Emergency Medicine Australasia最新文献

Purpose: Increasing ED-CT Pulmonary Angiography (CTPA) use raises concerns about overuse and low yield. CTPA numbers at Sir Charles Gairdner ED were seemingly increasing. This single-site, retrospective, observational study looked for increasing usage over ten years, and whether lower yields suggested over-testing.

Methods: Two linked hypotheses: (1) CTPA rates increased over a decade and (2) if CTPA is increasing significantly, yield reduces suggesting overuse. For Hypothesis 1, ED-CTPA per 1000 attendances 2014-2023 were calculated from radiology imaging data. For Hypothesis 2, 2023/24 CTPA results were reviewed for demographics, PE diagnosis, imaging quality, and largest vessel with PE, using similar methods to previous studies. We calculated 700 cases needed reviews if CTPA increased 5%-6% annually (previous regional studies) and yield decreased inversely. Statistical analysis compared rates over time and compared 2012-2013 versus 2023-2024 for Hypothesis 1. For Hypothesis 2, analysis was for difference in proportions for yield (and largest vessel with PE) versus previous 2012-2013 data.

Results: Rates of ED-CTPA increased 65% over 2014-2023 but yield was stable (16.3% vs. 15.7%). PE diagnoses increased by over 60% (1.3-2.1 PE/1000). Large vessel PE (≥ lobar) decreased significantly (59.9%-40.5%), intermediate-vessel PE increased (20%-35.1%), but small vessel PE was unchanged (19.2 vs. 24.3%). Women ≤ 50 years had significantly lower yield (5.4%).

Conclusions: CTPA use increased markedly, without expected decreased yield. Increased PE diagnosis rates suggest maintained diagnostic discrimination. Large vessel PE proportions reduced, but small PE rates didn't increase significantly. Younger women seem over-investigated with low yield (5.6%) versus all other groups.

Objective: To describe the association between concurrent patient volume in the emergency department (ED) and adverse outcomes for admitted patients.

Methods: This was a data linkage analysis using routinely collected data from Level six EDs in New South Wales Australia. Adult patients (aged ≥ 16 years) presenting to ED between 1 April 2022 and 31 March 2023 and admitted to an inpatient unit from ED were included. The exposures of interest were ED patient (total and admitted) volume at the time of patient arrival. The primary outcome was an adverse outcome, defined as 30-day all-cause mortality or intensive care unit admission from an inpatient ward. Multivariable logistic and Cox proportional hazards models were used to adjust for covariates.

Results: There were 142,362 cases analysed. There was a relationship between ED patient volume deciles and proportion of adverse outcomes, increasing from 5% to 7%. The adjusted odds of adverse outcomes associated with the second quintile of total patient volume was 16% higher (odds ratio, OR [95% confidence interval] 1.16 [1.07-1.25]) and 26% higher in the third quintile (1.26 [1.17-1.36]) relative to the first quintile. Based on modelling, excess mortality associated with increasing ED patient volumes was estimated to be around 1000 deaths per annum.

Conclusion: We found a relationship between increasing ED patient volumes at the time of arrival and adverse outcomes for admitted patients.

Background: Emergency care (EC) systems provide an integrated platform for addressing urgent healthcare needs. It has been estimated that time-sensitive conditions comprise approximately half of the total burden of disease in low- and middle-income countries (LMICs), but data from the Pacific region are limited. This study sought to determine the burden of 'emergency medical diseases' (EMDs) in the Melanesian countries of Fiji, Papua New Guinea, Solomon Islands, and Vanuatu.

Methods: Morbidity and mortality data for Fiji, Papua New Guinea, Solomon Islands, and Vanuatu were sourced from the Institute for Health Metrics and Evaluation's Global Burden of Disease Project database (2019 dataset). Diseases were categorised into EMDs and non-EMDs based on previously published definitions, namely, whether their assessment or management is time-sensitive or not. Descriptive statistics were used to summarise the burden of EMDs, with disability-adjusted life years (DALYs) used as the primary measure of morbidity.

Findings: EMDs account for 43%-60% of mortality and 37%-52% of morbidity in Fiji, Papua New Guinea, Solomon Islands, and Vanuatu. The five most prevalent EMDs in these countries (ischaemic heart disease, stroke, injuries, lower respiratory tract infections, and diarrhoeal illnesses) cause 37%-60% of all deaths.

Interpretation: Approximately half of all pre-pandemic mortality and morbidity in Melanesia is attributable to EMDs. This is consistent with previously reported literature for LMICs and confirms the need for resilient EC systems in the Pacific.

Musculoskeletal conditions are a major cause of emergency department presentations. In this Opinion paper, we argue that Australian hospital reporting and coding of musculoskeletal care are both inconsistent and underestimated. This has important implications for health service planning and policy. A more inclusive and clinically informed reporting approach is essential.

Objectives: Assess the effects of Age, Period and Cohort (APC) in the trends in emergency department (ED) visits in 2003-2023 in Australia.

Methods: For this retrospective observational study, we obtained data on all ED visits in Australia in 2003-2023 from the Australian Institute of Health and Welfare and applied an APC model to separate Age, Period and Cohort effects.

Results: The total number of ED visits increased from 4,306,183 in 2003 to 7,194,861 in 2013 (67% increase). A 25% increase was observed in 2013-2023 (n = 9,014,526 visits in 2023). Rates of ED visits have increased in Australia in 2003-2023 from 218 per 1000 residents to 338 per 1000. Rates of ED visits were higher in patients aged > 85 years and have increased in 2003-2023 from 525 per 1000 to 835 per 1000 (59% increase). The increase in the number of ED visits per capita was slightly lower in those aged 65-74 (from 226 per 1000 in 2003 to 338 per 1000 in 2023, 50% increase) and those aged 75-84 years (350 per 1000 to 526 per 1000, 50% increase) compared to residents aged > 85 years.

Conclusions: Our APC modelling shows a deceleration in the increase in the rate of ED visits in the last decade, despite at the same age younger generations having higher rates of ED visits than older generations. The consistent increase in ED visits per capita in those aged < 75 years has major implications for healthcare planning and policies needed to reduce ED demand.

Objective: The ED workforce experiences high levels of workplace violence (WPV), but data is often poorly captured. This study aimed to review WPV incidents and rates of formal reporting.

Methods: Prospective electronic QR survey of WPV incidents in ED.

Results: Ninety respondents reported WPV incidents in ED, compared to 45 formal reports. Most WPV cases reported by nurses were from patients and were verbal in nature. Concerningly, almost 1/5 were considering leaving the ED after the WPV incident.

Conclusion: WPV is a significant, ongoing, underreported issue in ED that harms staff well-being and threatens the retention of the future workforce.

Objective: To review a newly implemented medical staff self-rostering process in a small metropolitan emergency department to ensure sustainability without compromising emergency department safe staffing guidelines.

Methods: We performed a multi-methods study on the implementation and user experience of a novel rostering process for registrars and CMOs in a small emergency department. Quantitative analysis was performed using a Likert scale to assess operational and implementation success as well as data on hours spent on roster generation, number of sick calls and number of shift swaps. Qualitative structured interviews were also analysed using an inductive process resulting in a thematic analysis.

Results: Our implementation outcome scoring showed a median score of 5 for all three domains of the implementation questionnaire including acceptability (IQR 4-5), appropriateness (IQR 4-5) and feasibility (IQR 4-5). Our thematic analysis demonstrated strong themes around flexibility and choice, usability and interface, responsibility for a complete roster, as well as wellbeing and balance. Our analysis of roster metrics showed a large reduction in required shift swaps (29 vs. 163) and time spent on roster development and publication (4 h vs. 20 h) over a 13-week rostering period. While consultant time spent on roster development and publication was reduced, this was accompanied by a redistribution of workload to participating staff, who spent a median of 1.4 h per rostering cycle.

Conclusions: We conclude that in a small metropolitan hospital, self-rostering is a feasible and implementable operational intervention with improvements in employee wellbeing.

Objective: To investigate the impact of increasing age on clinical outcomes in major trauma patients. Primary outcomes assessed included time to diagnostic imaging, length of hospital stay, and mortality rates both in-hospital and at 30 days post-injury.

Methods: A retrospective observational study was conducted involving major trauma patients presenting to a tertiary referral centre over a 6-year period, 2017-2023. The effect of increasing age on triage, investigation and management, and clinical outcomes, including length of stay and mortality, was examined.

Results: Analysis demonstrated that the likelihood of trauma team activation decreased with increasing age, independent of injury severity score. Increasing age was a significant predictor of in-hospital mortality (odds ratio: 1.06, 95% confidence interval: 1.05-1.07). Rates of computed tomography (CT) utilisation were comparable between older and younger cohorts (≥ 65 vs. < 65 years, 94.8% vs. 94.9%); yet, older patients experienced significantly longer median wait times for imaging (130 min [≥ 65] vs. 79 min [< 65]).

Conclusions: Increasing age is associated with decreased trauma team activation rates irrespective of injury severity. Furthermore, older trauma patients exhibit substantially higher mortality rates, with a marked increase observed beyond initial hospital discharge. Age-specific trauma team activation criteria may reduce under-triage and potentially improve outcomes in older patients.