CELPI: trial protocol for a randomised controlled trial of a Carer End of Life Planning Intervention in people dying with dementia.

BACKGROUND: Dementia is a leading cause of death in developed nations. Despite an often distressing and symptom laden end of life, there are systematic barriers to accessing palliative care in older people dying of dementia. Evidence exists that 70% of people living with severe dementia attend an emergency department (ED) in their last year of life. The aim of this trial is to test whether a Carer End of Life Planning Intervention (CELPI), co-designed by consumers, clinicians and content specialists, improves access to end of life care for older people with severe dementia, using an ED visit as a catalyst for recognising unmet needs and specialist palliative care referral where indicated. METHODS: A randomised controlled trial (RCT) enrolling at six EDs across three states in Australia will be conducted, enrolling four hundred and forty dyads comprising a person with severe dementia aged ≥ 65 years, and their primary carer. Participants will be randomly allocated to CELPI or the control group. CELPI incorporates a structured carer needs assessment and referral to specialist palliative care services where indicated by patient symptom burden and needs assessment. The primary outcome measure is death of the person with dementia in the carer-nominated preferred location. Secondary outcomes include carer reported quality of life of the person dying of dementia, hospital bed day occupancy in the last 12 months of life, and carer stress. An economic evaluation from the perspective of a health funder will be conducted. DISCUSSION: CELPI seeks to support carers and provide optimal end of life care for the person dying of dementia. This trial will provide high level evidence as to the clinical and cost effectiveness of this intervention. TRIAL REGISTRATION: ACTRN12622000611729 registered 22/04/2022.

RESPOND: a programme to prevent secondary falls in older people presenting to the emergency department with a fall: protocol for an economic evaluation.

BACKGROUND: Falls remain common for community-dwelling older people and impose a substantial economic burden to the healthcare system. RESPOND is a novel falls prevention programme that aims to reduce secondary falls and fall injuries among older people who present to a hospital emergency department (ED) with a fall. The present protocol describes a prospective economic evaluation examining the incremental cost-effectiveness of the RESPOND programme, compared with usual care practice, from the Australian health system perspective. METHODS AND DESIGN: This economic evaluation will recruit 528 participants from two major tertiary hospital EDs in Australia and will be undertaken alongside a multisite randomised controlled trial. Outcome and costing data will be collected for all participants over the 12-month trial. It will compare the RESPOND falls prevention programme with usual care practice (current community-based falls prevention practices) to determine its incremental cost-effectiveness according to three intermediate clinical outcomes: (1) falls prevented, (2) fall injuries prevented and (3) injurious falls prevented. In addition, utilities will be derived from a generic quality-of-life measure (EQ-5D-5L) and used to calculate the 'incremental cost per quality-adjusted life years gained'. DISCUSSION: The results of this study will provide healthcare decision makers with evidence to assist with setting spending thresholds for preventive health programmes and inform selection of emergency and community service models of care. TRIAL REGISTRATION NUMBER: The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000336684); Pre-results.

Neutrophil activation during acute human anaphylaxis: analysis of MPO and sCD62L.

BACKGROUND: The mechanisms involved in the amplification of the mast cell response during anaphylaxis are unclear. Mouse models of anaphylaxis demonstrate the critical involvement of neutrophils. These innate immune cells are highly abundant in peripheral blood and can be rapidly activated to trigger both local and systemic inflammation. OBJECTIVE: To investigate neutrophil activation in peripheral blood during acute human anaphylaxis. METHODS: Patients presenting to the emergency department with anaphylaxis underwent blood sampling upon enrolment and at up to three subsequent time-points. Traditional anaphylaxis biomarkers, histamine and mast cell tryptase, were measured by ELISA and ImmunoCAP, respectively. Plasma myeloperoxidase concentrations were measured by ELISA, serum soluble CD62L concentrations by cytometric bead array, and both compared to healthy controls. RESULTS: In 72 patients, 37 (51%) had severe anaphylaxis, 33 (60%) were histamine positive, and 47 (70%) were mast cell tryptase positive. At enrolment, myeloperoxidase concentrations were 2.9- (95% CI: 1.3, 6.5) and 5.0- (95% CI: 2.4, 10.5) fold higher in moderate and severe patients, respectively, compared with healthy controls, and remained stable over the first 5 h following symptom onset. At enrolment, soluble CD62L was 29% (95% CI: 19, 38) and 31% (95% CI: 22, 40) lower in moderate and severe patients, respectively, than healthy controls, and was stable over the first 5 h. There were no associations between myeloperoxidase or soluble CD62L concentrations and either histamine or mast cell tryptase concentrations. CONCLUSIONS AND CLINICAL RELEVANCE: These results provide compelling evidence for the involvement of neutrophils during acute human anaphylaxis, suggesting they are activated early in the reaction, regardless of mast cell activation. This important finding increases our understanding of the basic mechanisms of anaphylaxis, a necessary precursor to improving treatment and prevention.

RESPOND--A patient-centred programme to prevent secondary falls in older people presenting to the emergency department with a fall: protocol for a multicentre randomised controlled trial.

INTRODUCTION: Participation in falls prevention activities by older people following presentation to the emergency department (ED) with a fall is suboptimal. This randomised controlled trial (RCT) will test the RESPOND programme, an intervention designed to improve older persons' participation in falls prevention activities through delivery of patient-centred education and behaviour change strategies. DESIGN AND SETTING: A RCT at two tertiary referral EDs in Melbourne and Perth, Australia. PARTICIPANTS: 528 community-dwelling people aged 60-90 years presenting to the ED with a fall and discharged home will be recruited. People who require an interpreter or hands-on assistance to walk; live in residential aged care or >50 km from the trial hospital; have terminal illness, cognitive impairment, documented aggressive behaviour or a history of psychosis; are receiving palliative care or are unable to use a telephone will be excluded. METHODS: Participants will be randomly allocated to the RESPOND intervention or standard care control group. RESPOND incorporates (1) a home-based risk factor assessment; (2) education, coaching, goal setting and follow-up telephone support for management of one or more of four risk factors with evidence of effective interventions and (3) healthcare provider communication and community linkage delivered over 6 months. Primary outcomes are falls and fall injuries per person-year. DISCUSSION: RESPOND builds on prior falls prevention learnings and aims to help individuals make guided decisions about how they will manage their falls risk. Patient-centred models have been successfully trialled in chronic and cardiovascular disease; however, evidence to support this approach in falls prevention is limited. TRIAL REGISTRATION NUMBER: The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000336684).

Is comorbid status the best predictor of one-year mortality in patients with severe sepsis and sepsis with shock?

Understanding longer term outcomes in critically ill patients will assist treatment decisions, allocation of scarce resources and clinical research in that population. The aim of this study was to compare a well-validated means of determining comorbidity, the Charlson Comorbidity Score, to other verified risk stratification models in predicting one-year mortality and other outcomes in emergency department patients with severe sepsis and sepsis with shock. We conducted a planned subgroup analysis of a prospective observational study, the Critical Illness and Shock Study, in adult patients with sepsis meeting study criteria for critical illness. From emergency department arrival, patients were prospectively enrolled with data collected for a minimum of one year post-enrolment. Scoring systems were derived from this data and compared using receiver-operating characteristic curves. One hundred and four patients were enrolled. The 28-day mortality was 18% and one-year mortality 40%. For predicting one-year mortality, the area under the receiver-operating characteristic curve for age-weighted Charlson Comorbidity Score (0.71, 95% confidence interval 0.61 to 0.81) was at least as good or superior to other scoring systems analysed. The intensive care unit admission rate was 45% and the median hospital length-of-stay was eight days. We conclude that in patients who present to the emergency department with severe sepsis or sepsis with shock, age-weighted Charlson Comorbidity Score is a predictor of one-year mortality that is simple to calculate and at least as accurate as other validated scoring systems.

Front-loading allied health intervention in the emergency department does not reduce length of stay for admitted older patients.

AIMS: Allied health intervention may play an important role in the timely discharge of older people admitted to hospital. The impact of early allied health intervention on length of stay has not been quantified. We sought to determine whether early allied health intervention conducted in the emergency department (ED) reduces hospital length of stay in older patients admitted with common diagnoses. METHODS: A non-randomised prospective pragmatic study in ED patients aged 65 and over diagnosed with one or more of six conditions (cerebrovascular insufficiency; fractured neck of femur; cardiac failure; myocardial ischaemia; exacerbation of chronic airways disease; respiratory tract infection). Intervention patients receiving comprehensive allied health assessment/intervention by at least one professional working in a care coordination team were compared with patients who underwent no assessment. The primary outcome measure was hospital length of stay measured in hours from commencement of inpatient bed occupancy to discharge or death. A zero truncated negative binomial regression model was used to analyse length of stay while adjusting for covariates. RESULTS: In 2121 patients and 1451 comparators, there was no difference in length of stay (median 88 vs 87 h) on unadjusted (log-rank p 0.28) or adjusted (IRR 0.97, p 0.32) analysis. CONCLUSIONS: Front loading allied health assessment in ED has no effect on hospital length of stay.

Transfer from residential aged care to emergency departments: an analysis of patient outcomes.

BACKGROUND: In order to design optimal systems to meet the acute healthcare needs of the frail elderly living in residential care, good clinical information is essential. The aims of this study were to analyse the casemix and outcomes of patients transferred from residential aged care facilities to public hospital emergency departments in New South Wales. METHODS: Individual patient data from six hospital emergency departments and inpatient wards were obtained from merged databases and analysed using descriptive and comparative statistics. RESULTS: Outcomes in 4680 patient transfers over a 12-month period in 2006-2007 were analysed. Transfers occur mostly in high-acuity patients, with approximately three of every four transfers admitted; one in every 12 dying; and admitted patients undergoing an average of 2.4 interventions or procedures during each hospital stay. Several variables are associated with prolonged length of emergency department stay including triage urgency, type of hospital and transfers occurring in winter or out of hours. CONCLUSIONS: Patients transferred from aged care facilities to emergency departments are predominantly high-acuity patients with a substantial likelihood of hospitalisation, intervention and death. Nevertheless, scope exists for some episodes of acute care, in both discharged and admitted patients, to be provided outside a hospital setting.

Topical anaesthesia and intravenous cannulation success in paediatric patients: a randomized double-blind trial.

BACKGROUND: It is not known whether the choice of topical anaesthetic influences the likelihood of successful i.v. cannulation in the paediatric population. The null hypothesis of this study was that no difference exists in the initial success rate of cannulation between two commonly used topical anaesthetics. METHODS: A randomized double-blind trial conducted on patients between the age of 12 months and 12 yr presenting to a tertiary hospital emergency department. Patients requiring cannulation were randomized to either 4% amethocaine gel (AnGEL) or 5% lidocaine and prilocaine in a 1:1 emulsion (EMLA). The primary endpoint was success of initial attempt at i.v. cannulation. RESULTS: One hundred and seventy-seven patients were analysed of 203 enrolled. The success rate of AnGEL (73/97, 75%) and EMLA (59/80, 74%) did not significantly differ (chi2(1) 0.05, P=0.82). CONCLUSIONS: No difference exists in the cannulation success rates between the two anaesthetics. The choice of topical anaesthetic in paediatric cannulation should be based on other factors such as cost, time to anaesthesia, efficacy of the agent, and adverse effect profile.

Announcing the emergent patient in the emergency department: a randomised trial.

OBJECTIVE: To determine which of three commonly used methods for notifying medical staff of the arrival of an emergent case to the triage area of an emergency department (ED) is optimal. METHODS: Prospective, randomised trial. Patients arriving with conditions rated as emergencies (triage category 2) were randomised to one of three notification arms: by microphone, by telephone, or by computer. The proportion of patients seen by a doctor within 10 minutes of arrival to the ED in each arm was compared. RESULTS: A total of 1000 patients were enrolled. The proportion seen within 10 minutes for patients announced by microphone was significantly greater than those announced by telephone or computer (67.0% v 63.2% v 57.3%, respectively; chi2 6.30, p = 0.04). No method achieved the benchmark proportion of 80% of patients seen within 10 minutes of arrival. CONCLUSIONS: A microphone announcement heard by overhead speakers should be incorporated with other strategies to improve the timeliness of medical assessment of emergent cases.

The effect of the InterLink cannula on fluid flow rates and haemolysis.

OBJECTIVE: To examine the effect of the InterLink cannula system (Becton Dickinson, New Jersey, NY, USA) on intravenous fluid flow rates and red blood cell haemolysis. METHODS: An in vitro study was performed with crystalloid and packed red blood cells run through intravenous catheters of various sizes, with and without the InterLink cannula. Data recorded and analysed included fluid flow rates and plasma free haemoglobin concentration. RESULTS: The InterLink cannula significantly reduced flow of crystalloid through a 14G catheter (reduction of median flow rate by 0.72 L/h, 12.3%, P < 0.001). There was a reduction of flow of packed red blood cells through a 14G catheter (0.11 L/h) but this was not statistically significant. There was no significant reduction of flow through smaller catheters and no significant effect on red blood cell haemolysis. CONCLUSIONS: The InterLink cannula reduced flow rates through large diameter intravenous catheters. Because of other factors affecting fluid infusion in vivo this is of minor clinical significance. No increased haemolysis of red blood cells occurred with the InterLink cannula.