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Poster Program Abstracts

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  2. Poster Program Abstracts

Who are our older emergency department patients?

Judy Lowthian PhD MPH BAppSc (SpPath),1 Andrea Curtis BSc (Hons) PhD,1 Johannes Stoelwinder MD FRACMA FACHSE,1 John McNeil AO MBBS PhD FRAC, FAFPHM,1 Peter Cameron MBBS MD FACEM1,2

1School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia; 2Alfred Hospital Emergency & Trauma Centre, Melbourne, Australia

Background

Population ageing is projected to impact on health services utilisation including Emergency Departments (EDs); with older patients reportedly having a high rate of return visits. We describe and compare patterns in ED utilisation between older and younger adults, and quantify the proportion of return visits.

Methods

Population-based retrospective analysis of metropolitan Melbourne public hospital ED data, 1999/2000 to 2008/2009. Numbers of patients, presentations, re-presentations and rates per 1000 population were calculated, with comparison of older (aged ≥70 years) and younger (15–69 years) attendances.

Results

Presentations rose over the study period, by 61% for older adults compared with a 55% increase for younger adults. Rates per 1000 population rose with increasing age. Of the population aged ≥70 years, 39% presented to EDs compared with 17% of the population aged 15–69 years in 2008/2009.

Twenty-seven percent of the increase in older adult presentations was driven by a cohort who attended ≥4 times in 2008/2009; with the number of older patients presenting ≥X4 doubled over the decade, contributing to 23% of all older presentations in 2008/2009.

ED length of stay rose with increasing age; 69% of older adults remained in ED for ≥4 hours compared with 39% of younger adults in 2008/2009. The number of older adult ED hospital admissions doubled over the decade.

Conclusions

Older patients are disproportionately represented amongst ED attendances. They also have an increasing propensity to re-present to EDs, indicating a need to identify the clinical, social and health system related risk factors for re-attendance by specific patients.

Is the increase in emergency short-stay admissions sustainable? Trends across Melbourne 2000 to 2009

Judy Lowthian PhD MPH BAppSc (SpPath),1 Johannes Stoelwinder MD FRACMA FACHSE,1 John McNeil AO MBBS PhD FRACP FAFPHM,1 Peter Cameron MBBS MD FACEM1

1School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia; 2Alfred Hospital Emergency & Trauma Centre, Melbourne, Australia

Objectives

To describe the trends in emergency admissions over 10 years in terms of volume, age-specific rates, hospital length of stay (LOS) and clinical reasons.

Design, Participants and Setting

Retrospective analysis of population-based linked Department of Health Emergency Department (ED) and hospital admission data for metropolitan Melbourne 1999/2000 to 2008/2009.

Outcome Measures

Hospital admission numbers (total, single day/overnight, ≥2 days LOS); admission rates per 1000 person-years (total, single day/overnight, ≥2 days LOS; hospital LOS.

Results

The volume of patients admitted to hospital through EDs rose by 56% over the 10 years to June 2009. The number of same day/overnight admissions rose by 60%, equating to a 5.9% average annual increase beyond that accounted for by demographic change (95% CI 5.7% to 6.5%). The volume of patients admitted for ≥2 days also increased, however the admission rate per 1000 persons for these longer stay patients declined over the decade by 9% (95% CI 5% to 12%).

The most frequent discharge diagnoses were injury or poisoning, and disorders of the circulatory, respiratory or digestive systems. The numbers and mortality rate for ED admissions declined over the decade.

Conclusion

Emergency hospital admissions have risen over the last decade even after adjustment for population changes. There was a disproportionate rise in same day/overnight admissions, and disproportionate re-presentation of the elderly. This is possibly related to changes in ED models of care including introduction of short stay units, improved diagnostic and therapeutic capability, and risk-averse management to optimise safe discharge, within the context of time-based performance targets.

‘Who's running the place?’ Registrar in charge shifts in a tertiary ED: a pilot program

Simon Craig FACEM GCHPE,1,2 Jonathan Dowling FACEM PgCertTox (Cardiff)1,2

1Emergency Department, Monash Medical Centre, Melbourne, Australia; 2Monash University, Melbourne, Australia

Objectives

Emergency registrars usually gain experience ‘running’ an Emergency Department (ED) overnight – without supervision. This paper describes the introduction of ‘registrar in charge’ (RIC) shifts into a tertiary adult ED over a 6-month period. A senior emergency registrar was allocated ‘in charge’ of the ED from morning handover with one-to-one supervision and support by an emergency physician (EP).

Methods

Each registrar was allocated at least one RIC shift during their 13-week ED term. Structured questionnaires gathered quantitative and qualitative data regarding the educational impact of the shifts, any adverse effects on departmental function, changes to work practices, and perceptions of teaching and learning.

Results

During the study period, 16 senior ED registrars were rostered for 26 RIC shifts. 15 had at least one RIC shift; one registrar's shift was cancelled due to staffing issues. The study questionnaires were completed by 16/16 registrars and 13/16 EPs.

The RIC shifts were viewed positively by the emergency registrars: 93% reported useful feedback, felt that the shifts provided a good insight into their workplace behaviour, and that they should be rolled out across other departments. All felt the shifts were relevant to their learning needs, and should be continued. EPs were also positive in their evaluation, and reported little negative impact on departmental function.

Respondents suggested that RIC shifts should occur 2–3 times per term, with each shift lasting 4–6 hours.

Conclusion

RIC shifts are a feasible and effective method to teach running the floor in the ED. Further study is recommended.

Effect of position and weight force on inferior vena cava diameter: implications for arrest-related death

Donald M Dawes,1,2 Jeffrey D Ho,3,4 James R Miner4

1Santa Barbara Police Department, Santa Barbara, CA, USA; 2Lompoc Valley Medical Center, Lompoc, CA, USA; 3Meeker County Sheriff's Office, Litchfield, MN, USA; 4Hennepin County Medical Center, Minneapolis, MN, USA

Introduction

The physiology of many sudden, unexpected Arrest-Related Deaths (ARDs) proximate to restraint has not been elucidated. A sudden decrease in central venous return during restraint procedures could be physiologically detrimental. In this study, we use ultrasound to measure the size of the Inferior Vena Cava (IVC) as a surrogate of central venous.

Methods

This was a prospective, observational study of volunteer human subjects. The IVC was visualized from the abdomen in both the longitudinal and transverse section in the standing and prone positions without weight force applied, and with 100 lbs (45 kg) and 147 lbs (67 kg) of weight force on the upper back in the prone position. Maximum and minimum measurements were determined in each section to account for possible respiratory variation of the IVC.

Results

The IVC significantly decreased in size with each successive change: from standing to prone, from prone to prone with 100 lbs (45 kg) weight compression, from prone with 100 lbs (45 kg) weight compression to prone with 147 lbs (67 kg) weight compression (P < 0.0001). The vital sign measurements had no statistical change.

Conclusions

The physiology involved in many sudden, unexpected ARDs has not been elucidated. However, in our study, we found a significant decrease in IVC diameter with weight force compression to the upper thorax when the subject was in the prone position. While in our rested, healthy volunteers this did not result in a change in vital signs, this may be important in high-risk, impaired subjects and have implications for the tactics of restraint to aid in the prevention of sudden, unexpected ARD cases.

An incident-level profile of TASER device deployments in Arrest-Related Deaths (ARDs)

Donald M Dawes,1,2 Jeffrey D Ho,3,4 Michael White5

1Santa Barbara Police Department, Santa Barbara, CA, USA; 2Lompoc Valley Medical Center, Lompoc, CA, USA; 3Meeker County Sheriff's Office, Litchfield, MN, USA; 4Hennepin County Medical Center, Minneapolis, MN, USA; 5Arizona State University, School of Criminology and Criminal Justice Phoenix, AZ, USA

Introduction

There are numerous unanswered questions regarding officer, suspect and incident-level characteristics of the nearly 400 police-citizen encounters in which a suspect has died proximate to the use of a TASER.

Methods

The authors employed a unique data triangulation method that merged two independent information sources, print media archives and Medical Examiner (ME) reports, to do a descriptive analysis of 392 TASER-proximate arrest related deaths (ARDs) from 2001–2008.

Results

The descriptive analysis shows several trends: (i) the geographic pattern of ARDs is associated with population size, the number of officers per state and TASER device sales patterns; (ii) the typical suspect in these study cases was a middle-aged male who was intoxicated or mentally ill and in crisis. Drugs were identified as the primary cause of death in approximately one-quarter of cases and a contributing factor in an additional 30% of cases; (iii) the ARDs were complex, dynamic encounters between suspects who were actively and aggressively resisting police, and officers who were drawing deeply into their arsenal of force options in an attempt to control and arrest them; (iv) 86% of the ME reports reviewed cited drugs, heart problems, and ExDS as the most common causes of death (alone or in combination); (v) longitudinal analysis showed consistency in most incident, suspect and officer characteristics.

Conclusion

The ARDs examined in this study were complex, prolonged encounters that often involved multiple force options used in combination with the TASER device, as police attempted to gain control over persistently resistant and combative suspects.

Paediatric emergency abdominal x-rays: ‘are we overdoing it?’

Jan Riley MBBS BMedSc,1 Simon Craig FACEM GCHPE,2,3 Michael Ditchfield MBBS MD FRANZCR1,3,4

1Diagnostic Imaging Department, Southern Health, Melbourne, Australia; 2Emergency Department, Monash Medical Centre, Melbourne, Australia; 3Monash University, Melbourne, Australia; 4Diagnostic Imaging Department, Monash Children's, Melbourne, Australia

Background

Paediatric abdominal x-rays (AXRs) are commonly requested in the emergency department (ED) but are thought to be unhelpful in the majority of presentations and expose the patient to unnecessary radiation. The introduction of a guideline may assist in reducing inappropriate requests.

Objectives

This study sought to describe existing paediatric AXR ordering practices across three Victorian EDs.

Methods

We performed a retrospective cohort study of ED paediatric AXRs ordered from July 2010 to July 2011 across one tertiary paediatric ED and two mixed EDs, and identified the five most common indications. These were presented to a panel of seven clinicians and a consensus opinion was sought on the utility of radiological findings in guiding management decisions.

Results

Of the total 489 charts reviewed, the most common indication was undifferentiated abdominal pain 19.1% (n = 94) followed by constipation 17.3% (n = 85), first presentation of swallowed foreign body 14.7% (n = 72), bowel obstruction 12.0% (n = 59) and intussusception 5.7% (n = 28). The percentage of these AXRs considered useful by consensus opinion was respectively, 3.2% (n = 3), 0% (n = 0), 51.4% (n = 37), 54.2% (n = 32) and 14.3% (n = 4).

Conclusions

It is possible that up to 42.1% of paediatric AXRs ordered in our study were inappropriate. Our cross-sectional data is likely representative of the wider Victorian ED setting and the introduction of an evidence-based guideline correlated with clinician consensus may significantly reduce unnecessary requests.

Experiments with teamwork training: in situ simulation

Kim M Yates MBChB MMedSc (Hons) PGCertClinEd FACEM,1,2 Adrienne Adams MBChB FACEM,3 Willem Landman MBBS PGCertClinEd FACEM,1,2 Jane Francis RN,1 Carmen Haines CompRGN PGCertMedHealthSc,1 Diane Bratton RN PGCertAdultEd2

1Emergency Department, Waitakere Hospital, Waitemata District Health Board, Auckland, New Zealand; 2Emergency Department, North Shore Hospital, Waitemata District Health Board, Auckland, New Zealand; 3Emergency Care, Middlemore Hospital, Auckland, New Zealand

Patient safety literature emphasises the importance of teamwork skills and human factors in preventing medical errors. Unless specific teamwork training occurs, teamwork skills are often learnt by experience and role modelling, so learning is haphazard. In the Emergency Department (ED) team composition is multidisciplinary and varies from shift-to-shift, and even patient-to-patient on a given shift. The MedTeams Project showed that formal ED teamwork training improves team behaviours, decreases medical errors and improves attitudes toward teamwork.

Waitemata District Health Board in Auckland, New Zealand has 2 EDs staffed with more than 70 doctors and 200 nurses, many working part-time. The continuing medical education programme consists of weekly meetings with a monthly session at the Waitakere Simulation Centre, however these are primarily attended by doctors. Weekly in-situ simulations at each ED were started as redevelopments occurred, such as the expansion of Paediatric services and the opening of a new ED facility, aiming to include a broader range of staff in the simulations, and improve teamwork.

The pros and cons of in-situ simulation and the Waitemata experience will be discussed.

Experiments with teamwork training: small group sessions and video vignettes

Kim M Yates MBChB MMedSc (Hons) PGCertClinEd FACEM,1 Willem Landman MBBS PGCertClinEd FACEM1

1Emergency Departments, North Shore & Waitakere Hospitals, Waitemata District Health Board, Auckland, New Zealand

Patient safety literature emphasises the importance of teamwork skills and human factors in preventing medical errors. Unless specific teamwork training occurs, teamwork skills are often learnt by experience and role modelling, so learning is haphazard. The MedTeams Project showed that formal ED teamwork training improves team behaviours, decreases medical errors and improves attitudes toward teamwork. Inter-professional discussions amongst our ED clinicians and educators identified that priorities for teamwork training should be communication including elements of situation monitoring, followed by leadership including team structuring and coordination, with excellent patient-centred care as the goal.

Waitemata District Health Board in Auckland, New Zealand has 2 EDs staffed by more than 70 doctors, many working part-time. The continuing medical education programme consists of weekly meetings with a monthly session at the Waitakere Simulation Centre. Feedback on teamwork is given in the monthly simulation sessions, and weekly in-situ simulations, however the educator group felt that there was a need to focus on improving specific teamwork skills, particularly those related to communication, team leadership and team membership.

The challenges of devising interactive teamwork educational sessions to demonstrate and allow practice of specific skills will be discussed, using examples from the Waitemata experience of small group sessions and video vignettes.

Steroids for emergency patients with low back pain and radiculopathy (SEBRA): the SEBRA trial

Ravichandra Balakrishnamoorthy,1 Isabelle Horgan,1 Siegfried Perez MD (trainee),1,2 Gerben Keijzers MBBS FACEM,1,2 Michael Steele PhD3

1Faculty of Health Sciences and Medicine, Bond University, Brisbane, Australia; 2Department of Emergency Medicine, Gold Coast Hospital, Queensland Health, Brisbane, Australia; 3Faculty of Business, Bond University, Brisbane, Australia

Objectives

The management of low back pain with radiculopathy (LBPR) is challenging in the emergency setting. Routine management consists of analgesia and physiotherapy. Small studies suggest that systemic corticosteroids may be of benefit. We aimed to determine whether a single dose of 8mg IV Dexamethasone would produce a significant decrease in visual pain scores in 24 hours for patients with LBPR.

Methods

We conducted a randomized, double-blinded study in ED patients with uncomplicated LBPR. Eligible patients were randomized (using sequentially numbered opaque sealed envelopes) to receive either 8 mg IV Dexamethasone or placebo. All patients received standardized medications and physiotherapy. The primary outcome was visual pain score at 24 hours. Secondary outcomes included change in functional disability using the Oswestry functional disability scale, change in passive straight leg raise angles, use of breakthrough pain medications (oxycodone) and adverse events.

Findings

Patient recruitment is expected to continue until April 2012. We aim to recruit 120 patients. Results will be presented at ICEM 2012.

Conclusions

IV Dexamethasone is a promising drug for the treatment of acute low back pain with radiculopathy presenting to the emergency department. This study will provide high-level evidence regarding this evidence gap and a recommendation will be presented.