Triaging older major trauma patients in the emergency department: an observational study.

BACKGROUND: The objective of this study was to compare the triage category assigned to older trauma patients with younger trauma patients upon arrival to the emergency department. The focus was to examine whether older major trauma patients were less likely to be assigned an emergency triage category on arrival to the emergency department after controlling for relevant demographics, injury characteristics and injury severity. METHODS: This was an observational study using data from the Queensland Trauma Registry. All trauma patients aged 15 years and older who presented to contributing hospitals between 1 January 2005 and 31 December 2009 with an Injury Severity Score (ISS)>15 were included. Logistic regression analysis examined the odds of assignment to emergency (Australasian Triage Scale (ATS) 1 or 2) versus urgent (ATS 3-5) treatment for patients across various age categories after adjustment for relevant demographics, injury characteristics and injury severity. RESULTS: The study used data on 6923 patients with a median (IQR) age of 43 (26-62) years and a mortality of 11.4% (95% CI 10.7% to 12.2%). Compared with individuals aged 15-34, the adjusted odds of being assigned an ATS category 1 or 2 were 30% lower (OR=0.68, 95% CI 0.57 to 0.81) for individuals aged 55-75 years and were 50% lower (OR=0.46, 95% CI 0.37 to 0.56) for individuals aged 75 years or older. CONCLUSIONS: Among patients with an ISS>15, older major trauma patients were less likely to be assigned an emergency triage category compared with younger patients. This suggests that the elderly may be undertriaged and provides a potential area of study for reducing mortality and morbidity in older trauma patients.

Interventions targeting the elderly population to reduce emergency department utilisation: a literature review.

OBJECTIVE: High utilisation of emergency department (ED) among the elderly is of worldwide concern. This study aims to review the effectiveness of interventions targeting the elderly population in reducing ED utilisation. METHODS: Major biomedical databases were searched for relevant studies. Qualitative approach was applied to derive common themes in the myriad interventions and to critically assess the variations influencing interventions' effectiveness. Quality of studies was appraised using the Effective Public Health Practice Project (EPPHP) tool. RESULTS: 36 studies were included. Nine of 16 community-based interventions reported significant reductions in ED utilisation. Five of 20 hospital-based interventions proved effective while another four demonstrated failure. Seven key elements were identified. Ten of 14 interventions associated with significant reduction on ED use integrated at least three of the seven elements. All four interventions with significant negative results lacked five or more of the seven elements. Some key elements including multidisciplinary team, integrated primary care and social care often existed in effective interventions, while were absent in all significantly ineffective ones. CONCLUSIONS: The investigated interventions have mixed effectiveness. Our findings suggest the hospital-based interventions have relatively poorer effects, and should be better connected to the community-based strategies. Interventions seem to achieve the most success with integration of multi-layered elements, especially when incorporating key elements such as a nurse-led multidisciplinary team, integrated social care, and strong linkages to the longer-term primary and community care. Notwithstanding limitations in generalising the findings, this review builds on the growing body of evidence in this particular area.

Local trends in emergency department attendances by older patients in an ageing national population.

Nursing-led aged care services were set up at our Emergency Department (ED) in 2004-05 to assist in the appropriate discharge of older patients. This study examined local trends in ED attendances by older patients. A retrospective study was conducted at an inner-city adult ED in a region with a 2.2% annual growth rate. Patient demographics, Australasian Triage Scale (ATS) category and admission/discharge status were collected from January 2002 to December 2006. Total ED attendances increased 7.7% from 66 687 in 2002 to 71 801 in 2006. Older patients' attendances, however, decreased 3.1% from 12 356 to 11 971. This decrease in ED attendances by older patients was unexpected. This may represent local population trends and/or be related to ED services designed to manage older patients and nursing home residents in the community. The planning of health services for older people therefore needs to take into consideration the influences on local trends in changing population demographics.

Improvement in the accuracy of references in the journal Emergency Medicine Australasia.

OBJECTIVE: To study any change in reference accuracy in the Australasian emergency medicine journal (now known as Emergency Medicine Australasia), in the 10 years since a previous analysis was undertaken. METHOD: A sample of 100 randomly selected references was compared with the results from the previous analysis. RESULTS: There was a significant reduction in the number of citations with errors and in the total number of errors. CONCLUSION: This paper demonstrates a significant improvement in the accuracy of references in the journal Emergency Medicine Australasia over the past decade. This paper did not identify the reasons for this improvement, but potential causes might include the introduction of a web-based peer review and manuscript submission process, as well as improved reference bibliography systems by authors. In addition, an increase in the overall standard of paper submitted to the journal might have contributed to this improvement.

Palliative care in the emergency department: an oxymoron or just good medicine?

In 2006, the American Board of Emergency Medicine co-sponsored hospice and palliative medicine as a recognized medical subspecialty. There is recognition of the need for these skills to be available in EDs in the USA. This article discusses the rationale for integrating a palliative approach in the ED. We need to engage our palliative care colleagues to increase clinical support to meet the needs of these vulnerable patients and to foster collaborative educational opportunities.

Review article: Part two: Goal-directed resuscitation--which goals? Perfusion targets.

Haemodynamic targets, such as cardiac output, mean arterial blood pressure and central venous oxygen saturations, remain crude predictors of tissue perfusion and oxygen supply at a cellular level. Shocked patients may appear adequately resuscitated based on normalization of global vital signs, yet they are still experiencing occult hypoperfusion. If targeted resuscitation is employed, appropriate use of end-points is critical. In this review, we consider the value of directing resuscitation at the microcirculation or cellular level. Current technologies available include sublingual capnometry, video microscopy of the microcirculation and near-infrared spectroscopy providing a measure of tissue oxygenation, whereas base deficit and lactate potentially provide a surrogate measure of the adequacy of global perfusion. The methodology and evidence for these technologies guiding resuscitation are considered in this narrative review.

Review article: Part one: Goal-directed resuscitation--which goals? Haemodynamic targets.

The use of appropriate resuscitation targets or end-points may facilitate early detection and appropriate management of shock. There is a fine balance between oxygen delivery and consumption, and when this is perturbed, an oxygen debt is generated. In this narrative review, we explore the value of global haemodynamic resuscitation end-points, including pulse rate, blood pressure, central venous pressure and mixed/central venous oxygen saturations. The evidence supporting the reliability of these parameters as end-points for guiding resuscitation and their potential limitations are evaluated.

Emergency medicine and futile care: Taking the road less travelled.

Debate around medical futility has produced a vast literature that continues to grow. Largely absent from the broader literature is the role of emergency medicine in either starting measures that prove to be futile, withholding treatment or starting the end of life communication process with patients and families. In this discussion we review the status of the futility debate in general, identify some of the perceived barriers in managing futile care in the ED including the ethical and legal issues, and establish the contribution of emergency medicine in this important debate. We conclude that emergency physicians have the clinical ability and the legal and moral standing to resist providing futile treatment. In these situations they can take a different path that focuses on comfort care thereby initiating the process of the much sought after 'good death'.

Exercise-associated hyponatraemia on the Kokoda Trail.

OBJECTIVE: The objective of the present study was to determine the prevalence of exercise-associated hyponatraemia in hikers/trekkers along the Kokoda Trail. METHODS: This was a cross-sectional study of 191 trekkers on the Kokoda Trail, Papua New Guinea. Blood was taken and analysed immediately using point-of-care technology 2 days walk from each end of the Trail. RESULTS: The main outcome measure was hyponatraemia defined as serum sodium level less than 135 mmol/L. Three participants (1.6%, 95% CI 0.5-4.5%) were found to have mild hyponatraemia. The hyponatraemic group had a median estimated fluid intake on the day of testing that was almost double that of the normal sodium group (6 L vs 3.3 L). CONCLUSION: Exercise-associated hyponatraemia occurs in trekkers on the Kokoda Trail. Strategies for prevention of exercise-associated hyponatraemia should be delivered to trekkers via the trekking companies, chiefly focussing on only drinking in response to thirst.