A collaborative pharmacist-led intervention to prevent hospital readmissions among elderly patients discharged from the emergency department: a retrospective cohort study.

Unplanned hospital readmission is a safety and quality healthcare measure, conferring significant costs to the healthcare system. Elderly individuals, particularly, are at high risk of readmissions, often due to issues related to medication management. Pharmacists play a pivotal role in addressing medication-related concerns, which can potentially reduce readmissions. This retrospective single-centre cohort study, conducted from November 2022 to February 2023 in an emergency department, aimed to determine if integrating emergency medicine pharmacists into Emergency Department care models reduces unplanned hospital readmissions within 28 days and to identify the interventions they employ. The inclusion criteria included patients aged ≥ 65, taking ≥ 3 medications, and presenting with falls, cognition changes, or reduced mobility and were planned for discharge to home from the emergency department. Collaborating with the Emergency Department Aged Care Service Emergency Team, a pharmacist provided comprehensive medication management consultations, discharge liaison services, and other pharmacy related interventions to eligible participants whenever the pharmacist was available. Patients who met the eligibility criteria but did not receive pharmacist interventions due to the pharmacist's unavailability served as the control group. This method was chosen to ensure that the control group consisted of comparable patients who only differed in terms of receiving the pharmacist intervention. The study included 210 participants, with 120 receiving pharmacist interventions and 90 acting as controls. The results revealed a significant reduction in unplanned hospital readmissions among participants who received pharmacist interventions (10.0%, n = 12) compared to controls (22.2%, n = 20), with a notable difference of 12.2% (95% confidence interval 2.4-23.4%, p = 0.01). A total of 107 interventions were documented, emphasising medication selection recommendations (28.0%) and identification of adverse drug reactions/drug-drug interactions (21.5%) as primary areas of focus. These findings suggest that integrating skilled pharmacists into Emergency Department Aged Care Service Emergency Team (ASET) lowered the rate of unplanned hospital readmission within 28 days resulting in improved hospital performance metric outcomes. This highlights the potential role of pharmacists in addressing medication-related issues and enhancing the quality and safety of healthcare delivery, particularly for elderly patients transitioning from the ED to home care settings.

Serratus Anterior Plane Blocks for Early Rib Fracture Pain Management: The SABRE Randomized Clinical Trial.

Importance: Rib fractures secondary to blunt thoracic trauma typically result in severe pain that is notoriously difficult to manage. The serratus anterior plane block (SAPB) is a regional anesthesia technique that provides analgesia to most of the hemithorax; however, SAPB has limited evidence for analgesic benefits in rib fractures. Objective: To determine whether the addition of an SAPB to protocolized care bundles increases the likelihood of early favorable analgesic outcomes and reduces opioid requirements in patients with rib fractures. Design, Setting, and Participants: This multicenter, open-label, pragmatic randomized clinical trial was conducted at 8 emergency departments across metropolitan and regional New South Wales, Australia, between April 12, 2021, and January 22, 2022. Patients aged 16 years or older with clinically suspected or radiologically proven rib fractures were included in the study. Participants were excluded if they were intubated, transferred for urgent surgical intervention, or had a major concomitant nonthoracic injury. Data were analyzed from September 2022 to July 2023. Interventions: Patients were randomly assigned (1:1) to receive an SAPB in addition to usual rib fracture management or standard care alone. Main Outcomes and Measures: The primary outcome was a composite pain score measured 4 hours after enrollment. Patients met the primary outcome if they had a pain score reduction of 2 or more points and an absolute pain score of less than 4 out of 10 points. Results: A total of 588 patients were screened, of whom 210 patients (median [IQR] age, 71 [55-84] years; 131 [62%] male) were enrolled, with 105 patients randomized to receive an SAPB plus standard care and 105 patients randomized to standard care alone. In the complete-case intention-to-treat primary outcome analysis, the composite pain score outcome was reached in 38 of 92 patients (41%) in the SAPB group and 18 of 92 patients (19.6%) in the control group (relative risk [RR], 0.73; 95% CI, 0.60-0.89; P = .001). There was a clinically significant reduction in overall opioid consumption in the SAPB group compared with the control group (eg, median [IQR] total opioid requirement at 24 hours: 45 [19-118] vs 91 [34-155] milligram morphine equivalents). Rates of pneumonia (6 patients [10%] vs 7 patients [11%]), length of stay (eg, median [IQR] hospital stay, 4.2 [2.2-7.7] vs 5 [3-7.3] days), and 30-day mortality (1 patient [1%] vs 3 patients [4%]) were similar between the SAPB and control groups. Conclusions and Relevance: This randomized clinical trial found that the addition of an SAPB to standard rib fracture care significantly increased the proportion of patients who experienced a meaningful reduction in their pain score while also reducing in-hospital opioid requirements. Trial Registration: http://anzctr.org.au Identifier: ACTRN12621000040864.

Derivation of a clinical decision rule to exclude cerebral venous sinus thrombosis in emergency department patients: A retrospective cohort study.

OBJECTIVE: To derive a clinical decision rule to exclude cerebral venous sinus thrombosis (CVST) in the ED. A secondary aim was to derive a rule that incorporated clinical parameters and the non-contrast CT brain. METHODS: Single-centre, retrospective cohort study. Patients suspected of CVST were identified from the radiology database for CT/MR venograms. Clinical features included in the rule were determined by literature review. The presence of these features in participants was determined by chart review. Variables were tested for univariate association with CVST using logistic regression. Variable selection was accomplished using a forward-stepwise process, calculating the sensitivity/specificity of a rule containing the variable of most significance, then repeating the process after adding the next most significant variable. RESULTS: Forty-five out of 912 participants had confirmed CVST. The primary clinical rule was answering 'no' to all the following: any prothrombotic risk factor, age ≥54 years, confusion: sensitivity 95.6% (95% confidence interval [CI] 84.9-99.5%), specificity 40.9% (95% CI 37.6-44.2%), negative predictive value 99.4% (95% CI 97.9-99.9%) and positive predictive value 7.7% (95% CI 7.1-8.3%). The rule classified 39.5% of participants as CVST ruled out. The rule incorporating the non-contrast CT brain was answering 'no' to all the following: abnormal non-contrast CT brain, any prothrombotic risk-factor, age ≥54 years, confusion: sensitivity 100.0% (95% CI 91.6-100.0%), specificity 42.0% (95% CI 38.7-45.4%), negative predictive value 100.0% (95% CI not calculated) and positive predictive value 7.8% (95% CI 7.4-8.2%). The rule classified 40.0% of participants as CVST ruled out. CONCLUSIONS: A clinical decision rule was derived to rule out CVST. These results require validation before adoption into clinical practice.

Effect of an intervention for patients 65 years and older with blunt chest injury: Patient and health service outcomes.

INTRODUCTION: Blunt chest injury in older adults, aged 65 years and older, leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes in older adults with blunt chest injury. METHODS: ChIP comprised multidimensional implementation guidance in three key pillars of care for blunt chest injury: respiratory support, analgesia, and complication prevention. Implementation was guided using the Behaviour Change Wheel. This proof-of-concept controlled pre- and post-test study with two intervention and two control sites in Australia was conducted from July 2015 to June 2019. The primary outcomes were non-invasive ventilation (NIV) use, unplanned Intensive Care Unit (ICU) admissions, and in-hospital mortality. Secondary outcomes were health service and costing outcomes. RESULTS: There were 1122 patients included in the analysis, with 673 at intervention sites (331 pre-test and 342 post-test) and 449 at control sites (256 pre-test and 193 post-test). ChIP was associated with unplanned ICU admissions and in NIV use with a reduction of the odds in the post vs the pre periods in the intervention sites when compared to the controls (ratio of OR=0.13, 95%CI=0.03-0.55) and (ratio of OR=0.14, 95%CI=0.02-0.98) respectively. There was no significant change in mortality. Implementing ChIP was also associated with health service team reviews with an increased odds in the post vs pre periods in the intervention sites in comparison to the controls for surgical review (ratio of OR =6.93, 95%CI=4.70-10.28), ICU doctor (ratio of OR =5.06, 95%CI=2.26-9.25), ICU liaison (ratio of OR =14.14, 95%CI=3.15-63.31), and pain (ratio of OR =5.59, 95%CI=3.25-9.29). ChIP was also related to incentive spirometry (ratio of OR=6.35, 95%CI= 3.15-12.82) and overall costs (ratio of mean ratio=1.34, 95%CI=1.09-1.66) with a higher ratio for intervention sites. CONCLUSION: Implementation of ChIP using the Behaviour Change Wheel was associated with reduced unplanned ICU admissions and NIV use and improved health care delivery. TRIAL REGISTRATION: ANZCTR: ACTRN12618001548224, approved 17/09/2018.

The HEART score to identify emergency department patients suspected of an acute coronary syndrome who can be removed from cardiac monitoring: A retrospective chart review.

OBJECTIVE: Continuous cardiac monitoring has been recommended for ED patients being evaluated for possible acute coronary syndrome (ACS) due to concern for arrhythmia, although evidence suggests this risk is low. Indiscriminate use of monitored beds restricts access for other critically unwell patients and contributes to overcrowding. The objective of the present study was to determine if a low/intermediate-risk HEART score identified patients at very low risk for a clinically important arrhythmia who could be removed from cardiac monitoring. METHODS: This was a single centre, retrospective, cohort study of consecutive ED patients in a tertiary referral hospital evaluated for possible ACS from July to August 2017. Patients with ST-elevation myocardial infarction or an arrhythmia at presentation which would mandate monitoring were excluded. Data was obtained by medical chart review. The primary outcome was the occurrence of an arrhythmia requiring treatment while in ED. RESULTS: Inter-rater reliability for data extraction demonstrated very strong agreement (kappa 0.87, 95% confidence interval 0.83-0.91). There were 653 participants included with 83 (12.7%) having a final diagnosis of ACS. Three (0.5%) clinically important arrhythmias occurred. There were no cases of ventricular tachycardia, ventricular fibrillation or cardiac arrest. Five hundred and forty (82.7%) participants were low/intermediate-risk HEART score and one (0.2%) clinically important arrhythmia occurred (this was supraventricular tachycardia treated by a valsalva manoeuvre). CONCLUSION: Among ED patients presenting with a possible ACS, a low/intermediate-risk HEART score identified those at very low risk for having a clinically important arrhythmia while in ED.

Implementation of a hospital-wide multidisciplinary blunt chest injury care bundle (ChIP): Fidelity of delivery evaluation.

BACKGROUND: Ineffective intervention for patients with blunt chest wall injury results in high rates of morbidity and mortality. To address this, a blunt chest injury care bundle protocol (ChIP) was developed, and a multifaceted plan was implemented using the Behaviour Change Wheel. OBJECTIVE: The purpose of this study was to evaluate the reach, fidelity, and dose of the ChIP intervention to discern if it was activated and delivered to patients as intended at two regional Australian hospitals. METHODS: This is a pretest and post-test implementation evaluation study. The proportion of ChIP activations and adherence to ChIP components received by eligible patients were compared before and after intervention over a 4-year period. Sample medians were compared using the nonparametric median test, with 95% confidence intervals. Differences in proportions for categorical data were compared using the two-sample z-test. RESULTS/FINDINGS: Over the 19-month postimplementation period, 97.1% (n = 440) of eligible patients received ChIP (reach). The median activation time was 134 min; there was no difference in time to activation between business hours and after-hours; time to activation was not associated with comorbidities and injury severity score. Compared with the preimplementation group, the postimplementation group were more likely to receive evidence-based treatments (dose), including high-flow nasal cannula use (odds ratio [OR] = 6.8 [95% confidence interval {CI} = 4.8-9.6]), incentive spirometry in the emergency department (OR = 7.5, [95% CI = 3.2-17.6]), regular analgesia (OR = 2.4 [95% CI = 1.5-3.8]), regional analgesia (OR = 2.8 [95% CI = 1.5-5.3]), patient-controlled analgesia (OR = 1.8 [95% CI = 1.3-2.4]), and multiple specialist team reviews, e.g., surgical review (OR = 9.9 [95% CI = 6.1-16.1]). CONCLUSIONS: High fidelity of delivery was achieved and sustained over 19 months for implementation of a complex intervention in the acute context through a robust implementation plan based on theoretical frameworks. There were significant and sustained improvements in care practices known to result in better patient outcomes. Findings from this evaluation can inform future implementation programs such as ChIP and other multidisciplinary interventions in an emergency or acute care context.

Impact of a care bundle for patients with blunt chest injury (ChIP): A multicentre controlled implementation evaluation.

BACKGROUND: Blunt chest injury leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes. ChIP provides guidance in three key pillars of care for blunt chest injury-respiratory support, analgesia and complication prevention. ChIP was implemented using a multi-faceted implementation plan developed using the Behaviour Change Wheel. METHODS: This controlled pre-and post-test study (two intervention and two non-intervention sites) was conducted from July 2015 to June 2019. The primary outcome measures were unplanned Intensive Care Unit (ICU) admissions, non-invasive ventilation use and mortality. RESULTS: There were 1790 patients included. The intervention sites had a 58% decrease in non-invasive ventilation use in the post- period compared to the pre-period (95% CI 0.18-0.96). ChIP was associated with 90% decreased odds of unplanned ICU admissions (95% CI 0.04-0.29) at the intervention sites compared to the control groups in the post- period. There was no significant change in mortality. There were higher odds of health service team reviews (surgical OR 6.6 (95% CI 4.61-9.45), physiotherapy OR 2.17 (95% CI 1.52-3.11), ICU doctor OR 6.13 (95% CI 3.94-9.55), ICU liaison OR 55.75 (95% CI 17.48-177.75), pain team OR 8.15 (95% CI 5.52 --12.03), analgesia (e.g. patient controlled analgesia OR 2.6 (95% CI 1.64-3.94) and regional analgesia OR 8.8 (95% CI 3.39-22.79), incentive spirometry OR 8.3 (95% CI 4.49-15.37) and, high flow nasal oxygen OR 22.1 (95% CI 12.43-39.2) in the intervention group compared to the control group in the post- period. CONCLUSION: The implementation of a chest injury care bundle using behaviour change theory was associated with a sustained improvement in evidence-based practice resulting in reduced unplanned ICU admissions and non-invasive ventilation requirement. TRIAL REGISTRATION: ANZCTR: ACTRN12618001548224, approved 17/09/2018.

Neurologic outcomes following the introduction of a policy for using soft cervical collars in suspected traumatic cervical spine injury: A retrospective chart review.

OBJECTIVE: In trauma patients with potential cervical spine injury, immobilisation with a rigid cervical collar is widely recommended to prevent a secondary spinal cord injury. There is a lack of evidence for the effectiveness of this practice, but increasing evidence for complications from rigid collars. Soft foam collars may mitigate some of these issues and are used in our health service in place of rigid collars in selected patients at risk for traumatic cervical spine injury. The objective of the present study was to describe the neurological outcome of patients according to the cervical stabilisation technique used. METHODS: A multi-centre, retrospective, consecutive, case series of all patients assessed for a traumatic cervical spine injury from October 2017 to July 2018 was conducted. Data were obtained by a medical chart review. The primary outcome was the development of a new neurological deficit because of spinal cord injury while in hospital. RESULTS: Inter-rater reliability of data abstraction demonstrated very strong agreement (kappa 0.85, 95% confidence interval 0.80-0.90). Of 2036 patients, 1133 were managed in a soft collar. A new neurological deficit because of spinal cord injury developed in two patients managed in a rigid collar. One case managed in a soft collar was uncertain because of an incomplete baseline neurological examination. CONCLUSION: The use of soft foam cervical collars in patients at risk for a cervical spine injury does not appear to increase the risk for secondary spinal cord injury but larger prospective studies are required before a robust conclusion on safety can be claimed.

Assessing the validity of two-dimensional carotid ultrasound to detect the presence and absence of a pulse.

BACKGROUND: Traditional assessment of return of cardiac output in cardiac arrest by manual palpation has poor accuracy. Point of care ultrasound of a major artery has been suggested as an alternative. We conducted a diagnostic accuracy study of two-dimensional carotid ultrasound to detect the presence or absence of a pulse, using cardiopulmonary bypass patients for pulse and pulseless states. METHODS: A cross-sectional multi-patient, multi-reader repeated measures diagnostic study was conducted. For patients undergoing routine cardiopulmonary bypass, a portable ultrasound was used to record four 10-s videos the common carotid artery, three aimed for a pulse in high (>90 mmHg), medium (70-90 mmHg) and low (<70 mmHg) systolic blood pressure (SBP) ranges, and a pulseless video was recorded on cardiopulmonary bypass. Critical care physicians viewed the videos and were asked to nominate within 10 s if a pulse was present. True pulse-status was determined via the arterial-line waveform. RESULTS: Twenty-three patients had all four videos collected. Median patient age was 64 (IQR 14), sixteen were male (70%) and median BMI was 27. The median SBP in high-, medium- and low-SBP groups were 120 mmHg, 83 mmHg and 69 mmHg respectively. Forty-six physicians reviewed a subset of 24 videos. Overall sensitivity was 0.91 (95% confidence interval 0.89-0.93) and specificity 0.90 (95% CI 0.86-0.93). Sensitivity was highest in the high-SBP group (0.96, 95% CI 0.93-0.98) and lowest in the low-SBP group (0.83, 95% CI 0.78-0.87). CONCLUSION: 2D ultrasound of the common carotid artery is both sensitive and specific for detection of the presence or absence of a pulse.

Conservative versus Interventional Treatment for Spontaneous Pneumothorax.

BACKGROUND: Whether conservative management is an acceptable alternative to interventional management for uncomplicated, moderate-to-large primary spontaneous pneumothorax is unknown. METHODS: In this open-label, multicenter, noninferiority trial, we recruited patients 14 to 50 years of age with a first-known, unilateral, moderate-to-large primary spontaneous pneumothorax. Patients were randomly assigned to immediate interventional management of the pneumothorax (intervention group) or a conservative observational approach (conservative-management group) and were followed for 12 months. The primary outcome was lung reexpansion within 8 weeks. RESULTS: A total of 316 patients underwent randomization (154 patients to the intervention group and 162 to the conservative-management group). In the conservative-management group, 25 patients (15.4%) underwent interventions to manage the pneumothorax, for reasons prespecified in the protocol, and 137 (84.6%) did not undergo interventions. In a complete-case analysis in which data were not available for 23 patients in the intervention group and 37 in the conservative-management group, reexpansion within 8 weeks occurred in 129 of 131 patients (98.5%) with interventional management and in 118 of 125 (94.4%) with conservative management (risk difference, -4.1 percentage points; 95% confidence interval [CI], -8.6 to 0.5; P = 0.02 for noninferiority); the lower boundary of the 95% confidence interval was within the prespecified noninferiority margin of -9 percentage points. In a sensitivity analysis in which all missing data after 56 days were imputed as treatment failure (with reexpansion in 129 of 138 patients [93.5%] in the intervention group and in 118 of 143 [82.5%] in the conservative-management group), the risk difference of -11.0 percentage points (95% CI, -18.4 to -3.5) was outside the prespecified noninferiority margin. Conservative management resulted in a lower risk of serious adverse events or pneumothorax recurrence than interventional management. CONCLUSIONS: Although the primary outcome was not statistically robust to conservative assumptions about missing data, the trial provides modest evidence that conservative management of primary spontaneous pneumothorax was noninferior to interventional management, with a lower risk of serious adverse events. (Funded by the Emergency Medicine Foundation and others; PSP Australian New Zealand Clinical Trials Registry number, ACTRN12611000184976.).

The incidence of airway haemorrhage in manual versus mechanical cardiopulmonary resuscitation.

OBJECTIVE: The aim of this study was to compare the incidence of airway haemorrhage between participants who received manual cardiopulmonary resuscitation (CPR) and those who had received mechanical CPR using the LUCAS device. METHODS: A retrospective cohort study was conducted by means of a medical chart review. All non-traumatic cardiac arrest patients that presented to the ED, from May 2014 to February 2018, were recruited. The groups were stratified according to those who had the majority of CPR performed using the LUCAS and those who had the majority of CPR performed manually. The primary outcome was the proportion of participants with airway haemorrhage, defined as blood observed in the endotracheal tube, pharynx, trachea or mouth, and documented in the doctor or nursing notes. Logistic regression analysis was performed to adjust for confounders. RESULTS: 12 of 54 (22%) participants in the majority LUCAS CPR group had airway haemorrhage, compared with 20 of 215 (9%) participants in the majority manual CPR group, a difference of 13% (95% CI 3% to 26%, p=0.02). The unadjusted odds for developing airway haemorrhage in the majority LUCAS CPR group was 2.8 (95% CI 1.3 to 6.1). After adjusting for confounders, the odds for developing airway haemorrhage in the majority LUCAS CPR group was 2.5 (95% CI 1.1 to 5.7). CONCLUSIONS: The LUCAS mechanical CPR device is associated with a higher incidence of airway haemorrhage compared with manual CPR. Limitations in the study design mean this conclusion is not robust.

Development and evaluation of a code frame to identify potential primary care presentations in the hospital emergency department.

OBJECTIVE: A major challenge in evaluating the appropriateness of ED presentations is the lack of a universal and workable definition of patients who could have received primary care instead. Our objective was to develop a standardised code frame to identify potential primary care patients in the ED. METHODS: A standardised code frame to identify which patients could potentially be treated in a primary care setting was developed and tested on all patient episodes of care who presented to the ED of the St George Hospital, Sydney, between December 2016 and February 2017. Sensitivity and specificity of the code frame were performed. The code frame was then tested on all presentations from 2011 to 2016 in the St George Hospital and The Sutherland Hospital in Sydney. RESULTS: Of 19 916 ED presentations, 5810 (29%) were potential primary care presentations. The code frame had a sensitivity of 99.9% and a specificity of 49.0%. Results were consistent (28%) when applied to 5 years of presentations (601 168 presentations). CONCLUSION: This standardised code frame enables accurate retrospective local and national data estimations. The code frame could be used prospectively to evaluate interventions such as diverting patients to primary care settings, and to identify populations for specifically targeted interventions. The conservative nature of the code frame ensures that only those that can safely receive care in a primary care setting are identified as potential primary care.

Prospective Validation of a Checklist to Predict Short-term Death in Older Patients After Emergency Department Admission in Australia and Ireland.

BACKGROUND: Emergency departments (EDs) are pressured environment where patients with supportive and palliative care needs may not be identified. We aimed to test the predictive ability of the CriSTAL (Criteria for Screening and Triaging to Appropriate aLternative care) checklist to flag patients at risk of death within 3 months who may benefit from timely end-of-life discussions. METHODS: Prospective cohorts of >65-year-old patients admitted for at least one night via EDs in five Australian hospitals and one Irish hospital. Purpose-trained nurses and medical students screened for frailty using two instruments concurrently and completed the other risk factors on the CriSTAL tool at admission. Postdischarge telephone follow-up was used to determine survival status. Logistic regression and bootstrapping techniques were used to test the predictive accuracy of CriSTAL for death within 90 days of admission as primary outcome. Predictability of in-hospital death was the secondary outcome. RESULTS: A total of 1,182 patients, with median age 76 to 80 years (IRE-AUS), were included. The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% confidence interval [CI] = 7.7-8.6) versus 5.7 (95% CI = 5.1-6.2) and Irish mean of 7.7 (95% CI = 6.9-8.5) versus 5.7 (95% CI = 5.1-6.2). The model with Fried frailty score was optimal for the derivation (Australian) cohort but prediction with the Clinical Frailty Scale (CFS) was also good (areas under the receiver-operating characteristic [AUROC] = 0.825 and 0.81, respectively). Values for the validation (Irish) cohort were AUROC = 0.70 with Fried and 0.77 using CFS. A minimum of five of 29 variables were sufficient for accurate prediction, and a cut point of 7+ or 6+ depending on the cohort was strongly indicative of risk of death. The most significant independent predictor of short-term death in both cohorts was frailty, carrying a twofold risk of death. CriSTAL's accuracy for in-hospital death prediction was also good (AUROC = 0.795 and 0.81 in Australia and Ireland, respectively), with high specificity and negative predictive values. CONCLUSIONS: The modified CriSTAL tool (with CFS instead of Fried's frailty instrument) had good discriminant power to improve certainty of short-term mortality prediction in both health systems. The predictive ability of models is anticipated to help clinicians gain confidence in initiating earlier end-of-life discussions. The practicalities of embedding screening for risk of death in routine practice warrant further investigation.

Which frailty scale for patients admitted via Emergency Department? A cohort study.

OBJECTIVES: To determine the prevalence of frailty in Emergency Departments (EDs); examine the ability of frailty to predict poor outcomes post-discharge; and identify the most appropriate instrument for routine ED use. METHODS: In this prospective study we simultaneously assessed adults 65+yrs admitted and/or spent one night in the ED using Fried, the Clinical Frailty Scale (CFS), and SUHB (Stable, Unstable, Help to walk, Bedbound) scales in four Australian EDs for rapid recognition of frailty between June 2015 and March 2016. RESULTS: 899 adults with complete follow-up data (mean (SD) age 80.0 (8.3) years; female 51.4%) were screened for frailty. Although different scales yielded vastly different frailty prevalence (SUHB 9.7%, Fried 30.4%, CFS 43.7%), predictive discrimination of poor discharge outcomes (death, poor self-reported health/quality of life, need for community services post-discharge, or reattendance to ED after the index hospitalization) for all identical final models was equivalent across all scales (AUROC 0.735 for Fried, 0.730 for CFS and 0.720 for SUHB). CONCLUSION: This study confirms that screening for frailty in older ED patients can inform prognosis and target discharge planning including community services required. The CFS was as accurate as the Fried and SUHB in predicting poor outcomes, but more practical for use in busy clinical environments with lower level of disruption. Given the limitations of objectively measuring frailty parameters, self-report and clinical judgment can reliably substitute the assessment in EDs. We propose that in a busy ED environment, frailty scores could be used as a red flag for poor follow-up outcome.

Role of venous blood gases in hypercapnic respiratory failure chronic obstructive pulmonary disease patients presenting to the emergency department.

BACKGROUND: Many patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) have type 2 respiratory failure (T2RF). Often arterial blood gases are not performed and correlation with venous blood gases (VBG) is controversial. The venous pH and bicarbonate (HCO3 ) are useful, but VBG pCO2 (PvCO2 ) is considered too unpredictable. AIM: To examine the utility of VBG in this cohort of patients. METHODS: A prospective study of AECOPD patients with T2RF presenting to the emergency department was performed. Patients being considered for non-invasive ventilation and who required an arterial blood gas were invited to participate. A subsequent VBG was also taken, and Bland-Altman plots were used for analysis. RESULTS: Sixty-three patients were included in this study. The limits of agreement for pH and HCO3 were narrow. Wider limits of agreement with a systematic bias of 7.7 mmHg were noted with pCO2 . CONCLUSIONS: The utility of VBG pH and HCO3 was again demonstrated. VBG pCO2 in this cohort of patients may have a role in the assessment of patients with AECOPD. Further study is needed on the possible role of VBG in the management of such patients with T2RF particularly those using non-invasive ventilation.

Position of the abdominal seat belt sign and its predictive utility for abdominal trauma.

OBJECTIVE: In a motor vehicle crash, compressive forces from the lap component of the seat belt may produce an abdominal abrasion/contusion known as the 'seat belt sign', and is associated with abdominal and lumbar injuries. Previous research has not taken into account the position of this sign in relation to the anterior superior iliac spine (ASIS). Our aim was to demonstrate an association between the seat belt sign position in relation to ASIS and the presence of abdominal/lumbar injury. METHODS: A mixed prospective and retrospective observational study of patients involved in a motor vehicle crash was conducted. The presence of a seat belt sign was recorded as above ASIS, at/below ASIS, or none. Injury data were extracted from discharge summaries, radiology reports and operation reports. Proportions of patients with injuries were compared across the three groups. RESULTS: Four hundred and sixty-four participants were enrolled. For participants with a seat belt sign above ASIS, compared to those with no seat belt sign, the positive likelihood ratio for a seat belt related injury was 4.2 (95% CI 2.6-6.8). When the seat belt sign was at/below the level of ASIS the positive likelihood ratio was 1.5 (95% CI 0.4-5.7). CONCLUSION: The seat belt sign is associated with abdominal and lumbar injury; however, the location is important. This association is strong when the seat belt sign is above ASIS, but when the sign is at/below the ASIS the injury rate is similar to participants with no seat belt sign. Routine imaging of the abdomen may be appropriate only for those with a seat belt sign above ASIS.

Predictive validity of the CriSTAL tool for short-term mortality in older people presenting at Emergency Departments: a prospective study.

ABSTRACT: To determine the validity of the Australian clinical prediction tool Criteria for Screening and Triaging to Appropriate aLternative care (CRISTAL) based on objective clinical criteria to accurately identify risk of death within 3 months of admission among older patients. METHODS: Prospective study of ≥ 65 year-olds presenting at emergency departments in five Australian (Aus) and four Danish (DK) hospitals. Logistic regression analysis was used to model factors for death prediction; Sensitivity, specificity, area under the ROC curve and calibration with bootstrapping techniques were used to describe predictive accuracy. RESULTS: 2493 patients, with median age 78-80 years (DK-Aus). The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% CI 7.7-8.6 vs. 5.8 95% CI 5.6-5.9) and Danish mean 7.1 (95% CI 6.6-7.5 vs. 5.5 95% CI 5.4-5.6). The model with Fried Frailty score was optimal for the Australian cohort but prediction with the Clinical Frailty Scale (CFS) was also good (AUROC 0.825 and 0.81, respectively). Values for the Danish cohort were AUROC 0.764 with Fried and 0.794 using CFS. The most significant independent predictors of short-term death in both cohorts were advanced malignancy, frailty, male gender and advanced age. CriSTAL's accuracy was only modest for in-hospital death prediction in either setting. CONCLUSIONS: The modified CriSTAL tool (with CFS instead of Fried's frailty instrument) has good discriminant power to improve prognostic certainty of short-term mortality for ED physicians in both health systems. This shows promise in enhancing clinician's confidence in initiating earlier end-of-life discussions.

Efficacy of a tool to predict short-term mortality in older people presenting at emergency departments: Protocol for a multi-centre cohort study.

BACKGROUND: Prognostic uncertainty inhibits clinicians from initiating timely end-of-life discussions and advance care planning. This study evaluates the efficacy of the CriSTAL (Criteria for Screening and Triaging to Appropriate aLternative care) checklist in emergency departments. METHODS: Prospective cohort study of patients aged ≥65 years with any diagnosis admitted via emergency departments in ten hospitals in Australia, Denmark and Ireland. Electronic and paper clinical records will be used to extract risk factors such as nursing home residency, physiological deterioration warranting a rapid response call, personal history of active chronic disease, history of hospitalisations or intensive care unit admission in the past year, evidence of proteinuria or ECG abnormalities, and evidence of frailty to be concurrently measured with Fried Score and Clinical Frailty Scale. Patients or their informal caregivers will be contacted by telephone around three months after initial assessment to ascertain survival, self-reported health, post-discharge frailty and health service utilisation since discharge. Logistic regression and bootstrapping techniques and AUROC curves will be used to test the predictive accuracy of CriSTAL for death within 90 days of admission and in-hospital death. DISCUSSION: The CriSTAL checklist is an objective and practical tool for use in emergency departments among older patients to determine individual probability of death in the short-term. Its validation in this cohort is expected to reduce clinicians' prognostic uncertainty on the time to patients' death and encourage timely end-of-life conversations to support clinical decisions with older frail patients and their families about their imminent or future care choices.

Implementation evaluation and refinement of an intervention to improve blunt chest injury management-A mixed-methods study.

AIMS AND OBJECTIVES: To investigate uptake of a Chest Injury Protocol (ChIP), examine factors influencing its implementation and identify interventions for promoting its use. BACKGROUND: Failure to treat blunt chest injuries in a timely manner with sufficient analgesia, physiotherapy and respiratory support, can lead to complications such as pneumonia and respiratory failure and/or death. DESIGN: This is a mixed-methods implementation evaluation study. METHODS: Two methods were used: (i) identification and review of the characteristics of all patients eligible for the ChIP protocol, and (ii) survey of hospital staff opinions mapped to the Theoretical Domains Framework (TDF) to identify barriers and facilitators to implementation. The characteristics and treatment received between the groups were compared using the chi-square test or Fischer's exact test for proportions, and the Mann-Whitney U-test for continuous data. Quantitative survey data were analysed using descriptive statistics. Qualitative data were coded in NVivo 10 using a coding guide based on the TDF and Behaviour Change Wheel (BCW). Identification of interventions to change target behaviours was sourced from the Behaviour Change Technique Taxonomy Version 1 in consultation with stakeholders. RESULTS: Only 68.4% of eligible patients received ChIP. Fifteen facilitators and 10 barriers were identified to influence the implementation of ChIP in the clinical setting. These themes were mapped to 10 of the 14 TDF domains and corresponded with all nine intervention functions in the BCW. Seven of these intervention functions were selected to address the target behaviours and a multi-faceted relaunch of the revised protocol developed. Following re-launch, uptake increased to 91%. CONCLUSIONS: This study demonstrated how the BCW may be used to revise and improve a clinical protocol in the ED context. RELEVANCE TO CLINICAL PRACTICE: Newly implemented clinical protocols should incorporate clinician behaviour change assessment, strategy and interventions. Enhancing the self-efficacy of emergency nurses when performing assessments has the potential to improve patient outcomes and should be included in implementation strategy.

Study protocol for a randomised controlled trial of invasive versus conservative management of primary spontaneous pneumothorax.

INTRODUCTION: Current management of primary spontaneous pneumothorax (PSP) is variable, with little evidence from randomised controlled trials to guide treatment. Guidelines emphasise intervention in many patients, which involves chest drain insertion, hospital admission and occasionally surgery. However, there is evidence that conservative management may be effective and safe, and it may also reduce the risk of recurrence. Significant questions remain regarding the optimal initial approach to the management of PSP. METHODS AND ANALYSIS: This multicentre, prospective, randomised, open label, parallel group, non-inferiority study will randomise 342 participants with a first large PSP to conservative or interventional management. To maintain allocation concealment, randomisation will be performed in real time by computer and stratified by study site. Conservative management will involve a period of observation prior to discharge, with intervention for worsening symptoms or physiological instability. Interventional treatment will involve insertion of a small bore drain. If drainage continues after 1 hour, the patient will be admitted. If drainage stops, the drain will be clamped for 4 hours. The patient will be discharged if the lung remains inflated. Otherwise, the patient will be admitted. The primary end point is the proportion of participants with complete lung re-expansion by 8 weeks. Secondary end points are as follows: days in hospital, persistent air leak, predefined complications and adverse events, time to resolution of symptoms, and pneumothorax recurrence during a follow-up period of at least 1 year. The study has 95% power to detect an absolute non-inferiority margin of 9%, assuming 99% successful expansion at 8 weeks in the invasive treatment arm. The primary analysis will be by intention to treat. ETHICS AND DISSEMINATION: Local ethics approval has been obtained for all sites. Study findings will be disseminated by publication in a high-impact international journal and presentation at major international Emergency Medicine and Respiratory meetings. TRIAL REGISTRATION NUMBER: ACTRN12611000184976; Pre-results.