EMA June 2013

Issue 3 (Vol. 25) of Emergency Medicine Australasia published online on 13 June 2013
From Andrew Gosbell & Tony Brown

Private hospital emergency departments in Australia (Abstract) Although 45% of Australians have private health insurance and 41% of inpatient care is delivered in private settings, only 6% of ED visits occur in private hospitals. In this first ever descriptive study of patient characteristics in Australian private EDs, Fitzgerald and colleagues analysed routinely collected data aggregated from 83,279 patients presenting across four participating EDs for a one year period, and compared this with public ED datasets. Variability in private ED data systems limited the range of data that could be combined as well as detailed comparisons. Nonetheless, attendance patterns by day of week and time of day were similar to public EDs. However the acuity of public ED patients was more likely to be in triage categories 1 and 2. There were similar arrival methods to public and private EDs, but self-referral was higher for public ED patients. The proportion of patients staying less than 4 hours was slightly higher in private EDs and mean LOS was, on average, 30 minutes shorter across all triage categories in private EDs, however hospital admission rates were higher from private EDs. The most significant difference was patient’s health insurance status, with only 14% of public ED patients having some form of insurance, compared with 79% of patients in private EDs. Private hospital EDs have a significant role in the Australian emergency health system, although data systems are required that enable a nationally consistent dataset, aligned to data elements routinely collected in public EDs, to allow comparative benchmarking and whole of system analyses to inform evidence-based public policy

Factors involved in intensive care unit (ICU) mortality following medical retrieval (Abstract) Inter-hospital transfers of critically ill patients delay access to definitive care and are associated with increased ICU and hospital LOS and higher mortality rates. Visser et al, describe a data linkage study of Adult Retrieval Victoria and ICU datasets to determine factors related to ICU mortality in transferred critically ill patients over a one year period. Advanced patient age, cardiac conditions, lower mean arterial blood pressure and tachycardia on completion of retrieval were associated with increased ICU mortality in the study cohort. These findings support the need for clinician awareness of retrieval patients being at greatest risk and optimised cardiac support for these patients.

Procedural sedation and analgesia for reduction of paediatric distal forearm fractures in the ED (Abstract) Distal forearm fracture is a painful injury that is a common paediatric ED presentation. Early reduction enables best outcomes and if this can be achieved in the ED, costly hospital admission can be avoided. This multicentre survey by Schofield et al, from the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network, evaluated current clinical practices for procedural sedation and analgesia (PSA) and reduction of forearm fracture in children. Ketamine and nitrous oxide were the most frequently used PSA agents, with guidelines for use of these agents available in almost all PREDICT sites. Most physicians would reduce fractures up to 25o angulation, with higher displacement referred to theatre. Better definitions on cut-off points for fracture reduction in the ED, standardised practice guidelines for specific PSA agents, and improved access to image intensifiers in EDs are recommended

Demography is destiny  (#FOAMed) The increasing numbers of older patients presenting with acute exacerbations of chronic illness and complex geriatric syndromes pose significant challenges to the practice of emergency medicine in Australasia. This perspective, from Arendts and Lowthian, calls for a proactive approach to geriatric emergency medicine practice, research, education and policy development. There are several areas where ED processes can be improved, including quality of geriatric clinical care in the ED, up-skilling the emergency physician workforce in areas of geriatric medicine and introduction of evidence-based models and systems of care that better meet the needs of older patients. However, the greatest gains in addressing this issue are likely to be achieved outside the ED. As such, a framework for research and policy development is proposed to improve care for older people with less hospital occupancy through strategies that avoid ED attendances, reduce hospital admissions from ED, improve ED clinical care for common geriatric presentations and avoid ineffective or futile treatment at times of critical illness

Diagnostic vaginal examination in early pregnancy bleeding   (#FOAMed) Bleeding in early pregnancy is a common ED presentation and vaginal examination is traditionally considered ‘essential’ for diagnostic assessment. In this prospective randomised control trial of stable patients presenting with first trimester bleeding, Johnstone demonstrates that vaginal examination does not improve diagnostic accuracy and is unlikely to inform management or disposition of the patient. Not only is this physical examination unpleasant and invasive for the patient, this study challenges clinical convention with evidence that the examination does not contribute any additional diagnostic information. Decisions on operative or conservative management of early pregnancy bleeding are much better based on ultrasound performed within a day of presentation. As such vaginal examination should no longer be required for routine assessment of patients with early pregnancy bleeding.

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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