Forensic medical services vary in structure and practice between metropolitan and rural centres in Australia. Limited access to trained forensic clinicians, resource constraints, and geographical isolation create challenges for rural clinicians—particularly trainees. The ACEM policy outlines the ED's dual role in managing medical needs and ensuring timely evidence collection and reporting. In rural settings, it's not always possible for a forensic medical officer to assess patients on site. Early evidence kits (EEKs) can preserve the chain of evidence by enabling the patient to self-collect. Emphasising continuing education, forensic management protocols, and incorporating EEK training into staff induction can improve clinician awareness in forensic cases.
{"title":"Forensic Medicine in Rural Australia","authors":"Ami Clubb, Brittany Hulbert","doi":"10.1111/1742-6723.70193","DOIUrl":"10.1111/1742-6723.70193","url":null,"abstract":"<div>\u0000 \u0000 <p>Forensic medical services vary in structure and practice between metropolitan and rural centres in Australia. Limited access to trained forensic clinicians, resource constraints, and geographical isolation create challenges for rural clinicians—particularly trainees. The ACEM policy outlines the ED's dual role in managing medical needs and ensuring timely evidence collection and reporting. In rural settings, it's not always possible for a forensic medical officer to assess patients on site. Early evidence kits (EEKs) can preserve the chain of evidence by enabling the patient to self-collect. Emphasising continuing education, forensic management protocols, and incorporating EEK training into staff induction can improve clinician awareness in forensic cases.</p>\u0000 </div>","PeriodicalId":11604,"journal":{"name":"Emergency Medicine Australasia","volume":"37 6","pages":""},"PeriodicalIF":1.4,"publicationDate":"2025-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145809832","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Timothy J. Schultz, Paul Tait, Brendan Major, Andrew Partington, Darren Daff, Pamela Everingham, Rebecca Perry, Jackie Davidson, Jonathan Karnon
Objective
We measured multidisciplinary staff perceptions of the working environment, attitudes to telemedicine and the experience of working in a virtual emergency department (ED) to permit comparison with studies of physical EDs.
Methods
In September 2024, we conducted an online survey of 63 staff in a South Australian virtual ED. The survey comprised the Working Environment Scale (WES-10) and questions assessing attitudes to telemedicine and open-ended questions on attractors and challenges to work. Descriptive statistics and non-parametric inferential statistics were used to compare responses between professions; content analysis was conducted on open-ended data.
Results
The response rate was 52% (n = 33, comprising 5 clerical, 16 doctors, 11 nurses and 1 paramedic). The WES-10 scores were (median, interquartile range): Self-realisation (3.6, 3.2–4.3), Workload (3.0, 2.4–3.0), Conflict (1.5, 1.0–2.0) and Nervousness (1.5, 1.0–2.0). We identified inconsistencies in the scoring of previous studies of the physical ED working environment that complicate comparison, although the results suggest that the virtual ED is viewed at least as positively as the physical ED, particularly for Self-realisation. Staff had generally very positive attitudes towards telemedicine, except for future plans for professional development and preference for virtual care. Delivering novel care and having a positive workplace culture were the main attractions to working at the virtual ED, whereas limitations in assessing patients were the main challenge.
Conclusions
Virtual ED staff viewed their workplaces and telemedicine positively and were attracted to the delivery of a novel form of healthcare. Greater consistency of WES-10 measurement is necessary.
{"title":"Working Environment in a Virtual Emergency Department: A Cross-Sectional Study","authors":"Timothy J. Schultz, Paul Tait, Brendan Major, Andrew Partington, Darren Daff, Pamela Everingham, Rebecca Perry, Jackie Davidson, Jonathan Karnon","doi":"10.1111/1742-6723.70191","DOIUrl":"10.1111/1742-6723.70191","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>We measured multidisciplinary staff perceptions of the working environment, attitudes to telemedicine and the experience of working in a virtual emergency department (ED) to permit comparison with studies of physical EDs.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>In September 2024, we conducted an online survey of 63 staff in a South Australian virtual ED. The survey comprised the Working Environment Scale (WES-10) and questions assessing attitudes to telemedicine and open-ended questions on attractors and challenges to work. Descriptive statistics and non-parametric inferential statistics were used to compare responses between professions; content analysis was conducted on open-ended data.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The response rate was 52% (<i>n</i> = 33, comprising 5 clerical, 16 doctors, 11 nurses and 1 paramedic). The WES-10 scores were (median, interquartile range): Self-realisation (3.6, 3.2–4.3), Workload (3.0, 2.4–3.0), Conflict (1.5, 1.0–2.0) and Nervousness (1.5, 1.0–2.0). We identified inconsistencies in the scoring of previous studies of the physical ED working environment that complicate comparison, although the results suggest that the virtual ED is viewed at least as positively as the physical ED, particularly for Self-realisation. Staff had generally very positive attitudes towards telemedicine, except for future plans for professional development and preference for virtual care. Delivering novel care and having a positive workplace culture were the main attractions to working at the virtual ED, whereas limitations in assessing patients were the main challenge.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Virtual ED staff viewed their workplaces and telemedicine positively and were attracted to the delivery of a novel form of healthcare. Greater consistency of WES-10 measurement is necessary.</p>\u0000 </section>\u0000 </div>","PeriodicalId":11604,"journal":{"name":"Emergency Medicine Australasia","volume":"37 6","pages":""},"PeriodicalIF":1.4,"publicationDate":"2025-12-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145793537","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Yuta Tamberg, Melyssa Roy, Waldir Rodrigues de Souza Jr., John Eastwood
Objective
To compare patterns and characteristics of emergency department visits initiated by frequent presenters and other ED attenders.
Methods
We performed a quantitative retrospective data analysis of routinely collected ED data across three public hospitals within New Zealand's Southern district. The study population comprised: (1) frequent presenters (i.e., patients who visited any of the EDs on 10 or more occasions in any continuous 365-day period between 01/01/2018 and 31/12/2022) and (2) all other ED presenters during the same period. We compared visit-based and per-person metrics characterising presentation flow, utilisation patterns and demographics.
Results
Frequent presenters constituted 0.6% of all ED attenders (1259 out of 196,136) and initiated 6.8% of all ED visits (32,541 out of 479,975). Visits by frequent presenters showed no seasonality or day-of-the-week patterns and occurred mostly during daylight hours. Frequent presenters differed from non-frequent presenters by having more clustered visits, shorter intervals between presentations, higher presentation severity (more visits were triaged urgent and above), more arrivals by ambulance and police, a higher incomplete treatment rate, more referrals and short stay admissions.
Conclusion
Frequent presenters make a sizeable contribution to ED load in terms of visit numbers and urgency. The nature of differences between frequent and non-frequent presenters indicates greater and more complex health needs in the former cohort. At the same time the diversity of visits in the frequent presenters' histories shows potential for redirecting some patients and/or presentations to other care providers.
{"title":"Frequent Presenters to Southern New Zealand Emergency Departments Differ From Other ED Attenders","authors":"Yuta Tamberg, Melyssa Roy, Waldir Rodrigues de Souza Jr., John Eastwood","doi":"10.1111/1742-6723.70185","DOIUrl":"10.1111/1742-6723.70185","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To compare patterns and characteristics of emergency department visits initiated by frequent presenters and other ED attenders.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We performed a quantitative retrospective data analysis of routinely collected ED data across three public hospitals within New Zealand's Southern district. The study population comprised: (1) frequent presenters (i.e., patients who visited any of the EDs on 10 or more occasions in any continuous 365-day period between 01/01/2018 and 31/12/2022) and (2) all other ED presenters during the same period. We compared visit-based and per-person metrics characterising presentation flow, utilisation patterns and demographics.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Frequent presenters constituted 0.6% of all ED attenders (1259 out of 196,136) and initiated 6.8% of all ED visits (32,541 out of 479,975). Visits by frequent presenters showed no seasonality or day-of-the-week patterns and occurred mostly during daylight hours. Frequent presenters differed from non-frequent presenters by having more clustered visits, shorter intervals between presentations, higher presentation severity (more visits were triaged urgent and above), more arrivals by ambulance and police, a higher incomplete treatment rate, more referrals and short stay admissions.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Frequent presenters make a sizeable contribution to ED load in terms of visit numbers and urgency. The nature of differences between frequent and non-frequent presenters indicates greater and more complex health needs in the former cohort. At the same time the diversity of visits in the frequent presenters' histories shows potential for redirecting some patients and/or presentations to other care providers.</p>\u0000 </section>\u0000 </div>","PeriodicalId":11604,"journal":{"name":"Emergency Medicine Australasia","volume":"37 6","pages":""},"PeriodicalIF":1.4,"publicationDate":"2025-12-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145767440","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Danlu Liang, Paul Buntine, Louise Roberts, Liam Hackett, Joseph Miller, Patrick J. Owen, Andrew W. Teh
Objective
Recent onset atrial fibrillation is common in emergency departments and treated with resource- and time-intensive electrical cardioversion despite most patients spontaneously reverting to sinus rhythm within 48 h. We investigated whether discharging patients with a portable electrocardiograph to monitor rhythm was feasible and could improve emergency department workflow.
Methods
This single-centre proof-of-concept study recruited adults presenting to the emergency department with recent onset, haemodynamically stable, sustained atrial fibrillation, with a clear onset time within 24 h and who owned a smartphone able to pair with the AliveCor single-lead electrocardiograph. Patients were discharged on rate-control and anticoagulant medication where appropriate. Portable electrocardiograph transmissions were sent six-hourly to assess spontaneous reversion to sinus rhythm. If patients remained in atrial fibrillation by 48 h, they represented to the emergency department for direct current cardioversion. Patients continued to send electrocardiograph transmissions for 4 weeks to monitor rhythm.
Results
Most (91%; n = 21/23) patients spontaneously reverted from atrial fibrillation to sinus rhythm within 48 h of symptom-onset, with only two patients returning for direct current cardioversion. All patients remained in sinus rhythm at 4-week follow-up. Patients found the device easy to use and appreciated not returning for cardioversion.
Conclusions
Selected patients presenting to emergency departments with recent onset atrial fibrillation can be discharged home with an expectation that they will revert spontaneously to sinus rhythm, potentially reducing unnecessary electrical cardioversion. Remote electrocardiograph monitoring was feasible for identifying patients who failed to revert to sinus rhythm, allowing timely recall to the emergency department for scheduled cardioversion.
{"title":"Use of Single Lead ECG to Assist Cardioversion in Atrial Fibrillation in the Emergency Department (SELECTED): Proof of Concept Study","authors":"Danlu Liang, Paul Buntine, Louise Roberts, Liam Hackett, Joseph Miller, Patrick J. Owen, Andrew W. Teh","doi":"10.1111/1742-6723.70190","DOIUrl":"10.1111/1742-6723.70190","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>Recent onset atrial fibrillation is common in emergency departments and treated with resource- and time-intensive electrical cardioversion despite most patients spontaneously reverting to sinus rhythm within 48 h. We investigated whether discharging patients with a portable electrocardiograph to monitor rhythm was feasible and could improve emergency department workflow.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This single-centre proof-of-concept study recruited adults presenting to the emergency department with recent onset, haemodynamically stable, sustained atrial fibrillation, with a clear onset time within 24 h and who owned a smartphone able to pair with the AliveCor single-lead electrocardiograph. Patients were discharged on rate-control and anticoagulant medication where appropriate. Portable electrocardiograph transmissions were sent six-hourly to assess spontaneous reversion to sinus rhythm. If patients remained in atrial fibrillation by 48 h, they represented to the emergency department for direct current cardioversion. Patients continued to send electrocardiograph transmissions for 4 weeks to monitor rhythm.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Most (91%; <i>n</i> = 21/23) patients spontaneously reverted from atrial fibrillation to sinus rhythm within 48 h of symptom-onset, with only two patients returning for direct current cardioversion. All patients remained in sinus rhythm at 4-week follow-up. Patients found the device easy to use and appreciated not returning for cardioversion.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Selected patients presenting to emergency departments with recent onset atrial fibrillation can be discharged home with an expectation that they will revert spontaneously to sinus rhythm, potentially reducing unnecessary electrical cardioversion. Remote electrocardiograph monitoring was feasible for identifying patients who failed to revert to sinus rhythm, allowing timely recall to the emergency department for scheduled cardioversion.</p>\u0000 </section>\u0000 </div>","PeriodicalId":11604,"journal":{"name":"Emergency Medicine Australasia","volume":"37 6","pages":""},"PeriodicalIF":1.4,"publicationDate":"2025-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145755735","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
To evaluate the clinical effectiveness and cost-effectiveness of the integrated Geriatric Emergency Medicine (iGEM) Short Stay Unit (SSU) model in the management of patients presenting from residential aged care facilities (RACF) to the Emergency Department (ED).
Methods
This is a retrospective cohort study comparing patients admitted to the iGEM SSU in July 2024 (Cohort Ia) with matched contemporaneous (Cohort Ib) and historical (May 2024, July 2023) controls who met iGEM criteria but were managed under standard ED pathways. Inclusion criteria comprised geriatric RACF patients presenting with stable, low-acuity conditions such as uncomplicated infections, minor trauma, dehydration, or requiring transfusions suitable for short-stay management.
Results
A total of 531 geriatric patients from RACFs were included. A progressive improvement in service efficiency was observed with the iGEM SSU model. The average ED length of stay decreased from 18.3 h in July 2023 (Cohort III) to 6.5 h in July 2024 (Cohort Ia), accompanied by a reduction in inpatient admission rates (51% to 5.3%) and overall hospital LOS (8.1 days to 1.7 days). Quality outcomes also improved, with lower readmission and complication rates observed in cohort Ia compared with earlier standard-care cohorts, supporting the model's clinical efficiency.
Conclusions
The iGEM SSU model was associated with greater efficiency, reduced inpatient admissions, shorter hospital length of stay, and potential cost savings compared to standard geriatric emergency care in this retrospective case–control study. These findings suggest that iGEM may help to alleviate ED pressures and optimise hospital resource utilisation without compromising patient safety.
{"title":"Evaluating the Effectiveness of the Integrated Geriatric Emergency Medicine Short Stay Unit Model of Care: A Retrospective Cohort Study","authors":"Karina Hochholzer, Caroline O'Donnell, Daya Jeganathan, Dmitrii Shek, Joanne Medlin, Golo Ahlenstiel","doi":"10.1111/1742-6723.70189","DOIUrl":"10.1111/1742-6723.70189","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>To evaluate the clinical effectiveness and cost-effectiveness of the integrated Geriatric Emergency Medicine (iGEM) Short Stay Unit (SSU) model in the management of patients presenting from residential aged care facilities (RACF) to the Emergency Department (ED).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This is a retrospective cohort study comparing patients admitted to the iGEM SSU in July 2024 (Cohort Ia) with matched contemporaneous (Cohort Ib) and historical (May 2024, July 2023) controls who met iGEM criteria but were managed under standard ED pathways. Inclusion criteria comprised geriatric RACF patients presenting with stable, low-acuity conditions such as uncomplicated infections, minor trauma, dehydration, or requiring transfusions suitable for short-stay management.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>A total of 531 geriatric patients from RACFs were included. A progressive improvement in service efficiency was observed with the iGEM SSU model. The average ED length of stay decreased from 18.3 h in July 2023 (Cohort III) to 6.5 h in July 2024 (Cohort Ia), accompanied by a reduction in inpatient admission rates (51% to 5.3%) and overall hospital LOS (8.1 days to 1.7 days). Quality outcomes also improved, with lower readmission and complication rates observed in cohort Ia compared with earlier standard-care cohorts, supporting the model's clinical efficiency.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>The iGEM SSU model was associated with greater efficiency, reduced inpatient admissions, shorter hospital length of stay, and potential cost savings compared to standard geriatric emergency care in this retrospective case–control study. These findings suggest that iGEM may help to alleviate ED pressures and optimise hospital resource utilisation without compromising patient safety.</p>\u0000 </section>\u0000 </div>","PeriodicalId":11604,"journal":{"name":"Emergency Medicine Australasia","volume":"37 6","pages":""},"PeriodicalIF":1.4,"publicationDate":"2025-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145721800","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Emily Nehme, Karen Smith, Colin Jones, Peter Cameron, Ziad Nehme
Objective
To examine the impact of a revised ambulance clinical response model (CRM) on 24- and 72-h patient outcomes and triage accuracy.
Methods
Retrospective study of consecutive ambulance calls in Victoria, Australia between 01/01/2015 and 31/12/2018 linked with hospital and death records. Negative binomial interrupted time series analyses were used.
Results
Among callers referred away from emergency ambulance dispatch, the revised CRM was not associated with any change in mortality; although there was an increasing trend in recontacts. Among all callers, triage accuracy improved; however under-triage was more common.
Conclusion
Ongoing CRM reforms should be informed by patient safety outcomes.
{"title":"Revising the Ambulance Clinical Response Model in Victoria, Australia: The Impact on Patient Safety","authors":"Emily Nehme, Karen Smith, Colin Jones, Peter Cameron, Ziad Nehme","doi":"10.1111/1742-6723.70188","DOIUrl":"10.1111/1742-6723.70188","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To examine the impact of a revised ambulance clinical response model (CRM) on 24- and 72-h patient outcomes and triage accuracy.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Retrospective study of consecutive ambulance calls in Victoria, Australia between 01/01/2015 and 31/12/2018 linked with hospital and death records. Negative binomial interrupted time series analyses were used.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Among callers referred away from emergency ambulance dispatch, the revised CRM was not associated with any change in mortality; although there was an increasing trend in recontacts. Among all callers, triage accuracy improved; however under-triage was more common.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Ongoing CRM reforms should be informed by patient safety outcomes.</p>\u0000 </section>\u0000 </div>","PeriodicalId":11604,"journal":{"name":"Emergency Medicine Australasia","volume":"37 6","pages":""},"PeriodicalIF":1.4,"publicationDate":"2025-12-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145707935","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Lu Bai, Shijia Gao, Frada Burstein, Jithin Sajeev, Simon Craig, Diana Egerton-Warburton, Gerard O'Reilly, Peter Cameron, Gabriel Blecher, Liam Hackett, Joseph Miller, Emily Schembri, Patrick J. Owen, Paul Buntine
Background
Diagnostic testing is overused in emergency departments, and clinical decision support may reduce unnecessary ordering. We examined the effects of nudge-based clinical decision support interventions on test ordering among emergency department clinicians.
Methods
This triple-blind four-arm parallel (1:1:1:1) individually randomised vignette-based experiment included 243 clinicians (male: 54%) from eight emergency departments. Clinicians were presented with a case study (81-year-old woman, simple syncopal event, no injury) and randomised to Nudge #1 (large range of tests and free text), Nudge #2 (Nudge #1 with inline evidence-based advice), Nudge #3 (limited range of tests and free text), or control (free text only). The primary outcome was between-group differences in total tests ordered. Secondary outcomes excluded the most common tests (full blood examination and urea/electrolytes) and were stratified by clinical experience (< 10 or ≥ 10 years).
Results
There were no differences in total tests ordered compared to control for Nudge #1 (incident-rate ratio [95% CI]: 1.05 [0.83, 1.32], p = 0.691), Nudge #2 (0.85 [0.67, 1.08], p = 0.189), or Nudge #3 (0.90 [0.71, 1.14], p = 0.378). When FBE and U&E were excluded, total tests ordered compared to control were lower for Nudge #2 (0.58 [0.39, 0.86], p = 0.007), and Nudge #3 (0.50 [0.33, 0.76], p = 0.001). Secondary analyses revealed effects for clinicians with < 10 years of experience only.
Conclusion
While potentially of limited value for reducing the total number of tests ordered, nudge-based clinical decision support interventions that manipulate decision structure and employ decision assistance may reduce tests other than FBE and U&E in emergency departments, especially among less experienced clinicians.
{"title":"Nudging Emergency Department Clinicians to Reduce Unnecessary Diagnostic Test Ordering: A Multi-Arm Vignette-Based Experiment","authors":"Lu Bai, Shijia Gao, Frada Burstein, Jithin Sajeev, Simon Craig, Diana Egerton-Warburton, Gerard O'Reilly, Peter Cameron, Gabriel Blecher, Liam Hackett, Joseph Miller, Emily Schembri, Patrick J. Owen, Paul Buntine","doi":"10.1111/1742-6723.70187","DOIUrl":"10.1111/1742-6723.70187","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Diagnostic testing is overused in emergency departments, and clinical decision support may reduce unnecessary ordering. We examined the effects of nudge-based clinical decision support interventions on test ordering among emergency department clinicians.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This triple-blind four-arm parallel (1:1:1:1) individually randomised vignette-based experiment included 243 clinicians (male: 54%) from eight emergency departments. Clinicians were presented with a case study (81-year-old woman, simple syncopal event, no injury) and randomised to Nudge #1 (large range of tests and free text), Nudge #2 (Nudge #1 with inline evidence-based advice), Nudge #3 (limited range of tests and free text), or control (free text only). The primary outcome was between-group differences in total tests ordered. Secondary outcomes excluded the most common tests (full blood examination and urea/electrolytes) and were stratified by clinical experience (< 10 or ≥ 10 years).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>There were no differences in total tests ordered compared to control for Nudge #1 (incident-rate ratio [95% CI]: 1.05 [0.83, 1.32], <i>p</i> = 0.691), Nudge #2 (0.85 [0.67, 1.08], <i>p</i> = 0.189), or Nudge #3 (0.90 [0.71, 1.14], <i>p</i> = 0.378). When FBE and U&E were excluded, total tests ordered compared to control were lower for Nudge #2 (0.58 [0.39, 0.86], <i>p</i> = 0.007), and Nudge #3 (0.50 [0.33, 0.76], <i>p</i> = 0.001). Secondary analyses revealed effects for clinicians with < 10 years of experience only.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>While potentially of limited value for reducing the total number of tests ordered, nudge-based clinical decision support interventions that manipulate decision structure and employ decision assistance may reduce tests other than FBE and U&E in emergency departments, especially among less experienced clinicians.</p>\u0000 </section>\u0000 </div>","PeriodicalId":11604,"journal":{"name":"Emergency Medicine Australasia","volume":"37 6","pages":""},"PeriodicalIF":1.4,"publicationDate":"2025-12-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145707906","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Gabriel Ayonmegbesimi Akra, Arunesh Das, Victoria Kristensen, Elizabeth Coren, Cynthia Wu, Duncan James Reed, Bronwyn Shin
Objective
To evaluate the interobserver agreement of emergency physicians in classifying ankle fractures using the Danis-Weber system and to assess whether an educational intervention improves diagnostic consistency.
Methods
Thirteen emergency physicians from Gosford and Wyong Hospitals in NSW, Australia, independently classified 100 ankle radiographs on two separate occasions, spaced 4 weeks apart. Between the two assessments, participants were emailed an educational PowerPoint presentation on the Danis-Weber classification system. Interobserver agreement was measured using Cohen's Kappa statistic. Accuracy and changes in performance between the two quizzes were also assessed, with statistical significance determined using a paired t-test.
Results
The first test demonstrated moderate interobserver agreement (Kappa = 0.51, p < 0.00001), whereas the second test showed substantial agreement (Kappa = 0.61, p < 0.00001). However, the improvement in agreement between the two rounds was not statistically significant (p = 0.63). Physician accuracy scores were 83% in the first test and 88% in the second, which also did not represent a statistically significant difference (p = 0.63).
Conclusions
Emergency physicians at both Hospitals demonstrated moderate to substantial interobserver agreement in applying the Danis-Weber classification system to ankle fractures, with performance levels comparable to those of orthopaedic and trauma surgeons internationally. However, the educational intervention in the form of an emailed presentation did not significantly improve either agreement or accuracy. Alternative educational strategies may be required to enhance diagnostic consistency in clinical practice.
{"title":"Interobserver Agreement of Ankle Fracture Classification Among Emergency Physicians","authors":"Gabriel Ayonmegbesimi Akra, Arunesh Das, Victoria Kristensen, Elizabeth Coren, Cynthia Wu, Duncan James Reed, Bronwyn Shin","doi":"10.1111/1742-6723.70179","DOIUrl":"10.1111/1742-6723.70179","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To evaluate the interobserver agreement of emergency physicians in classifying ankle fractures using the Danis-Weber system and to assess whether an educational intervention improves diagnostic consistency.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Thirteen emergency physicians from Gosford and Wyong Hospitals in NSW, Australia, independently classified 100 ankle radiographs on two separate occasions, spaced 4 weeks apart. Between the two assessments, participants were emailed an educational PowerPoint presentation on the Danis-Weber classification system. Interobserver agreement was measured using Cohen's Kappa statistic. Accuracy and changes in performance between the two quizzes were also assessed, with statistical significance determined using a paired <i>t</i>-test.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The first test demonstrated moderate interobserver agreement (Kappa = 0.51, <i>p</i> < 0.00001), whereas the second test showed substantial agreement (Kappa = 0.61, <i>p</i> < 0.00001). However, the improvement in agreement between the two rounds was not statistically significant (<i>p</i> = 0.63). Physician accuracy scores were 83% in the first test and 88% in the second, which also did not represent a statistically significant difference (<i>p</i> = 0.63).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Emergency physicians at both Hospitals demonstrated moderate to substantial interobserver agreement in applying the Danis-Weber classification system to ankle fractures, with performance levels comparable to those of orthopaedic and trauma surgeons internationally. However, the educational intervention in the form of an emailed presentation did not significantly improve either agreement or accuracy. Alternative educational strategies may be required to enhance diagnostic consistency in clinical practice.</p>\u0000 </section>\u0000 </div>","PeriodicalId":11604,"journal":{"name":"Emergency Medicine Australasia","volume":"37 6","pages":""},"PeriodicalIF":1.4,"publicationDate":"2025-12-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145707970","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Christopher Ennis, Jacob Tant, Brian Burns, Helen Oliver, Kevin Ostrowski, Matthew Oliver, Natalie Kruit, Ian Ferguson
Introduction
For patients in traumatic cardiac arrest (TCA) on scene, the brevity of the window for intervention means that hospital transfer is usually futile, and so pre-hospital resuscitative thoracotomy (PHRT) may represent the best chance of survival.
Methods
In this case series we describe all cases of PHRT undertaken from 1st Jan 2013 until 31st December 2024, in NSW, Australia by physician-paramedic teams. Data were abstracted by two operators, with adjudication by a third. Patients were excluded if RT was commenced in hospital.
Results
A total of 35,146 missions were conducted in our service over the study period; 14,072 were pre-hospital taskings. 34 patients underwent PHRT. 31 patients (91%, 95% CI 76%–98%) were male, and 32 cases (95%, 95% CI 79%–99%) were due to penetrating trauma. Electrical cardiac activity was the commonest sign of life, occurring in 25 patients (74%, 95% CI 55%–86%). 12 patients (35%, 95% CI 20%–54%) had pericardial effusions, and in 10 (29%, 95% CI 16%–48%) this was due to a single cardiac laceration. Five patients (15%, 95% CI 6%–32%) survived for more than 24 h in hospital, and 2 (6%, 95% CI 1%–21%) were discharged neurologically intact. Despite central stab wounds, the survivors had exsanguinated from extra-thoracic trauma, with no evidence of intrathoracic injury.
Conclusion
Our study demonstrates that even in low-volume settings, PHRT can achieve neurologically intact unexpected survivors.
对于现场外伤性心脏骤停（TCA）患者，短暂的干预窗口意味着医院转院通常是徒劳的，因此院前复苏开胸术（PHRT）可能是最佳的生存机会。方法：在这个病例系列中，我们描述了2013年1月1日至2024年12月31日在澳大利亚新南威尔士州由医生-护理人员团队进行的PHRT的所有病例。数据由两名操作员提取，第三名操作员进行裁决。如果患者在医院开始RT，则排除患者。结果：在研究期间，我们共执行了35 146次任务；14,072是院前任务。34例患者接受了PHRT治疗。31例（91%,95% CI 76%-98%）为男性，32例（95%,95% CI 79%-99%）为穿透性创伤。心电活动是最常见的生命体征，出现在25例患者中（74%,95% CI 55%-86%）。12例患者（35%,95% CI 20%-54%）有心包积液，其中10例（29%,95% CI 16%-48%）是由于单一心脏撕裂所致。5例患者（15%,95% CI 6%-32%）在医院存活超过24小时，2例患者（6%,95% CI 1%-21%）神经功能完好出院。尽管有中央刺伤，但幸存者因胸外创伤而失血过多，没有胸内损伤的证据。结论：我们的研究表明，即使在低容量环境下，PHRT也可以实现神经功能完整的意外幸存者。
{"title":"Pre-Hospital Resuscitative Thoracotomy Performed in New South Wales, Australia: A Case-Series","authors":"Christopher Ennis, Jacob Tant, Brian Burns, Helen Oliver, Kevin Ostrowski, Matthew Oliver, Natalie Kruit, Ian Ferguson","doi":"10.1111/1742-6723.70186","DOIUrl":"10.1111/1742-6723.70186","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>For patients in traumatic cardiac arrest (TCA) on scene, the brevity of the window for intervention means that hospital transfer is usually futile, and so pre-hospital resuscitative thoracotomy (PHRT) may represent the best chance of survival.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>In this case series we describe all cases of PHRT undertaken from 1st Jan 2013 until 31st December 2024, in NSW, Australia by physician-paramedic teams. Data were abstracted by two operators, with adjudication by a third. Patients were excluded if RT was commenced in hospital.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>A total of 35,146 missions were conducted in our service over the study period; 14,072 were pre-hospital taskings. 34 patients underwent PHRT. 31 patients (91%, 95% CI 76%–98%) were male, and 32 cases (95%, 95% CI 79%–99%) were due to penetrating trauma. Electrical cardiac activity was the commonest sign of life, occurring in 25 patients (74%, 95% CI 55%–86%). 12 patients (35%, 95% CI 20%–54%) had pericardial effusions, and in 10 (29%, 95% CI 16%–48%) this was due to a single cardiac laceration. Five patients (15%, 95% CI 6%–32%) survived for more than 24 h in hospital, and 2 (6%, 95% CI 1%–21%) were discharged neurologically intact. Despite central stab wounds, the survivors had exsanguinated from extra-thoracic trauma, with no evidence of intrathoracic injury.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Our study demonstrates that even in low-volume settings, PHRT can achieve neurologically intact unexpected survivors.</p>\u0000 </section>\u0000 </div>","PeriodicalId":11604,"journal":{"name":"Emergency Medicine Australasia","volume":"37 6","pages":""},"PeriodicalIF":1.4,"publicationDate":"2025-12-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145707900","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jamie Ranse, Amy L. Sweeny, Gerben Keijzers, Stephanie Rae Hagan, Sharon Mickan, Matthew Brendan Munn, Alison Hutton, Michelle Buckland, Laura Hamill, Catherine Delany, Katie East, Julia Crilly
Objective
This study aimed to identify uncomplicated acute alcohol intoxication (UAAI) practice changes in two Emergency Departments (EDs) and assess if these changes correlate with the conduct of a randomized controlled trial recommending practice change.
Methods
This dual-site retrospective observational cohort study used ED data over a 12-year period (2010 - 2021). The sample included patients with UAAI who presented to one health service in Australia. Changes in patient and health service outcomes were explored for UAAI ED presentations over time. Data were analysed using descriptive statistics, inferential statistics, and a monthly time series analysis.
Results
There were 2344 UAAI-related presentations during the study period. The time series identified two practice change points leading to three periods of practice change. The proportion of patients who received intravenous fluids (IVFs) decreased from 45.9% to 21.7% (p < 0.001). Most patients who presented with UAAI were discharged from the ED (69.4%, n = 1627/2344). Discharged patients had a reduced median length of stay over the study periods (p < 0.001).
Conclusions
Changing practice from an interventional approach for the administration of IVFs to an observation-based approach, for ED patients with UAAI is appropriate and can be sustained. This approach for the management of UAAI is supported by an established and growing evidence base. Factors regarding the reach, adoption and translation of evidence to clinical practice should be further explored.
{"title":"Uncomplicated Acute Alcohol Intoxication in the Emergency Department: A 12-Year Retrospective Study to Understand Practice Change in Intravenous Fluid Usage and Patient Outcomes","authors":"Jamie Ranse, Amy L. Sweeny, Gerben Keijzers, Stephanie Rae Hagan, Sharon Mickan, Matthew Brendan Munn, Alison Hutton, Michelle Buckland, Laura Hamill, Catherine Delany, Katie East, Julia Crilly","doi":"10.1111/1742-6723.70182","DOIUrl":"10.1111/1742-6723.70182","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>This study aimed to identify uncomplicated acute alcohol intoxication (UAAI) practice changes in two Emergency Departments (EDs) and assess if these changes correlate with the conduct of a randomized controlled trial recommending practice change.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This dual-site retrospective observational cohort study used ED data over a 12-year period (2010 - 2021). The sample included patients with UAAI who presented to one health service in Australia. Changes in patient and health service outcomes were explored for UAAI ED presentations over time. Data were analysed using descriptive statistics, inferential statistics, and a monthly time series analysis.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>There were 2344 UAAI-related presentations during the study period. The time series identified two practice change points leading to three periods of practice change. The proportion of patients who received intravenous fluids (IVFs) decreased from 45.9% to 21.7% (<i>p</i> < 0.001). Most patients who presented with UAAI were discharged from the ED (69.4%, <i>n</i> = 1627/2344). Discharged patients had a reduced median length of stay over the study periods (<i>p</i> < 0.001).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Changing practice from an interventional approach for the administration of IVFs to an observation-based approach, for ED patients with UAAI is appropriate and can be sustained. This approach for the management of UAAI is supported by an established and growing evidence base. Factors regarding the reach, adoption and translation of evidence to clinical practice should be further explored.</p>\u0000 </section>\u0000 </div>","PeriodicalId":11604,"journal":{"name":"Emergency Medicine Australasia","volume":"37 6","pages":""},"PeriodicalIF":1.4,"publicationDate":"2025-12-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145676927","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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