Applying the Ottawa subarachnoid haemorrhage rule on a cohort of emergency department patients with headache.

OBJECTIVE: The Ottawa subarachnoid haemorrhage (SAH) rule suggests that alert patients older than 15 years with a severe nontraumatic headache reaching maximum intensity within 1 h and absence of high-risk variables effectively have a SAH ruled out. We aimed to determine the proportion of emergency department (ED) patients with any headache fulfilling the entry criteria for the Ottawa SAH rule. PATIENTS AND METHODS: The Ottawa SAH rule was applied retrospectively in a substudy of a prospective snapshot of 34 EDs in Queensland, Australia, carried out over 4 weeks in September 2014. Patient aged 18 years and older with a nontraumatic headache of any potential cause were included. Clinical data and results of investigations were collected. RESULTS: Data were available for 644 (76%) patients. A total of 149 (23.1%, 95% confidence interval: 20.0-26.5%) fulfilled and 495 (76.9%, 95% confidence interval: 73.5-80.0%) did not fulfil the entry criteria. In patients who fulfilled the entry criteria, 30 (<5% overall) did not have any high-risk variables for SAH. In patients who fulfilled the entry criteria and had at least 1 high-risk feature, almost half (46%) received a computed tomographic brain. No SAH were missed. CONCLUSION: In this descriptive observational study, the majority of ED patients presenting with a headache did not fulfil the entry criteria for the Ottawa SAH rule. Less than 5% of the patients in this cohort could have SAH excluded on the basis of the rule. More definitive studies are needed to determine an accepted benchmark for the proportion of patients receiving further work-up (computed tomographic brain) after fulfilling the entry criteria for the Ottawa SAH rule.

Ambulance use is associated with higher self-rated illness seriousness: user attitudes and perceptions.

OBJECTIVES: The objective was to study the role and effect of patients' perceptions on reasons for using ambulance services in Queensland, Australia. METHODS: A cross-sectional survey was conducted of patients (n = 911) presenting via ambulance or self-transport at eight public hospital emergency departments (EDs). The survey included perceived illness severity, attitudes toward ambulance, and reasons for using ambulance. A theoretical framework was developed to inform this study. RESULTS: Ambulance users had significantly higher self-rated perceived seriousness, urgency, and pain than self-transports. They were also more likely to agree that ambulance services are for everyone to use, regardless of the severity of their conditions. In compared to self-transports, likelihood of using an ambulance increased by 26% for every unit increase in perceived seriousness; and patients who had not used an ambulance in the 6 months prior to the survey were 66% less likely to arrive by ambulance. Patients who had presented via ambulance stated they considered the urgency (87%) or severity (84%) of their conditions as reasons for calling the ambulance. Other reasons included requiring special care (76%), getting higher priority at the ED (34%), not having a car (34%), and financial concerns (17%). CONCLUSIONS: Understanding patients' perceptions is essential in explaining their actions and developing safe and effective health promotion programs. Individuals use ambulances for various reasons and justifications according to their beliefs, attitudes, and sociodemographic conditions. Policies to reduce and manage demand for such services need to address both general opinions and specific attitudes toward emergency health services to be effective.

Universal access to ambulance does not increase overall demand for ambulance services in Queensland, Australia.

OBJECTIVE: To determine the impact of the introduction of universal access to ambulance services via the implementation of the Community Ambulance Cover (CAC) program in Queensland in 2003-04. METHOD: The study involved a 10-year (2000-01 to 2009-10) retrospective analysis of routinely collected data reported by the Queensland Ambulance Service (QAS) and by the Council of Ambulance Authorities. The data were analysed for the impact of policy changes that resulted in universal access to ambulance services in Queensland. RESULTS: QAS is a statewide, publically funded ambulance service. In Queensland, ambulance utilisation rate (AUR) per 1000 persons grew by 41% over the decade or 3.9% per annum (10-year mean=149.8, 95% CI: 137.3-162.3). The AUR mean after CAC was significantly higher for urgent incidents than for non-urgent ones. However projection modelling demonstrates that URs after the introduction of CAC were significantly lower than the projected utilisation for the same period. CONCLUSIONS: The introduction of universal access under the Community Ambulance Cover program in Queensland has not had any significant independent long-term impact on demand overall. There has been a reduction in the long-term growth rate, which may have been contributed to by an 'appropriate use' public awareness program.

Management of Ocular Trauma in Emergency (MOTE) Trial: A pilot randomized double-blinded trial comparing topical amethocaine with saline in the outpatient management of corneal trauma.

BACKGROUND: It is unclear whether local anesthetic eye drops can be safely used for the topical anesthesia of patients with minor corneal injury who are discharged from the emergency department (ED). OBJECTIVES: To assess whether topical 0.4% amethocaine self-administered to a maximum recommended frequency of once every hour for 36-48 h is safe in the management of uncomplicated corneal injury in patients discharged from the ED. PATIENTS AND METHODS: A pilot randomized double-blinded trial comparing topical 0.4% amethocaine with topical normal saline. RESULTS: Forty-seven subjects were recruited, with 22 randomized to receive amethocaine and 25 to receive placebo (normal saline). Baseline characteristics, including corneal injury type, were similar in both groups. There were no significant functional or clinical adverse sequelae in the majority of enrolled patients who could be contacted at 2 weeks (17/22 for amethocaine and 21/25 for placebo). Follow-up for the primary study outcome was suboptimal, with only 7/22 from the amethocaine group and 9/25 from the saline group presenting for 36-48 h review; there was a statistically nonsignificant trend for persistence of the corneal defect in the amethocaine group as compared with the saline group (2/7 and 1/9, respectively). CONCLUSION: Compared with saline drops, amethocaine eye drops are not definitely safe but they are effective for topical analgesia in minor corneal injury. Until further definitive studies, topical nonsteroidal agents or long-lasting artificial tears may be preferred for the topical analgesia of minor corneal injury. Return for corneal re-evaluation will necessarily remain suboptimal in an otherwise self-limiting condition, leading to a bias even if study recruitment is good.

Subhepatically located appendicitis due to adhesions: a case report.

INTRODUCTION: Acute appendicitis occurs frequently and is a major indication for acute abdominal surgery. Subhepatic appendicitis has rarely been reported and is more difficult to diagnose. CASE PRESENTATION: A 71-year-old man with multiple medical comorbidities presented with undifferentiated right abdominal pain. Diagnostic difficulty was encountered due to subhepatic mal-location of the appendix and subsequently atypical presentation for acute appendicitis. CONCLUSION: Subhepatic anatomical location of the appendix makes it more difficult to diagnose acute appendicitis at any age, including in older adults.

After hours medical ward duties in a teaching hospital.

In many Australian hospitals a medical officer is available for urgent review of inpatients outside normal working hours. Current practice in nurse-initiated requests for medical officer involvement out of hours may adversely affect patient outcome as well as medical and nursing resource use at these times. Of 10 523 nurse-initiated requests for out-of-hours review recorded by medical officers at our hospital in 2002-2003, the most frequent reasons for the requests were medication review, IV fluid orders, IV resite, venesection, and pathology review, none of which are related to acute changes in clinical condition. Requests for routine review of medication and fluid orders were found to be rarely essential and often inappropriate. Medical officer activity was highest before midnight and least after midnight, suggesting most requests are fulfilled in the evening. Several strategies to reduce inappropriate out-of-hours requests were identified. Routine tasks could be completed by primary treating unit staff before going off duty. IV cannulation and venesection may be performed by appropriately trained phlebotomists or skilled advanced practice nursing staff. Meticulous ordering of 'as required' analgesia and night sedation would reduce unnecessary requests. Clinical protocols for nurse-initiated adjustment of drugs with variable dosing may also decrease inefficiencies. This would leave the ward cover medical officers more available for their primary function of urgent patient review.

Hypercapnia and oxygen therapy in older asthmatic patients.

Excessive oxygen administration in hypercapnic chronic obstructive pulmonary disease predisposes to worsening respiratory failure during intercurrent respiratory illness. Chronic hypercapnia is thought to downregulate carbon dioxide chemoreceptor sensitivity, adversely affecting respiratory function/mechanics and worsening ventilation-perfusion inequality. These patients are dependent on hypoxic drive to maintain adequate spontaneous respiration. Whether an analogous situation occurs in asthma in older adults is unknown. These conditions may be difficult to differentiate clinically, and both may respond adversely to the administration of excessive oxygen in the presence of chronic hypercapnia. Although unrestricted oxygen is beneficial and safe in children and young adults with asthma, it may lead to progressive hypercapnia in older patients with asthma, a potential risk highlighted by this case. To avert progressive hypercapnia, oxygen therapy that is carefully adjusted to achieve adequate, but not maximal, tissue oxygenation may be a safer strategy than unrestricted oxygen use in older asthmatic patients. However, the correction of hypoxia overrides strategies to avert oxygen-related hypercapnia.