EMA October 2012

Issue 5 (Vol. 24) of Emergency Medicine Australasia published online on 9 October 2012

Stroke thrombolysis: Editorials on the Third International Stroke Trial (IST-3) (#FOAMed) Recent release of the results of the Third International Stroke Trial (IST-3) does little to address the controversy on the use of tPA in acute ischaemic stroke (AIS). Nor does it diminish scepticism amongst emergency physicians regarding the benefits, or lack thereof, of stroke lysis. Hoffmann & Cooper contend that IST-3 was a poorly executed RCT which, while claiming to support thrombolysis in AIS, was actually an overwhelmingly negative study. Despite design flaws biasing in favour of the tPA treatment group, at 6 months follow up there was no difference in neurological outcome or mortality. Fatovich argues that as well as the primary outcome of IST-3 being completely negative in terms of therapeutic benefit of tPA, significant harms were also identified including an absolute increase in early deaths and increases in intracranial haemorrhage (ICH).  Findings from IST-3 indicate there in reality, there is still insufficient evidence for stroke lysis to be considered as the standard of clinical care. This is also consistent with the recently published ACEM position statement on use of this therapy in emergency settings.

A Primer for Clinical Researchers in the Emergency department: Part IV: Multicentre Research (Abstract) In the penultimate article in this series on five key topics for clinicians conducting research as part of their work in the ED, Oakley and colleagues provide practical advice on conducting multicentre research. The advantages, complexities and challenges of multicentre research are discussed in terms of two approaches: collaborative group research and large-scale investigator-led research. The ability to recruit large number of participants in a short time frame is an advantage for researchers; and the range of settings and variability in populations studied means that findings from these research approaches can have relevance and applicability across a wide extent of ED settings.

Inadequate Acute Hospital Beds and the Limits of Primary Care and Prevention  (#FOAMed) This provocative perspective by Cunningham and Sammut contends that metropolitan Australia has a significant shortage of acute hospital beds, and this is the single most important contributory factor in ED overcrowding. Simplistic benchmarking with OECD bed numbers ignores unmet demand, and the uneven distribution of beds across Australia masks serious shortages in metropolitan areas. The authors challenge perceptions that Australia is too dependent on hospital-based care, arguing that prevention and primary care strategies, while vital components of the healthcare system, have been incorrectly adopted as ‘solutions’ to reduce acute demand. Further, political focus on reducing elective surgery waiting times has been, and likely will always be, at the expense of acute services. Strong advocacy is required to rebuild metropolitan bed stocks to adequately meet acute hospital care needs of the future

Unravelling Relationships – Hospital Occupancy Levels, Discharge Timing, and Emergency Department Access Block  (Abstract) Khanna and colleagues analyse the relationship between bed occupancy rates and patient flow parameters and discharge initiatives across 23 Queensland hospitals. Three distinct phases of hospital performance decline are identified as occupancy increases, with triggering of discharge management requirements, access block driven ED overcrowding and ultimately whole of hospital overcrowding occurring at the respective tipping points. Findings suggest that modern hospital systems are capable of optimal operation above 90% occupancy rates, but that this must be determined for each individual hospital service. Efficient discharge strategies can have a significant effect on maintaining hospital systems at below these critical occupancy levels.

Analysis and impact of delays in ambulance to emergency department handovers  (Abstract) Ambulance ramping is a contemporary issue for Australasian EDs, yet little is known about clinical handover at the emergency medical service (EMS)-ED interface. In this large statewide (~200,000 EMS cases) retrospective time-in-motion study from 2009 Ambulance Service of NSW data, Cone et al analyse turnaround intervals and clinical handover delays. Median EMS turnaround time was 30 mins and median handover interval was 16 mins, however clinical handover delays were relatively common with 1 in 20 patients experiencing delays of more than 60 mins. This problem was greatest in urban areas, at larger hospitals, and during winter. Understanding the nature of these delays and contributory factors may assist in addressing root causes and increase real-time availability of EMS.