8% and one in three patients (37%) had a previous resuscitation plan/order. Senior consultant was present at the department for consultation by junior doctors for most of the patients (82%). Acknowledgment of either advance care directive or resuscitation plans/orders in clinical notes was only 9.5% (n = 116). CONCLUSION: Advance care directive prevalence was low with resuscitation plans/orders being more common. However, clinician acknowledgement was infrequent for both.

Utility of calcium, magnesium and phosphate testing in the emergency department.

OBJECTIVE: To determine how frequently calcium (Ca), magnesium (Mg) and phosphate (PO4 ) tests change ED patient management. METHODS: We undertook a retrospective observational study in an Australian tertiary referral ED. We enrolled adult patients (aged ≥18 years) who presented between 1 January and 30 June 2017 and who had a serum Ca, Mg or PO4 test ordered and completed during their ED stay. Patient symptoms, medical history, electrolyte levels and ED management changes were extracted from the electronic medical record. RESULTS: Of the 33 120 adults presented during the study period, 1716 (5.2%, 95% confidence interval [CI] 5.0-5.4) had at least one Ca, Mg or PO4 test completed in the ED. This included 4776 individual electrolyte tests, of which 776 (16.2%, 95% CI 15.2-17.3) were abnormal. Fifty-six (7.2% [95% CI 5.5-9.3] of patients with abnormal tests, 1.2% [95% CI 0.9-1.5] of all tests) tests were associated with a change in ED management. Twenty-six out of 1683 (1.5%) Ca levels were low with six (23.1%) management changes; 203 (12.1%) were high with 10 (4.9%) management changes. One hundred and twenty-eight out of 1579 (8.1%) Mg levels were low with 33 (25.8%) management changes; 30 (1.9%) were high with no management changes. Two hundred and twenty-five out of 1514 (14.9%) PO4 levels were low with six (2.7%) management changes; 164 (10.8%) were high with one (0.6%) management change. Fifty (2.9%) patients had management changes despite normal electrolyte levels. CONCLUSION: Ca, Mg and PO4 testing is common. However, the yield of clinically significant abnormal levels is low and patient management is rarely changed. Testing of these electrolytes needs to be rationalised.

Risk variables associated with abnormal calcium, magnesium and phosphate levels among emergency department patients.

OBJECTIVE: The utility of calcium, magnesium and phosphate measurement in the ED is limited. We aimed to determine clinical risk variables for abnormal levels of these electrolytes in order to inform the development of an ordering guideline. METHODS: We performed a retrospective, observational study of patients who presented to a tertiary referral ED between January and June 2017. Adult patients who had serum calcium, magnesium or phosphate tests completed during their ED stay were included. Presenting symptoms and signs, comorbidities, medication use and laboratory values were extracted from the medical record. Patients with missing data items were excluded. Logistic regression models determined clinical risk variables associated with low and high levels of each electrolyte. RESULTS: A total of 33 120 adults presented during the study period. Of the 1679 calcium, 1576 magnesium and 1511 phosphate tests, 228 (13.6%), 158 (10.0%) and 387 (25.6%) were abnormal, respectively. Significant risk variables (P < 0.05) for abnormal levels were: hypocalcaemia - vomiting, perioral numbness, hand/foot spasm, calcium and phosphate supplements and chemotherapy (odds ratio [OR] range 5.9-17.3); hypercalcaemia - female sex, vomiting, polyuria, confusion, hyperparathyroidism, cancer and type 1 diabetes (OR range 2.3-9.7); hypomagnesemia - female sex, proton pump inhibitor use, tacrolimus use, alcohol abuse and type 2 diabetes (OR range 2.2-13.1); hypermagnesemia - lethargy, thiazide use and chronic kidney disease (OR range 4.3-4.5); hypophosphatemia - nausea, seizure and glucocorticoid use (OR range 1.7-2.1); and hyperphosphataemia - polyuria, diuretics and chronic kidney disease (OR range 1.9-5.0). CONCLUSION: A range of demographic, comorbid, medication and clinical variables are associated with abnormal calcium, magnesium and phosphate levels. These findings will inform the development of clinical guidelines to rationalise calcium, magnesium and phosphate testing. Justification may be required for testing patients with no risk variables.

Comparison of emergency department time performance between a Canadian and an Australian academic tertiary hospital.

OBJECTIVE: To compare performance and factors predicting failure to reach Ontario and Australian government time targets between a Canadian (Sunnybrook Hospital) and an Australian (Austin Health) academic tertiary-level hospitals in 2012, and to assess for change of factors and performance in 2016 between the same hospitals. METHODS: This was a retrospective, observational study of patient administrative data in two calendar years. The main outcome measure was reaching Ontario and Australian ED time targets for admissions, high and low urgency discharges. Secondary outcomes were factors predicting failure to reach these targets. RESULTS: Between 2012 and 2016, Sunnybrook and Austin experienced increased patient volume of 10.2% and 19.2%, respectively. Bed capacity decreased at Sunnybrook (-10.8%) but increased at the Austin (+30.3%). For both years, Austin failed to achieve the Australian time target, but succeeded for all Ontario targets except for low urgency discharges. Sunnybrook failed all targets irrespective of year. The top factors for failing Ontario ED length-of-stay targets for both hospitals in 2012 and 2016 were bed request greater than 6 h, access block greater than 1 h, use of cross-sectional imaging, consultation and waiting for the emergency physician greater than 2 h. CONCLUSION: Austin outperformed Sunnybrook for Ontario and Australian government time targets. Both hospitals failed the Australian targets. Factors predicting failure to achieve targets were different between hospitals, but were mainly clinical resources. Sunnybrook focussed on increasing human resources. Austin focussed on increasing human resources, observation unit and hospital beds. Intrinsic hospital characteristics and infrastructure influenced target success.

Emergency presentations of acute biliary pain: changing patterns of management in a tertiary institute.

BACKGROUND: Acute biliary pain is the most common presentation of gallstone disease. Untreated patients risk recurrent pain, cholecystitis, obstructive jaundice, pancreatitis and multiple hospital presentations. We examine the outcome of implementing a policy to offer laparoscopic cholecystectomy on index presentation to patients with biliary colic in a tertiary hospital in Australia. METHODS: This is a retrospective cohort study of adult patients presenting to the emergency department (ED) with biliary pain during three 12-month periods. Outcomes in Group A, 3 years prior to policy implementation, were compared with groups 2 and 7 years post implementation (Groups B and C). Primary outcomes were representations to ED, admission rate and time to cholecystectomy. RESULTS: A total of 584 patients presented with biliary colic during the three study periods. Of these, 391 underwent cholecystectomy with three Strasberg Type A bile leaks and no bile duct injuries. The policy increased admission rates (A = 15.8%, B = 62.9%, C = 29.5%, P < 0.001) and surgery on index presentation (A = 12.0%, B = 60.7%, C = 27.4%, P < 0.001). There was a decline in time to cholecystectomy (days) (A = 143, B = 15, C = 31, P < 0.001), post-operative length of stay (days) (A = 3.6, B = 3.2, C = 2.0, P < 0.05) and representation rates to ED (A = 42.1%, B = 7.1%, C = 19.9%, P < 0.001). There was a decline in policy adherence in the later cohort. CONCLUSION: Index hospital admission and cholecystectomy for biliary colic decrease patient representations, time to surgery, post-operative stay and complications of gallstone disease. This study demonstrates the impact of the policy with initial improvement, the dangers of policy attrition and the need for continued reinforcement.

Aortic dissection detection risk score has high sensitivity with moderate inter-rater reliability.

OBJECTIVE: To retrospectively assess the accuracy and inter-rater reliability of the aortic dissection detection risk score (ADD-RS). METHODS: Single-centre, observational, diagnostic accuracy study undertaken in a university-affiliated, tertiary hospital ED. RESULTS: Two hundred patients were enrolled. Five patients were diagnosed with acute aortic dissection and had an elevated ADD-RS >0. The ADD-RS was 100% sensitive with a negative and positive predictive values of 100% (if ADD-RS ≥1). Inter-rater reliability was moderate (Kappa = 0.55). CONCLUSION: The ADD-RS was highly sensitive in our cohort. Further work to evaluate the score prospectively and in combination with a D-Dimer is required.

Taming the zebra: Unravelling the barriers to diagnosing aortic dissection.

Aortic dissection is a lethal cardiovascular emergency that continues to pose a diagnostic dilemma to the emergency physician. The condition is rare, can present atypically and is associated with a cumulative mortality for every hour that passes. While it is a recognised differential of acute chest pain, its prevalence in comparison to other causes often leads to the diagnosis being overlooked. The ED is a busy environment with high patient turnover and varying degrees of complexity and acuity. This increases susceptibility to cognitive bias and error-producing conditions that can lead to delayed or missed diagnosis. In reported cases where aortic dissection has been missed, clinician awareness of the disease was not the primary issue but failure to respond to clinical cues suggestive of aortic dissection was. To improve patient outcomes for this condition, it is important for clinicians to be aware of pertinent cognitive bias and error-producing conditions.

Case-control study to investigate variables associated with incidents and adverse events in the emergency department.

OBJECTIVE: To detect and analyse incidents (Is) and adverse events (AEs) in the ED. We hypothesised that I/AE are associated with patient load. METHODS: We undertook a case-control study in a tertiary level hospital ED (from 1 April 2012 to 31 March 2013). Three percent of patients were randomly selected and screened for I/AEs. I/AEs were adjudicated by consensus of four FACEMs. Controls were matched to cases 2:1. Logistic regression was used to analyse the data. RESULTS: We sampled 2167 patients. After exclusions, 217 I/AEs were detected and analysed. The I and AE rates were 6.0 and 4.1%, respectively. The serious AE rate was 0.8% and 30 day mortality was 0.1%. Diagnostic error occurred in 3.7% of all patients and adverse drug reactions in 2.5%. Seventy-seven percent of the I/AEs were judged preventable. ED occupancy of <35 patients was the reference group. Compared with this group, if 36-40 or 41-45 patients were in the ED, I/AEs were more likely to occur (odds ratio [OR] 2.37 [95% confidence interval (CI) 1.40-4.01, P < 0.0] and 1.8 [95% CI 1.03-3.15, P = 0.04], respectively) but not when there were >46 patients (OR 1.7, 95% CI 1.0-3.1). Higher hospital occupancy (90-99%) was a protective factor for sustaining an I/AE (OR 0.57, 95% CI 0.35-0.92, P = 0.02). CONCLUSION: I/AEs are common in the ED and a large proportion is preventable. Strategies for prevention are required. The relationship with patient load needs further clarification, since our data suggests increased I/AE rates with higher occupancy but not highest occupancy.

Variables associated with administration of analgesia, nurse-initiated analgesia and early analgesia in the emergency department.

OBJECTIVE: To determine the patient and clinical variables associated with administration of any analgesia, nurse-initiated analgesia (NIA, prescribed and administered by a nurse) and early analgesia (within 30 min of presentation). METHODS: We undertook a retrospective cohort study of patients who presented to a metropolitan ED in Melbourne, Australia, during July and August, 2013. The ED has an established NIA programme. Patients were included if they were aged 18 years or more and presented with a painful complaint. The study sample was randomly selected from a list of all eligible patients. Data were extracted electronically from the ED records and by explicit extraction from the medical record. Logistic regression models were constructed to assess associations with the three binary study end points. RESULTS: 1289 patients were enrolled. Patients were less likely to receive any analgesia if they presented 08:00-15:59 hours (OR 0.67, 95% CI 0.46 to 0.98) or 16:00-24:00 hours (OR 0.55, 95% CI 0.37 to 0.80) were triage category 5 (OR 0.20, 95% CI 0.08 to 0.49) or required an interpreter (OR 0.34, 95% CI 0.14 to 0.86). Patients were less likely to receive NIA or early analgesia if they were aged 56 years or more (OR 0.70 and 0.63; OR 0.57 and 0.21, respectively) or if they had received ambulance analgesia (OR 0.59, 95% CI 0.36 to 0.95; OR 0.38, 95% CI 0.20 to 0.74, respectively). CONCLUSIONS: Patients who present during the daytime, have a triage category of 5 or require an interpreter are less likely to receive analgesia. Older patients and those who received ambulance analgesia are less likely to receive NIA or early analgesia.

Factors associated with high levels of patient satisfaction with pain management.

OBJECTIVES: The objective was to determine, among emergency department (ED) patients, the factors associated with a high level of satisfaction with pain management. METHODS: This was a prospective cohort study in a single ED. Consecutive adult patients, with triage pain scores of ≥4 (numerical rating scale=0 to 10), were enrolled. Variables examined included demographics, presenting complaint, pain scores, nurse-initiated analgesia, analgesia administered, time to first analgesia, specific pain communication, and whether "adequate analgesia" was provided (defined as a decrease in pain score to <4 and a decrease from the triage pain score of ≥2). The level of patient satisfaction with their pain management (six-point scale: very unsatisfied to very satisfied) was determined by a blinded investigator 48 hours post discharge. Logistic regression analyses were undertaken. RESULTS: Data were complete for 476 patients: mean (±standard deviation [SD]) age was 43.6 (±17.2) years, and 237 were males (49.8%, 95% confidence interval [CI]=45.2% to 54.4%). A total of 190 (39.9%, 95% CI=35.5% to 44.5%) patients were "very satisfied" with their pain management, and 207 (43.5%, 95% CI=39.0% to 48.1%) patients received adequate analgesia. Three variables were associated with the patient being very satisfied: the provision of adequate analgesia (odds ratio [OR]=7.8, 95% CI=4.9 to 12.4), specific pain communication (OR=2.3, 95% CI=1.3 to 4.1), and oral opioid administration (OR=2.0, 95% CI=1.1 to 3.4). Notably, the provision of nurse-initiated analgesia to 211 patients (44.3%, 95% CI=39.8% to 48.9%) and the short time to analgesia (median=11.5 minutes; interquartile range [IQR]=2.0 to 85.8 minutes) were not associated with being very satisfied. CONCLUSIONS: The receipt of adequate analgesia (as defined) is highly associated with patient satisfaction. This variable may serve as a clinically relevant and achievable target in the pursuit of best-practice pain management.

Factors that impact on emergency department patient compliance with antibiotic regimens.

AIM: To investigate factors that impact upon compliance with antibiotic regimens among patients in the emergency department (ED). METHODS: This was a prospective cohort study of patients prescribed antibiotics in a single ED. Patients were identified by witnessing the consultation, medical records and 'after hours' prescriptions. Data were collected on demographics, presenting condition, usual medications, antibiotic regimen and instructions given. At follow up 7 days later, data were collected on compliance, antibiotic cost and packaging, side effects, difficulty with the regimen and other medical advice sought. The association between compliance and predictor variables was examined using multivariate logistic regression. RESULTS: 192 patients had complete data for analysis. Using two definitions of compliance (100% and ≥80% of prescribed doses), antibiotic compliance was 80% and 93%, respectively. Unemployment was negatively associated with 100% compliance (OR 0.24, 95% CI 0.07 to 0.78) and taking ≥2 regular medications was positively associated with 100% compliance (OR 4.2, 95% CI 1.2 to 15.5). No variable was associated with compliance at the ≥80% level. However, patients who were female, employed, born overseas, better educated, prescribed a single antibiotic or who had a longer course, a single dose per day, medication rather than a prescription and tablets rather than capsules tended to be more compliant. Forgetfulness, improvement of symptoms and side effects were the main reasons for non-compliance. CONCLUSION: Compliance was better than reported elsewhere. The good compliance among patients taking ≥2 regular medications may relate to their established medication routines. Scope exists for ED pharmacists to intervene with patients 'at risk' of poor antibiotic compliance.

Carbon monoxide and cyanide poisoning in fire related deaths in Victoria, Australia.

OBJECTIVE: This study was undertaken to examine the association of hydrogen cyanide and carboxyhaemoglobin in victims of fire related deaths in Australia. The secondary aim was to document demographic data about Australian fire related deaths. METHODS: An observational retrospective study was undertaken of autopsy reports from the Victorian Institute of Forensic Medicine. Reports of fire related deaths were electronically searched using the terms burns, "smoke" or "fire" as a cause of death in the calender years 1992 to 1998. Data on the circumstances of the fire and results of toxicological screening were obtained on 178 persons. Additional whole blood cyanide levels were determined if blood samples were available in storage. Demographics of the victims were analysed, as well as the relationship between carboxyhaemoglobin and whole blood cyanide levels. RESULTS: Most (82%) of the victims died at the scene, whilst 32 victims died after a period of hospitalisation (hours to weeks). Suicide as a result of self-immolation was the reported cause of death in 32 cases. Most of the fires were in houses (114) and cars (29). The blood ethanol level was zero in 112 cases; the remaining cases (53) had a mean level of 0.17%. Other central nervous system (CNS) depressants were recorded in 49 of the 134 cases that received a complete toxicological screen. Carboxyhaemoglobin levels were measured in only 154 of 178 cases. The carboxyhaemoglobin level was zero in 43 cases. The remaining cases (111) had a mean level of 40%; with 44 cases having a level greater than 50%, a level considered to be potentially lethal. Whole blood hydrogen cyanide levels were measured in only 138 of 178 cases. The hydrogen cyanide level was zero in 52 cases. The remaining cases (86) had a mean level of 1.65 mg/L; with 11 cases having a level greater than 3.0 mg/L (potentially fatal). Blood ethanol levels were significantly correlated with both carboxyhaemoglobin (R = 0.22, P < 0.01) and cyanide (R = 0.36, P < 0.001). In addition, a significant correlation (r = 0.34) between carboxyhaemoglobin and hydrogen cyanide levels was noted. CONCLUSIONS: This study showed a correlation between elevated blood ethanol and whole blood cyanide levels (r = 0.36, p < 0.001) and between elevated carboxyhaemoglobin and hydrogen cyanide levels (r = 0.34). Although the mean cyanide level was 1.3 mg/L (above the level some consider potentially toxic) in those cases with a carboxyhaemoglobin level of greater than 10%, there is insufficient data to permit recommendations for clinical care. Further studies are required on those victims that reach hospital alive.

Multidisciplinary assessment at triage: a new way forward.

OBJECTIVE: To evaluate a dual doctor and nurse triage system at a tertiary referral hospital. METHODS: Data were compared between periods of multidisciplinary triage and periods of standard triage. Data comparison was also made between rostered multidisciplinary triage shifts and non-multidisciplinary triage shifts. Staff satisfaction with the process was assessed. RESULTS: The percentage of patients seen within Australasian Triage Scale performance indicator thresholds increased from 75% to 81% in Category 2 patients (P = 0.12) and 56% to 78% in Category 3 patients (P < 0.0001). There was a reduction of 50% in the number of patients who left prior to being seen by a doctor (P = 0.024). Surveys showed high staff satisfaction with the process. CONCLUSIONS: We feel that multidisciplinary triage performs a useful function in our department enabling us to reduce waiting times. The process is widely accepted amongst the staff and it ensures a senior doctor assesses most patients. It reduces the number of patients leaving prior to being seen by a doctor and it provides one way of getting around access block and a physically small department.