Status epilepticus in Auckland, New Zealand: Treatment patterns and determinants of outcome in a prospective population-based cohort.

OBJECTIVE: Determination of the real-world performance of a health care system in the treatment of status epilepticus (SE). METHODS: Prospective, multicenter population-based study of SE in Auckland, New Zealand (NZ) over 1 year, with data recorded in the EpiNet database. Focus on treatment patterns and determinants of SE duration and 30-day mortality. The incidence, etiology, ethnic discrepancies, and seizure characteristics of this cohort have been published previously. RESULTS: A total of 365 patients were included in this treatment cohort; 326 patients (89.3%) were brought to hospital because of SE, whereas 39 patients (10.7%) developed SE during a hospital admission for another reason. Overall, 190 (52.1%) had a known history of epilepsy and 254 (70.0%) presented with SE with prominent motor activity. The mean Status Epilepticus Severity Score (STESS) was 2.15 and the mean SE duration of all patients was 44 min. SE self-terminated without any treatment in 84 patients (22.7%). Earlier administration of appropriately dosed benzodiazepine in the pre-hospital setting was a major determinant of SE duration. Univariate analysis demonstrated that mortality was significantly higher in older patients, patients with longer durations of SE, higher STESS, and patients who developed SE in hospital, but these did not maintain significance with multivariate analysis. There was no difference in the performance of the health care system in the treatment of SE across ethnic groups. SIGNIFICANCE: When SE was defined as 10 continuous minutes of seizure, overall mortality was lower than expected and many patients had self-limited presentations for which no treatment was required. Although there were disparities in the incidence of SE across ethnic groups there was no difference in treatment or outcome. The finding highlights the benefit of a health care system designed to deliver universal health care.

Status epilepticus in Auckland, New Zealand: Incidence, etiology, and outcomes.

OBJECTIVE: To determine the incidence, etiology, and outcome of status epilepticus (SE) in Auckland, New Zealand, using the latest International League Against Epilepsy (ILAE) SE semiological classification. METHODS: We prospectively identified patients presenting to the public or major private hospitals in Auckland (population = 1.61 million) between April 6, 2015 and April 5, 2016 with a seizure lasting 10 minutes or longer, with retrospective review to confirm completeness of data capture. Information was recorded in the EpiNet database. RESULTS: A total of 477 episodes of SE occurred in 367 patients. Fifty-one percent of patients were aged <15 years. SE with prominent motor symptoms comprised 81% of episodes (387/477). Eighty-four episodes (18%) were nonconvulsive SE. Four hundred fifty episodes occurred in 345 patients who were resident in Auckland. The age-adjusted incidence of 10-minute SE episodes and patients was 29.25 (95% confidence interval [CI] = 27.34-31.27) and 22.22 (95% CI = 20.57-23.99)/100 000/year, respectively. SE lasted 30 minutes or longer in 250 (56%) episodes; age-adjusted incidence was 15.95 (95% CI = 14.56-17.45) SE episodes/100 000/year and 12.92 (95% CI = 11.67-14.27) patients/100 000/year. Age-adjusted incidence (10-minute SE) was 25.54 (95% CI = 23.06-28.24) patients/100 000/year for males and 19.07 (95% CI = 16.91-21.46) patients/100 000/year for females. The age-adjusted incidence of 10-minute SE was higher in Maori (29.31 [95% CI = 23.52-37.14]/100 000/year) and Pacific Islanders (26.55 [95% CI = 22.05-31.99]/100 000/year) than in patients of European (19.13 [95% CI = 17.09-21.37]/100 000/year) or Asian/other descent (17.76 [95% CI = 14.73-21.38]/100 000/year). Seventeen of 367 patients in the study died within 30 days of the episode of SE; 30-day mortality was 4.6%. SIGNIFICANCE: In this population-based study, incidence and mortality of SE in Auckland lie in the lower range when compared to North America and Europe. For pragmatic reasons, we only included convulsive SE if episodes lasted 10 minutes or longer, although the 2015 ILAE SE classification was otherwise practical and easy to use.

EpiNet study of incidence of status epilepticus in Auckland, New Zealand: Methods and preliminary results.

The EpiNet project has been commenced to facilitate investigator-led collaborative research in epilepsy. A new Web-based data collection tool has been developed within EpiNet to record comprehensive data regarding status epilepticus and has been used for a study of status epilepticus in Auckland, New Zealand. All patients aged >4 weeks who presented to any of the five public hospitals and the major private hospital within Auckland city (population = 1.61 million) with an episode of status epilepticus between April 6, 2015 and April 5, 2016 were identified using multiple overlapping sources of information. For this study, status epilepticus was defined as any seizure exceeding 10 minutes in duration, or repeated seizures lasting >10 minutes without recovery between seizures. Patients who had either convulsive or nonconvulsive status epilepticus were included. Episodes of status epilepticus were classified according to the 2015 International League Against Epilepsy ILAE status epilepticus classification. A total of 477 episodes in 367 patients were considered as definite or probable status epilepticus; 285 episodes (62%) lasted >30 minutes, which is the duration that has previously been used for epidemiological studies of status epilepticus.

Effect of a text message intervention to reduce hazardous drinking among injured patients discharged from a trauma ward: a randomized controlled trial.

Screening and brief intervention for hazardous alcohol use in trauma care settings is known to reduce alcohol intake and injury recidivism, but is often not implemented due to resource constraints. Brief interventions delivered by mobile phone could overcome this challenge. This study aimed to evaluate the effect of a mobile phone text message intervention (YourCallTM) on hazardous drinkers admitted for an injury. The parallel two-group, single-blind, randomised controlled trial enrolled 598 injured patients aged 16-69 years identified as medium-risk drinkers at recruitment. The intervention group (n = 299) received 16 text messages incorporating brief intervention principles in the 4 weeks following discharge from hospital. Controls (n = 299) received usual care and one text message acknowledging participation in the trial. The primary outcome was the difference in hazardous alcohol use (assessed using AUDIT-C) between study groups at 3 months, with the maintenance of effect examined at 6 and 12 months' follow-up. Data were analysed using a mixed-effects model for repeated measures. Both groups had similar baseline features. Compared to controls, hazardous drinking was significantly lower in the intervention group at 3 months and maintained over the 12-month follow-up period (least squares mean difference in AUDIT-C scores: -0.322; 95% CI: -0.636, -0.008; p = 0.04). The intervention effect was similar among Maori (New Zealand's indigenous population) and non-Maori (interaction p = 0.59), and among younger (16-29 years) and older (30-69 years) patients (p = 0.77). The effectiveness of this intervention reflects the potential of low cost, scalable mobile health technologies to overcome common barriers in implementing alcohol harm reduction strategies following injury.

Effectiveness of the YourCall™ text message intervention to reduce harmful drinking in patients discharged from trauma wards: protocol for a randomised controlled trial.

BACKGROUND: Behavioural brief interventions (BI) can support people to reduce harmful drinking but multiple barriers impede the delivery and equitable access to these. To address this challenge, we developed YourCall™, a novel short message service (SMS) text message intervention incorporating BI principles. This protocol describes a trial evaluating the effectiveness of YourCall™ (compared to usual care) in reducing hazardous drinking and alcohol related harm among injured adults who received in-patient care. METHODS/DESIGN: Participants recruited to this single-blind randomised controlled trial comprised patients aged 16-69 years in three trauma-admitting hospitals in Auckland, New Zealand. Those who screened positive for moderately hazardous drinking were randomly assigned by computer to usual care (control group) or the intervention. The latter comprised 16 informational and motivational text messages delivered using an automated system over the four weeks following discharge. The primary outcome is the difference in mean AUDIT-C score between the intervention and control groups at 3 months, with the maintenance of the effect examined at 6 and 12 months follow-up. Secondary outcomes comprised the health and social impacts of heavy drinking ascertained through a web-survey at 12 months, and further injuries identified through probabilistic linkage to national databases on accident insurance, hospital discharges, and mortality. Research staff evaluating outcomes were blinded to allocation. Intention-to-treat analyses will include assessment of interactions based on ethnicity (Maori compared with non-Maori). DISCUSSION: If found to be effective, this mobile health strategy has the potential to overcome current barriers to implementing equitably accessible interventions that can reduce harmful drinking. TRIAL REGISTRATION: Universal Trial Number (UTN) U1111-1134-0028. ACTRN12612001220853 . Submitted 8 November 2012 (date of enrolment of first participant); Version 1 registration confirmed 19 November 2012. Retrospectively registered.

Use of the EpiNet database for observational study of status epilepticus in Auckland, New Zealand.

The EpiNet project has been established to facilitate investigator-initiated clinical research in epilepsy, to undertake epidemiological studies, and to simultaneously improve the care of patients who have records created within the EpiNet database. The EpiNet database has recently been adapted to collect detailed information regarding status epilepticus. An incidence study is now underway in Auckland, New Zealand in which the incidence of status epilepticus in the greater Auckland area (population: 1.5 million) will be calculated. The form that has been developed for this study can be used in the future to collect information for randomized controlled trials in status epilepticus. This article is part of a Special Issue entitled "Status Epilepticus".

Why do patients self-present to Middlemore Hospital Emergency Department?

AIM: To determine the drivers for acute (Australasian Triage Scale Category 3-5) demand in patients who self-present to New Zealand's Middlemore Hospital Emergency Department (MMH ED), we sought to establish a demographic profile of a sample of self-presenting patients and explore their reasons for presenting to ED rather than attending a primary care centre. METHOD: A prospective, observational study was undertaken of patients in Australasian Triage Scale Categories 3-5 (ATS 3-5) who self-presented to MMH ED over a 7 day period from 14 April 2011 to 21 April 2011. We studied two time periods, 0900-1200 and 1800-2200, to compare drivers for attendance to MMH ED during primary care service open hours and closed hours. A structured questionnaire was used to collect demographic data and outcomes. The cumulative 2011 demographic data for self-presentations to MMH was compared to the study data. RESULTS: 500 patients were approached to participate and 421 met the inclusion criteria. The mean age of presenters was 37.6 years (SD of 24.6) with 48.2% (95%CI 44-53%) being male and 23% (95%CI 19-27%) employed. Of those who indicated they had a general practitioner (GP), 23% (95%CI 21-30%) had contacted their GP prior to presentation to MMH ED, with 73% (n=73) advised to attend ED. Of the 73 patients told by their GP to attend ED, 30 (41.1%; 95%CI 31-53%) were admitted, with two patients being transferred to another district health board (DHB), and the remainder discharged home. Thirty-two percent of the self-presenting patients came to ED because they felt sick enough to require emergency care. Comparison of the data for the two time periods indicated only one significant difference: 14% of patients presented to ED in the morning because their GP was closed, whereas 28.7% of those who presented after hours did so for this reason. CONCLUSION: Almost 25% of self-presenting patients had contacted their GP or a health professional prior to their ED presentation and were advised to attend ED. The most common reason for patients to self-present at MMH ED is the belief that a hospital emergency department is the appropriate service to treat acute sickness. Neither cost nor knowledge of the Shorter Stays in Emergency Departments Health Target featured as a reason for attendance.

Does cost drive primary care patients to New Zealand's emergency departments? A systematic review.

AIM: The cost of primary care is often stated as a major contributing factor to presentations to New Zealand Emergency Departments. This review sought to determine whether this assumption is supported by the literature. METHODS: A structured search in Medline, hand search of the New Zealand Medical Journal and citation searching was conducted for articles exploring the reasons for presentation to New Zealand Emergency Departments. Articles were screened for relevance and potentially relevant articles, including those in the Grey literature were retrieved for full text review. Included studies were reviewed independently by the authors and data was extracted using a standardised template. Differences were resolved by consensus. RESULTS: There were 485 articles identified, of which 11 were relevant and included. A total of 8463 patients with minor illness or injury were interviewed. Of 5850 patients who were asked a direct question about cost, only 119 patients cited this as a reason for coming to ED (2%, 95%CI 1.7-2.4%). The most common reason for presentation was a belief that the Emergency Department was the most appropriate place to be seen for that problem. CONCLUSION: The cost of primary care is a factor in Emergency Department presentation for only a small minority of patients.

Analysis of junior doctor supervision in Australasian emergency departments.

BACKGROUND: Supervision of junior doctors in ED is vital but limited literature exists on how it is provided. OBJECTIVE: To assess Australasian ED supervision and review regional legislature supervision requirements. METHODS: Between December 2008 and June 2009 emails containing a link to a cross-sectional survey were sent to Directors of Emergency Medicine Training in all Australasian ED accredited for advanced training. Non-responding ED were subsequently contacted by telephone or email. Regional legislature supervision requirements were obtained from postgraduate medical councils. RESULTS: A total of 103 (98.1%) of 105 ED participated. Senior review in person was mandatory in 43.2% of ED for patients of PGY1 (postgraduate year 1 doctors) and 6.1% of ED for patients of PGY2 (P < 0.001). Of ED without mandatory review, 13% had written guidelines detailing which patients required review. When ED consultants were on-site, they most commonly provided supervision in 60.2% of ED and shared supervision equally with registrars in 35.7% of ED; when consultants were off-site registrars most commonly provided supervision in 87.6% of ED. Fewer major regional/rural base hospitals had 24 h PGY3 or above supervision than major referral and urban district hospitals (82.6% vs 100% and 100%, P < 0.01). Regional legislature requirements varied with no universal guidelines. CONCLUSION: There are significant differences between supervision requirements for PGY1 and PGY2. A minority of ED in Australasia do not have 24 h supervision by PGY3 or higher. Few ED have written guidelines for supervising PGY1 and PGY2. The majority of registrar supervision occurs without consultant oversight. Legislature requirements for supervision in ED are variable between regions.

Junior doctor strike model of care: Reduced access block and predominant Fellow of the Australasian College for Emergency Medicine staffing improve emergency department performance.

OBJECTIVE: To describe the response and analyse ED performance during a 5-day junior doctor strike. METHODS: Data were collected via the patient information management computer system. Key performance indicators included percentage seen within maximum waiting times per triage category (TC), ED length of stay, emergency medicine patients who did not wait to be seen, hospital bed occupancy and access block percentage. Comparisons were made for the same 5 days before the strike (BS), during the strike (S) and after the strike. RESULTS: Total doctor's shifts BS were 78.66 with 25% of these shifts being Fellow of the Australasian College for Emergency Medicine (FACEM) shifts. FACEM shifts were more common during the S period at 75% (P < 0.001). Total attendances (BS 631 vs S 596, P = 0.22) and TC percentages (P-values for TC 1, 2, 3, 4, 5, respectively, 1.0, 0.55, 0.88, 0.97, 0.46) in the BS, S and after-the-strike periods were not significantly different. Despite fewer total doctor shifts, the FACEM predominant model of care during the strike resulted in better percentages seen within the maximum waiting times for TC3 (66%), TC4 (78%) and TC5 (86%) (all P < 0.001). There was a reduction in patients who did not wait to be seen (28 BS vs 5 S, P < 0.001), ED length of stay (admissions: BS 451 min vs S 258 min, P < 0.001; discharges: BS 233 min vs S 144 min, P < 0.02) and referrals to inpatient services (P = 0.02). This occurred with reduced bed point occupancy of 66% and a consequent reduction in access block. CONCLUSION: FACEM staffing and reduced access block were significant factors in improved ED performance.

Acute gastroenteritis associated with seafood privately imported from the Pacific Islands.

AIMS: To investigate a potential link between consumption of food privately imported from the Pacific Islands and presentation with acute gastroenteritis to Middlemore Hospital Emergency Department. METHODS: This was a three month prospective observational case study that included patients aged greater than fifteen years presenting with acute gastroenteritis and a history of food privately imported from the Pacific Islands. Data included case demographics, symptoms, island of food origin and food type. Stool and blood samples were collected and analysed. RESULTS: Of 358 patients who presented to Middlemore Emergency Department during the study period with gastroenteritis, 34 (9.4%) had a history of consumption of food privately imported from the Pacific Islands. The seafood came from Tonga (23 cases), Samoa (10 cases) or Niue (1 case). The implicated seafood was shellfish (28 cases), jellyfish (2 cases), fish intestine (2 cases), seaweed or seaslug (1 case each). Fourteen patients (41%) provided stool samples; all were culture positive for Vibrio parahaemolyticus (VPH). CONCLUSIONS: This case series confirms a link between acute VPH gastroenteritis and consumption of seafood privately imported from the Pacific Islands. A number of public health initiatives to reduce the burden of VPH gastroenteritis among Auckland's Pacific Islanders have commenced. The Ministries of Health, Agriculture and Forestry are considering tighter controls or banning food privately imported from the Pacific Islands.