The Buddy Study: Local reach, adoption and implementation following a randomised controlled trial of conservative management of fifth metacarpal neck fractures.

OBJECTIVE: To understand the reach, adoption and implementation of the evidence that buddy strapping for uncomplicated fifth metacarpal neck fractures is non-inferior to plaster casting. METHODS: Mixed-method study using clinical audit of the years before and after the original randomised controlled study was published (2019) and staff questionnaires/semi-structured interviews. RESULTS: Sixty-nine percent of questionnaire respondents were aware of the original study findings (i.e. reach) and 57% had adopted the research findings. The proportion of patients receiving buddy strapping was 6% in 2014-2016 and 28% in 2019-2021 (implementation). Qualitative data provided insight into ongoing barriers to adoption and implementation including fear of reprisal, the need for permission, opinions of senior decision makers, perceptions about patient preferences, and an overall tendency to 'play it safe'. CONCLUSIONS: Even in a department where primary research is conducted, implementation requires ongoing attention to factors impacting reach and adoption.

Intubation for patients with overdose: Time to move on from the Glasgow Coma Scale.

Patients frequently present to the ED with drug overdose and reduced conscious level leading to coma. There is considerable practice variation around which patients require intubation. Indications include: (i) respiratory failure (including airway obstruction); (ii) to facilitate specific therapies or intubation as a therapy in itself; and (iii) for airway protection in the unprotected airway. We argue that intubating a patient purely for (iii) is outdated and that most patients can be safely observed. There is a paucity of good quality research in the area of drug overdose with reduced consciousness. Teaching may be outdated and based on the use of the Glasgow Coma Scale in head trauma. Current low quality research suggests observation is safe. We recommend that patients undergo an individualised risk assessment of the need for intubation. We propose a flow diagram to aid clinicians in safely observing comatose overdose patients. This can be applied if the drug is unknown, or there are multiple drugs involved.

Safety of rapid sequence intubation in an emergency training network.

OBJECTIVE: Rapid sequence intubation (RSI) is a core critical care skill. Emergency medicine trainees are exposed to relatively low numbers of RSIs. We aimed to improve patient outcomes by implementing an RSI checklist, electronic learning and audit, in line with current best evidence. METHODS: Prospective observational study of RSIs performed in the EDs of two Queensland hospitals between January 2014 and December 2016. Data collected included: first-pass success (FPS), predicted difficulty, indication for intubation, drugs used, positioning, number of attempts, checklist use and complications. Descriptive statistics and multivariable modelling were used to describe differences in FPS, and complications. RESULTS: Six hundred and fifty-five patients underwent RSI with FPS of 86.6%. Complications were reported in 15.9%, mainly hypotension (10.9%) and desaturation (4.0%). FPS improved with bougie use (88.9% vs 73.0% without bougie, P < 0.001) and video-laryngoscopy (88.2% vs 72.9% using standard laryngoscopy, P < 0.001). New desaturation was reduced with apnoeic oxygenation (2.0% vs 22.2%, P < 0.001), bougie use (2.8% vs 8.9%, P < 0.001), checklist use (2.3% vs 22.7%, P < 0.001) and achieving FPS (2.1% vs 16.3%, P < 0.001). Complications were reduced with checklist use (13.3% vs 43.2%, P < 0.001) and apnoeic oxygenation use (3.9% vs 31.1%, P < 0.001). Logistic regression found checklist use was associated with reduced desaturation (OR 0.1, 95% CI 0.04-0.27) and the composite variable of any complication (OR 0.39, 95% CI 0.17-0.89). CONCLUSIONS: Implementation of an evidence-based care bundle and audit of practice has created a safe environment for trainees to learn the core critical care skill of RSI. In our setting, checklist use was associated with fewer complications.