Effect of a waiting room communication strategy on imaging rates and awareness of public health messages for low back pain.

BACKGROUND: Few studies have investigated the effects of waiting room communication strategies on health-care behavior. OBJECTIVE: We aimed to determine the effect of a waiting room communication strategy, designed to raise awareness of potential harms of unnecessary imaging, on lumbar imaging rates in the emergency department (ED). METHODS: We conducted a controlled experimental study with a replicated time series design. The design included a 6-week run-in time. Following this there were alternating 1-week intervention and control periods. The intervention group received a communication strategy describing the potential harms of unnecessary imaging for low back pain, shown on a 55" LCD screen positioned in the ED waiting room. The communication strategy was designed by a creative innovation agency and included five digital posters and a patient leaflet. The control group received standard messaging for the waiting room at the time, shown on the same 55" LCD screen, and access to the patient leaflet. The primary outcome was the number and proportion of people presenting to ED with low back pain who received at least one lumbar imaging test, measured using routinely collected ED data. Secondary patient-reported outcomes (patient satisfaction and awareness of campaign messages) were collected from a sample of people presenting for any condition who responded to a text-message-based survey. RESULTS: For the imaging outcome, 337 people presenting to ED with low back pain were included over a 4-month period (intervention n = 99; control n = 238). All had available data on lumbar imaging. Use of lumbar imaging was 25% in those exposed to the communication strategy [95% confidence interval (CI) = 18% to 35%] compared with 29% in those exposed to the standard waiting room messaging [95% CI = 23% to 35%; odds ratio (OR) = 0.83, 95% CI = 0.49 to 1.41]. For the patient-reported outcomes, 349 patients presenting to ED for any condition responded to the survey (intervention n = 170; control n = 179; response rate = 33%). There was uncertain evidence that the intervention increased awareness of the communication strategy leaflet (OR = 2.00, 95% CI = 0.90 to 4.47). Other measures did not suggest between-group differences in patient satisfaction or awareness of the campaign messages. CONCLUSION: A communication strategy displayed in the ED waiting room may slightly reduce the proportion of patients with low back pain who receive lumbar imaging, although there is uncertainty due to imprecision. The campaign did not appear to increase awareness of campaign messages or affect patient satisfaction in a sample of patients presenting to the ED for any reason. Larger studies should investigate whether simple, low-cost waiting room communication strategies can raise awareness of unnecessary healthcare and influence health-care quality. TRIAL REGISTRATION: ACTRN12620000300976, 05/03/2020.

Paramedic-performed Fascia Iliaca Compartment Block for Femoral Fractures: A Controlled Trial.

BACKGROUND: Femoral (thigh) fractures are an important clinical problem commonly encountered by paramedics. These injuries are painful, and the need for extrication and transport adds complexity to the management of this condition. Whereas traditional analgesia involves parenteral opioids, regional nerve blockade for femoral fractures have been demonstrated to be effective when performed by physicians. Regional peripheral nerve blockade performed by paramedics may be suitable in the prehospital setting. STUDY OBJECTIVES: To examine the efficacy and feasibility of paramedic-performed fascia iliaca compartment block (FICB) for patients with suspected hip or femur fractures in the prehospital setting compared to intravenous morphine alone. METHODS: Prior to treatment allocation, all patients received a loading dose of morphine intravenously, then received either 1) FICB using lidocaine with epinephrine; or 2) standard care (further intravenous morphine only) in this nonblinded, randomized control trial. Participants rated their pain using a standard 11-point verbal numerical rating scale prior to and 15 min after receiving the allocated treatment. Secondary outcomes included effectiveness at other time points and incidence of adverse effects. RESULTS: We analyzed 11 and 13 patients in the FICB and standard care groups, respectively. Patients treated with FICB had a greater reduction in their median pain score than patients in the standard care group (50% vs. 22%, p = 0.025) after 15 min. In the FICB group, median pain scores decreased by 5 (interquartile range 4-6), compared to 2 (interquartile range 0-4) in the standard care group. The FICB procedure did not significantly impact on scene times. No immediately obvious adverse events were noted in the 11 participants who received FICB from paramedics. CONCLUSION: The study suggests that FICB can be performed by trained paramedics for patients with suspected femoral fractures.

Right care, right time, right place: improving outcomes for people with spinal cord injury through early access to intervention and improved access to specialised care: study protocol.

BACKGROUND: Traumatic spinal cord injury is a devastating condition impacting adversely on the health and wellbeing, functioning and independence, social participation and quality of life of the injured person. In Australia, there are approximately 15 new cases per million population per year; economic burden estimates suggest 2 billion dollars annually. For optimal patient outcomes expert consensus recommends expeditious transfer ("<24 hours of injury") to a specialist Spinal Cord Injury Unit, where there is an interdisciplinary team equipped to provide comprehensive care for the many and complex issues associated with traumatic spinal cord injury. No study of this patient population has been undertaken, that assessed the extent to which care received reflected clinical guidelines, or examined the patient journey and outcomes in relation to this. The aims of this study are to describe the nature and timing of events occurring before commencement of specialist care, and to quantify the association between these events and patient outcomes. METHODS AND DESIGN: The proposed observational study will recruit a prospective cohort over two years, identified at participating sites across two Australian states; Victoria and New South Wales. Included participants will be aged 16 years and older and diagnosed with a traumatic spinal cord injury. Detailed data will be collected from the point of injury through acute care and subacute rehabilitation, discharge from hospital and community reintegration. Items will include date, time, location and external cause of injury; ambulance response, assessments and management; all episodes of hospital care including assessments, vital signs, diagnoses and treatment, inter-hospital transfers, surgical interventions and their timing, lengths of stay and complications. Telephone follow-up of survivors will be conducted at 6, 12 and 24 months. DISCUSSION: There is limited population level data on the effect of delayed commencement of specialist care (>24 hours) in a Spinal Cord Injury Unit. Examining current health service and clinical intervention pathways in this Australian population-based sample, in relation to their outcomes, will provide an understanding of factors associated with patient flow, resource utilisation and cost, and patient and family quality of life. Barriers to streamlined effective early-care pathways and facilitators of optimal treatment for these patients will be identified.

Management and outcomes with 5-year mortality of patients with mildly elevated high-sensitivity troponin T levels not meeting criteria for myocardial infarction.

OBJECTIVES: To examine management and outcomes of patients presenting to EDs with symptoms suggestive of acute coronary syndrome, who have mild non-dynamically elevated high-sensitivity troponin T (HsTnT) levels, not meeting the fourth universal definition of myocardial infarction (MI) criteria (observation group). METHODS: Consecutive patients presenting to the ED with symptoms suggestive of acute coronary syndrome at Liverpool Hospital, Sydney, Australia, those having ≥2 HsTnT levels after initial assessment were adjudicated according to the fourth universal definition of MI, as MI ruled-in, MI ruled-out, or myocardial injury in whom MI is neither ruled-in nor ruled-out (>1 level ≥15 ng/L, called observation group); follow-up was 5 years. RESULTS: Of 2738 patients, 547 were in the observation group, of whom 62% were admitted to hospital, 52% to cardiac services, whereas 97% of MI ruled-in patients and 21% of MI ruled-out patients were admitted; P < 0.001. Non-invasive testing occurred in 42% of observation group patients (36% had echo-cardiography), and 16% had coronary angiography. Of observation group patients, MI rates were 1.5% during hospitalisation and 4% during the following year, similar to that in those with MI ruled-in, among those with MI ruled-out, the MI rate was 0.2%. The 1-year death rate was 13% among observation group patients and 11% MI ruled-in patients (P = 0.624), whereas at 5 years among observation group patients, type 1 MI and type 2 MI were 48%, 26% and 58%, respectively (P = 0.001). CONCLUSION: Very few unselected consecutive patients attending ED, with minor stable HsTnT elevation, had MI, although most had chronic myocardial injury. Late mortality rates among observation group patients were higher than those with confirmed type 1 MI but lower than those with type 2 MI.

Bystander cardiopulmonary resuscitation differences by sex - The role of arrest recognition.

PURPOSE: To assess whether bystander cardiopulmonary resuscitation (CPR) differed by patient sex among bystander-witnessed out-of-hospital cardiac arrests (OHCA). METHODS: This study is a retrospective analysis of paramedic-attended OHCA in New South Wales (NSW) between January 2017 to December 2019 (restricted to bystander-witnessed cases). Exclusions included OHCA in aged care, medical facilities, with advance care directives, from non-medical causes. Multivariate logistic regression examined the association of patient sex with bystander CPR. Secondary outcomes were OHCA recognition, bystander AED application, initial shockable rhythm, and survival outcomes. RESULTS: Of 4,491cases, females were less likely to receive bystander CPR in private residential (Adjusted Odds ratio [AOR]: 0.82, 95%CI: 0.70-0.95) and public locations (AOR: 0.58, 95%CI:0.39-0.88). OHCA recognition during the emergency call was lower for females arresting in public locations (84.6% vs 91.6%, p = 0.002) and this partially explained the association of sex with bystander CPR (∼44%). This difference in recognition was not observed in private residential locations (p = 0.2). Bystander AED use was lower for females (4.8% vs 9.6%, p < 0.001); however, after adjustment for location and other covariates, this relationship was no longer significant (AOR: 0.83, 95%CI: 0.60-1.12). Females were less likely to be in an initial shockable rhythm (AOR: 0.52, 95%CI: 0.44-0.61), but more likely to survive the event (AOR: 1.34, 95%CI: 1.15-1.56). There was no sex difference in survival to hospital discharge (AOR: 0.96, 95%CI: 0.77-1.19). CONCLUSION: OHCA recognition and bystander CPR differ by patient sex in NSW. Research is needed to understand why this difference occurs and to raise public awareness of this issue.

Behavioural 'nudging' interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial.

INTRODUCTION: Opioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and two in three will receive an opioid. NUDG-ED aims to determine the effectiveness of two different behavioural 'nudge' interventions on low-value care for ED patients with low back pain. METHODS AND ANALYSIS: NUDG-ED is a 2×2 factorial, open-label, before-after, cluster randomised controlled trial. The trial includes 8 ED sites in Sydney, Australia. Participants will be ED clinicians who manage back pain, and patients who are 18 years or over presenting to ED with musculoskeletal back pain. EDs will be randomly assigned to receive (i) patient nudges, (ii) clinician nudges, (iii) both interventions or (iv) no nudge control. The primary outcome will be the proportion of encounters in ED for musculoskeletal back pain where a person received a non-indicated lumbar imaging test, an opioid at discharge or both. We will require 2416 encounters over a 9-month study period (3-month before period and 6-month after period) to detect an absolute difference of 10% in use of low-value care due to either nudge, with 80% power, alpha set at 0.05 and assuming an intra-class correlation coefficient of 0.10, and an intraperiod correlation of 0.09. Patient-reported outcome measures will be collected in a subsample of patients (n≥456) 1 week after their initial ED visit. To estimate effects, we will use a multilevel regression model, with a random effect for cluster and patient, a fixed effect indicating the group assignment of each cluster and a fixed effect of time. ETHICS AND DISSEMINATION: This study has ethical approval from Southwestern Sydney Local Health District Human Research Ethics Committee (2023/ETH00472). We will disseminate the results of this trial via media, presenting at conferences and scientific publications. TRIAL REGISTRATION NUMBER: ACTRN12623001000695.

Estimation of cardiac output and systemic vascular resistance using a multivariate regression model with features selected from the finger photoplethysmogram and routine cardiovascular measurements.

BACKGROUND: Cardiac output (CO) and systemic vascular resistance (SVR) are two important parameters of the cardiovascular system. The ability to measure these parameters continuously and noninvasively may assist in diagnosing and monitoring patients with suspected cardiovascular diseases, or other critical illnesses. In this study, a method is proposed to estimate both the CO and SVR of a heterogeneous cohort of intensive care unit patients (N=48). METHODS: Spectral and morphological features were extracted from the finger photoplethysmogram, and added to heart rate and mean arterial pressure as input features to a multivariate regression model to estimate CO and SVR. A stepwise feature search algorithm was employed to select statistically significant features. Leave-one-out cross validation was used to assess the generalized model performance. The degree of agreement between the estimation method and the gold standard was assessed using Bland-Altman analysis. RESULTS: The Bland-Altman bias ±precision (1.96 times standard deviation) for CO was -0.01 ±2.70 L min-1 when only photoplethysmogram (PPG) features were used, and for SVR was -0.87 ±412 dyn.s.cm-5 when only one PPG variability feature was used. CONCLUSIONS: These promising results indicate the feasibility of using the method described as a non-invasive preliminary diagnostic tool in supervised or unsupervised clinical settings.

What causes adverse events in prehospital care? A human-factors approach.

BACKGROUND: The last decade has seen a vast amount of work directed at the investigation of patient harm events. Unfortunately, little of it has pertained to prehospital care and as such, risk remains unquantified and poorly understood in this setting. We hypothesised that adverse patient events occurring during the prehospital phase may fall into discernible patterns, and that an understanding of these patterns would be valuable in the development of mitigation strategies. METHODS: A survey tool was developed with reference to the human factors literature. Paramedics in a large Australian ambulance service were asked to recall an adverse event and to nominate factors that may have contributed to its occurrence. Responses were analysed using principal components analysis in order to identify contributory factors that could be statistically grouped together in meaningful patterns. RESULTS: The survey yielded 370 responses. Eight key single contributors and 14 groups of contributory factors were identified. Of the groups, only two were strongly associated with serious patient outcomes, such as reported significant deterioration or death. CONCLUSIONS: The deteriorating patient was identified as the leading single contributor to prehospital adverse events, and two perfect storm patient harm scenarios were found to contribute materially to adverse outcomes. This approach to identifying both single factors contributing to an incident and factors which could be grouped together in a pattern, appears useful in delineating risk in the acute prehospital setting, and warrants further exploration in this and other areas of patient safety.

Examining the Feasibility of Implementing Digital Mental Health Innovations Into Hospitals to Support Youth in Suicide Crisis: Interview Study With Young People and Health Professionals.

BACKGROUND: Hospitals are insufficiently resourced to appropriately support young people who present with suicidal crises. Digital mental health innovations have the potential to provide cost-effective models of care to address this service gap and improve care experiences for young people. However, little is currently known about whether digital innovations are feasible to integrate into complex hospital settings or how they should be introduced for sustainability. OBJECTIVE: This qualitative study explored the potential benefits, barriers, and collective action required for integrating digital therapeutics for the management of suicidal distress in youth into routine hospital practice. Addressing these knowledge gaps is a critical first step in designing digital innovations and implementation strategies that enable uptake and integration. METHODS: We conducted a series of semistructured interviews with young people who had presented to an Australian hospital for a suicide crisis in the previous 12 months and hospital staff who interacted with these young people. Participants were recruited from the community nationally via social media advertisements on the web. Interviews were conducted individually, and participants were reimbursed for their time. Using the Normalization Process Theory framework, we developed an interview guide to clarify the processes and conditions that influence whether and how an innovation becomes part of routine practice in complex health systems. RESULTS: Analysis of 29 interviews (n=17, 59% young people and n=12, 41% hospital staff) yielded 4 themes that were mapped onto 3 Normalization Process Theory constructs related to coherence building, cognitive participation, and collective action. Overall, digital innovations were seen as a beneficial complement to but not a substitute for in-person clinical services. The timing of delivery was important, with the agreement that digital therapeutics could be provided to patients while they were waiting to be assessed or shortly before discharge. Staff training to increase digital literacy was considered key to implementation, but there were mixed views on the level of staff assistance needed to support young people in engaging with digital innovations. Improving access to technological devices and internet connectivity, increasing staff motivation to facilitate the use of the digital therapeutic, and allowing patients autonomy over the use of the digital therapeutic were identified as other factors critical to integration. CONCLUSIONS: Integrating digital innovations into current models of patient care for young people presenting to hospital in acute suicide crises is challenging because of several existing resource, logistical, and technical barriers. Scoping the appropriateness of new innovations with relevant key stakeholders as early as possible in the development process should be prioritized as the best opportunity to preemptively identify and address barriers to implementation.

Examining training and attitudes to basic life support in multi-ethnic communities residing in New South Wales, Australia: A mixed-methods investigation.

BACKGROUND: Bystander response, including cardiopulmonary resuscitation (CPR), is critical to out-of-hospital cardiac arrest (OHCA) survival. Nearly 30% of Australian residents were born overseas, and little is known about their preparedness to perform CPR. In this mixed-methods study, we examined rates of training and willingness and barriers to performing CPR among immigrants in Australia. METHODS: First, we surveyed residents in New South Wales, Australia, using purposeful sampling to enrich immigrant populations. Multivariate logistic regression was used to examine the association between place of birth and willingness to perform CPR. Next, we conducted focus-group discussions with members of the region's largest migrant groups to explore barriers and relevant societal or cultural factors. RESULTS: Of the 1267 survey participants (average age 49.6 years, 52% female), 60% were born outside Australia, most in Asia and 73% had lived in Australia for more than 10 years. Higher rates of previous CPR training were reported among Australian-born participants compared with South Asian-born and East Asian-born (77%, 35%, 48%, respectively, p <0.001). In adjusted models, the odds of willingness to perform CPR on a stranger were significantly lower among migrants than Australian-born (adjusted OR: 0.64; 95% CI 0.49 to 0.83); however, this association was mediated by history of training. Themes emerging from the focus-group discussions included concerns about causing harm, fear of liability, and birthplace-specific social and cultural barriers. CONCLUSIONS: Targeted awareness and training interventions, which address common and culture-specific barriers to response and improved access to training, may improve confidence and willingness to respond to OHCA in multi-ethnic communities.

Spontaneous fluctuations in the peripheral photoplethysmographic waveform: roles of arterial pressure and muscle sympathetic nerve activity.

Assessment of spontaneous slow waves in the peripheral blood volume using the photoplethysmogram (PPG) has shown potential clinical value, but the physiological correlates of these fluctuations have not been fully elucidated. This study addressed the contribution of arterial pressure and muscle sympathetic nerve activity (MSNA) in beat-to-beat PPG variability in resting humans under spontaneous breathing conditions. Peripheral PPG waveforms were measured from the fingertip, earlobe, and toe in young and healthy individuals (n = 13), together with the arterial pressure waveform, electrocardiogram, respiration, and direct measurement of MSNA by microneurography. Cross-spectral coherence analysis revealed that among the PPG waveforms, low-frequency fluctuations (0.04-0.15 Hz) in the ear PPG had the highest coherence with arterial pressure (0.71 ± 0.15) and MSNA (0.44 ± 0.18, with a peak of 0.71 ± 0.16 at 0.10 ± 0.03 Hz). The normalized midfrequency powers (0.08-0.15 Hz), with an emphasis on the 0.1-Hz region, were positively correlated between MSNA and the ear PPG (r = 0.77, P = 0.002). Finger and toe PPGs had lower coherence with arterial pressure (0.35 ± 0.10 and 0.30 ± 0.11, respectively) and MSNA (0.33 ± 0.10 and 0.26 ± 0.10, respectively) in the LF band but displayed higher coherence between themselves (0.54 ± 0.09) compared with the ear (P < 0.001), which may suggest the dominance of regional vasomotor activities and a common sympathetic influence in the glabrous skin. These findings highlight the differential mechanisms governing PPG waveform fluctuations across different body sites. Spontaneous PPG variability in the ear includes a major contribution from arterial pressure and MSNA, which may provide a rationale for its clinical utility.

The methodology of the Australian Prehospital Outcomes Study of Longitudinal Epidemiology (APOStLE) Project.

This paper describes the methodology of a large emergency medical services (EMS) data linkage research project currently under way in the statewide EMS system of New South Wales, Australia. The paper is intended to provide the reader with an understanding of how linkage techniques can be used to facilitate EMS research. This project, the Australian Prehospital Outcomes Study of Longitudinal Epidemiology (APOStLE) Project, links data from six statewide sources (computer-assisted dispatch, EMS patient health care reports, emergency department data, inpatient data, and two death registries) to enable researchers to examine the patient's entire journey through the health care system, from the emergency 0-0-0 call to the emergency department and inpatient setting, through to discharge or death, for approximately 2.6 million patients transported by the Ambulance Service of New South Wales to emergency departments between June 2006 and July 2009. Manual, deterministic, and probabilistic data linkages are described, and potential applications of linked data in EMS research are outlined.

Paramedic-performed digital nerve block to facilitate field reduction of a dislocated finger.

This short report describes the use of digital nerve block by a paramedic to facilitate the reduction of a dislocated finger in the prehospital setting. The finger was successfully reduced at the scene without requiring administration of parenteral opioids. The patient was reluctant to visit an emergency department, but was able to be referred to a local primary care practice for postreduction imaging and further care. Paramedic-performed local and regional anesthesia has not been previously described in the emergency medicine or emergency medical services literature. With appropriate training, prehospital digital nerve blocks may be a feasible option to supplement existing paramedic analgesic options.

Do clinical safety charts improve paramedic key performance indicator results? (A clinical improvement programme evaluation).

INTRODUCTION: Is the Clinical Safety Chart clinical improvement programme (CIP) effective at improving paramedic key performance indicator (KPI) results within the Ambulance Service of New South Wales? METHODS: The CIP intervention area was compared with the non-intervention area in order to determine whether there was a statistically significant improvement in KPI results. RESULTS: The CIP was associated with a statistically significant improvement in paramedic KPI results within the intervention area. CONCLUSIONS: The strategies used within this CIP are recommended for further consideration.

Characteristics, clinical findings and outcomes of acute aortic dissection: A comparison between an Australian emergency department and the International Registry of Acute Aortic Dissection.

OBJECTIVES: Acute aortic dissection (AAD) is a rare, life-threatening condition for which the International Registry of Acute Aortic Dissection (IRAD) remains the most detailed clinical resource. The present study compared the characteristics, clinical findings and outcomes of patients presenting to Liverpool Hospital, NSW, Australia (LPOOL) with AAD to those in IRAD. Secondary aims were to identify LPOOL patient variables associated with 30-day mortality and to assess the impact of transfer times in the ED on 30-day mortality. METHODS: Retrospective observational study of patients presenting to LPOOL with AAD between 2011 and 2019. Clinical records were examined and compared with IRAD data. Variables in LPOOL associated (P < 0.10) with 30-day mortality by univariable analysis were subsequently entered in a multivariable logistic regression to identify independent predictors. Mediation analysis was performed to assess the impact of ED transfer times on 30-day mortality. RESULTS: The characteristics, clinical findings and outcomes of 156 LPOOL patients were overall similar to those in IRAD. Syncope, weakness or paralysis, raised lactate and chest X-ray abnormalities were identified as independent predictors of 30-day mortality. Time from ED to ICU explained 28% of the variance in survival at 30 days. CONCLUSIONS: The characteristics, clinical features and outcomes of patients with AAD presenting to LPOOL appeared similar to those reported by IRAD. The identification of independent mortality predictors serves to improve the understanding of local AAD presentations. Reducing ED to ICU transfer times may increase 30-day survival and further interdisciplinary research should be considered.

Prospective, multicentre observational study of point-of-care ultrasound practice in emergency departments across Australia and New Zealand: The POCUS-ED Registry.

OBJECTIVES: The present study aimed to describe the characteristics, performance, accuracy and significance of point-of-care ultrasound (POCUS) use in the ED, by utilising an expanded version of the ACEM-mandated special skills placement (SSP) logbook, to develop a novel clinical quality registry. METHODS: A prospective, observational study was performed across EDs in Australia and New Zealand over a 12-month period. Trainees undertaking ACEM-approved ultrasound (US) SSPs recorded all US scan interpretations and follow-up imaging reports in an online database. RESULTS: In total, 2647 USs were recorded by 26 special skills trainees across 10 EDs in Australia or New Zealand; of these 2356 scans (89%) were clinically indicated. Overall, 2493 scans (94%) were used for diagnostic assessment, of which 1147 (43%) had abnormal findings. Basic echocardiography, extended Focused Assessment with Sonography in Trauma and right upper quadrant scans were the most commonly used modalities. There were 134 US-guided procedures logged in the registry. Approximately 36% of scans were reported to alter the original provisional diagnosis, whereas in another 37% of cases, POCUS was thought to confirm the original clinical suspicion. The majority of scans (76.5%) entered into the registry were physically reviewed by the SSP supervisor. CONCLUSIONS: This multicentred registry provides a detailed description of the current utilisation of POCUS within special skills US placements across EDs in Australia and New Zealand. This data should inform clinical leaders in emergency US to improve both POCUS education and governance around this important tool.

Video head impulse testing to differentiate vestibular neuritis from posterior circulation stroke in the emergency department: a prospective observational study.

Background and aims: Vertigo is a common presentation to the emergency department (ED) with 5% of presentations due to posterior circulation stroke (PCS). Bedside investigations such as the head impulse test (HIT) are used to risk stratify patients, but interpretation is operator dependent. The video HIT (v-HIT) provides objective measurement of the vestibular-ocular-reflex (VOR) and may improve diagnostic accuracy in acute vestibular syndrome (AVS). We aimed to evaluate the use of v-HIT as an adjunct to clinical assessment to acutely differentiate vestibular neuritis (VN) from PCS. Methods: 133 patients with AVS were consecutively enrolled from the ED of our comprehensive stroke centre between 2018 and 2021. Patient assessment included a targeted vestibular history, HINTs examination (Head Impulse, Nystagmus and Test of Skew), v-HIT and MRI>48 hours after symptom onset. The HINTS/v-HIT findings were analysed and compared between VN, PCS and other cause AVS. Clinical course, v-HIT and MRI findings were used to determine diagnosis. Results: Final diagnosis was VN in 40%, PCS 15%, migraine 16% and other cause AVS 29%. PCS patients were older than VN patients (mean age 68.5±10.6 vs 60.1±14.2 years, p=0.14) and had more cardiovascular risk factors (3 vs 2, p=0.002). Mean VOR gain was reduced (<0.8) in ipsilateral horizontal and (<0.7) anterior canals in VN but was normal in PCS, migraine and other cause AVS. V-HIT combined with HINTs was 89% sensitive and 96% specific for a diagnosis of VN. Conclusions V-HIT combined with HINTs is a reliable tool to exclude PCS in the ED.

Diagnoses and trends in use of imaging for low back pain in four Australian emergency departments between 2012 and 2019.

OBJECTIVE: We aimed to determine, in those who present to the ED with low back pain (LBP): (i) the prevalence of four key diagnostic categories, (ii) trends in lumbar imaging from 2015 to 2019 and (iii) the effect of a new model of care on lumbar imaging in the ED. METHODS: We conducted a retrospective analysis of routinely collected medical data of four tertiary hospitals in Sydney, Australia. We analysed ED presentations for LBP between January 2012 and October 2019. Outcomes were the prevalence of four key diagnostic categories of LBP and use of lumbar imaging. We examined trends in lumbar imaging over time and used interrupted time series analysis to determine the impact of model of care implementation on imaging use. RESULTS: There were 31 168 presentations for LBP of which 64.5% were non-specific LBP, 27.2% were problems beyond the spine, 5.3% were LBP with neurological signs and 2.3% were serious spinal conditions. 28.9% received lumbar imaging; use did not change substantially between 2012 and 2019. Patients diagnosed with serious spinal conditions were more likely to receive imaging (59%) than those diagnosed with non-specific LBP (29%). Implementation of a state-wide model of care in November 2016 did not appear to influence imaging use. CONCLUSION: Most presentations to the ED for LBP are for non-specific LBP. Around 2% will have specific spinal pathology. Use of imaging in those diagnosed with non-specific LBP remains high and was unaffected by implementation of a state-wide model of care.

Improving community-based first response to out of hospital cardiac arrest (FirstCPR): protocol for a cluster randomised controlled trial.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) is associated with poor survival outcomes, but prompt bystander action can more than double survival rates. Being trained, confident and willing-to-perform cardiopulmonary resuscitation (CPR) are known predictors of bystander action. This study aims to assess the effectiveness of a community organisation targeted multicomponent education and training initiative on being willing to respond to OHCAs. The study employs a novel approach to reaching community members via social and cultural groups, and the intervention aims to address commonly cited barriers to training including lack of availability, time and costs. METHODS AND ANALYSIS: FirstCPR is a cluster randomised trial that will be conducted across 200 community groups in urban and regional Australia. It will target community groups where CPR training is not usual. Community groups (clusters) will be stratified by region, size and organisation type, and then randomly assigned to either immediately receive the intervention programme, comprising digital and in-person education and training opportunities about CPR and OHCA over 12 months, or a delayed programme implementation. The primary outcome is self-reported 'training and willingness-to-perform CPR' at 12 months. It will be assessed through surveys of group members that consent in intervention versus control groups and administered prior to control groups receiving the intervention. The primary analysis will follow intention-to-treat principles, use log binomial regression accounting for baseline covariates and be conducted at the individual level, while accounting for clustering within communities. Focus groups and interviews will be conducted to examine barriers and enablers to implementation and costs will also be examined. ETHICS AND DISSEMINATION: Ethical approval was obtained from The University of Sydney. Findings from this study will be disseminated via presentations at scientific conferences, publications in peer-reviewed journals, scientific and lay reports. TRIAL REGISTRATION NUMBER: ACTRN12621000367842.

The Emergency Medicine Education and Research by Global Experts (EMERGE) Network: Challenges and Lessons Learned.

INTRODUCTION: The Emergency Medicine Education and Research by Global Experts (EMERGE) network was formed to generate and translate evidence to improve global emergency care. We share the challenges faced and lessons learned in establishing a global research network. METHODS: We describe the challenges encountered when EMERGE proposed the development of a global emergency department (ED) visit registry. The proposed registry was to be a six-month, retrospective, deidentified, minimal dataset of routinely collected variables, such as patient demographics, diagnosis, and disposition. RESULTS: Obtaining reliable, accurate, and pertinent data from participating EDs is challenging in a global context. Barriers experienced ranged from variable taxonomies, need for language translation, varying site processes for curation and transfer of deidentified data, navigating institution- and country-specific data protection regulations, and substantial variation in each participating institution's research infrastructure including training in research-related activities. We have overcome many of these challenges by creating detailed data-sharing agreements with bilateral regulatory oversight agreements between EMERGE and participating EDs, developing relationships with and training health informaticians at each site to ensure secure transfer of deidentified data, and formalizing an electronic transfer process ensuring data privacy. CONCLUSION: We believe that networks like EMERGE are integral to providing the necessary platforms for education, training, and research collaborations for emergency care. We identified substantial challenges in data sharing and variation in local sites' research infrastructure and propose potential approaches to address these challenges.