EMA December 2013

Issue 6 (Vol. 25) of Emergency Medicine Australasia published online on 6 December 2013

True burden of GP patients in ED (#FOAMed) National reporting of inaccurate estimates of GP-type patients in ED, giving the impression that EDs are over-run with these types of patients, has led to misguided and wasteful initiatives that fail to address overcrowding. This editorial from Nagree and colleagues argues that a modification of ACEM’s method for estimating GP-type patients in ED, based on the number of discharged patients with ATS 4 or 5 and consultation time of 15-30 minutes implemented with a population-based denominator, would provide a meaningful indicator of access to GP services in the community. The authors’ note that the AIHW are reviewing their methodology and recommend that the modified ACEM method be used in future Australian hospital statistics as this would be more informative for health policy and relevant to healthcare planning.

Saline therapy for alcohol intoxication (#FOAMed) Alcohol intoxicated patients are routinely treated with i.v. normal saline; however there is a lack of evidence on the efficacy of this hydration therapy. This randomised controlled trial from Perez and colleagues, demonstrates that a single bolus saline infusion does not affect ED length of stay or deliver better patient outcomes when compared with observation alone. Given the time, resources and risks with this i.v. therapy, observation with periodic monitoring of blood alcohol levels in these patients is appropriate until they are sober and safe to discharge.

Burnout in Emergency Physicians (Abstract) The practice of emergency medicine is intellectually, physically and emotionally demanding for consultants and trainees, placing emergency physicians at risk of burnout. This review, from Arora et al, summarises the limited literature on this topic and concludes that burnout rates for emergency physicians is higher than other medical specialities; however, somewhat paradoxically, job satisfaction is also high. There is limited analysis of work- and non-work-related factors contributing to emergency physician burnout.  Given the potential negative impacts for patients, health institutions and physicians associated with this burnout, future research is essential to address this important well-being issue

Roll out of standardised approach to paediatric procedural sedation (Abstract) Many children presenting to EDs need minor procedures that require sedation to minimise discomfort and psychological distress. This report, from the Emergency Care Improvement & Innovation Clinical Network, describes a project that used a multimodal approach, grounded in quality and safety theory, to improve consistency in clinical practice, minimise risks and strengthen clinical governance arrangements for paediatric sedation across a number of Victorian EDs. Key activities addressed clinical governance, risk assessment and procedure documentation, training and credentialing of clinicians, and clinical audit of key quality and safety measures. This multi-modal implementation strategy supported by an evidence-based programme and resources enabled clinical practice improvements across organisational boundaries.

New oral anticoagulants (NOACs) (Abstract) Three NOACs are now available for clinical use in Australia. To inform the use of these agents in the ED setting, this comprehensive review by Wood provides an overview of the pharmacology, indications for use, and aspects of laboratory testing and the management of bleeding. Multicentre RCTs have demonstrated at least equivalent efficacy to the current standard of care, i.e. warfarin, including major bleeding rates but with important reductions in intracranial bleeding with all NOACs. Adverse serious bleeding events, as related to high-risk populations, and concerns regarding reversibility of NOACs are discussed

Characteristics and risk stratification of patients with acute chest pain (Abstract) Patients with acute chest pain are common ED presentations and account for a quarter of hospital admissions, yet most prove to be non-coronary related. This retrospective study, by Sander et al, examined consecutive patients with indeterminate chest pain admitted to a tertiary hospital medical assessment unit. While the majority (71%) of these patients had non-coronary conditions as a discharge diagnosis, clinical features and risk scores were able to identify most with myocardial ischemia. These results informed development of a risk stratification algorithm that could assist with triage, early discharge, test choice and need for telemetry.

BA MA (Oxon) MBChB (Edin) FACEM FFSEM. Emergency physician, Sir Charles Gairdner Hospital.  Passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | Twitter |

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