Poster Program Abstracts

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Use of emergency department ultrasound for the detection of lower extremity deep venous thrombosis

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Jonathan Theoret MDCM FRCPC,1,2,3 Tong V. Lam MD FRCPC,1,2,4 Adam Lund MD FRCPC1,2

1Royal Columbian Hospital, New Westminster, British Columbia, Canada; 2Eagle Ridge Hospital, Port Moody, British Columbia, Canada; 3Saint Paul's Hospital, Vancouver, British Columbia, Canada; 4Vancouver General Hospital, Vancouver, British Columbia, Canada

Introduction/Background: The management of patients presenting to the emergency department (ED) with suspected deep venous thrombosis (DVT) can often be challenging due to the limited availability of formal ultrasonography. In recent years, the applications of ED ultrasound (EDUS) have expanded to include evaluation for DVT.

Objective: To determine if ultrasound scans performed by ED physicians and residents after a brief training session have a high sensitivity and specificity when compared to formal US for the assessment of lower extremity DVT.

Methods: ED physicians and residents have attended a 30-minute training session prior to the start of patient recruitment. Any patient ≥19 year of age presenting to the ED with suspected DVT was asked to provide consent. Prior to completion of the EDUS scan, clinicians were asked to document whether they planned to anti-coagulate the patient based on their risk factor profile and clinical presentation. The EDUS scan included a two-point compression test at the common femoral vein and popliteal vein sites. The patients were subsequently booked for formal ultrasonography, as is the current standard of care. The EDUS and formal ultrasound were subsequently compared.

Results: Currently 140 patients have been enrolled in the study, with a target of 176. Preliminary analysis has demonstrated high sensitivity and specificity for the detection of DVT. Patient enrolment will close in two months.

Conclusion: EDUS can reliably identify patients at very low risk for lower extremity deep venous thrombosis.

Public point of view for the increasing violence towards emergency staff

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Al Behçet MD, Emine Sarcan MD, Suat Zengin MD, Cuma Yıldırım MD, Mehmet Doğan MD, Sinem Kabul MD

Emergency Department of Medicine School Faculty, Gaziantep University, Gaziantep, Turkey

Objective: In this study we researched the public point of view towards the increasing violence in health, their relationship with violence, the reasons for violence and what could be done to prevent it.

Material and Methods: This study was performed between November 2012 and February 2013 in Gaziantep city center by The Emergency Department of Gaziantep University Medical Faculty. A survey consisting of 33 questions was performed face-to-face with 1600 participants representative of the general population. Chi-square and Yates correction Chi-square test were used. P < 0.05 was considered statistically significant.

Results: 52.7% percent of the participants had exercised violence on health workers including doctors (28.2%) and nurses (17.8%). 38.5% of the participants exercised violence at least once and two percent more than five times. The most important reasons for violence according to the participants were the workers not abiding their obligations (15.9%), the prolonged waiting time in the hospital (15%), violence provocation on media (13.6%) and the politicians declarations against the health workers (9.7%). 20.3% percent thought violence was an advocacy method. The major cause of irritation was the participant's not being taken into consideration (28%). 13.3% percent thought that doctors should be beaten/killed for the patients not being able to be saved. 14.3% percent were happy with the news that a health worker was beaten or killed. People who exercised violence or who had a tendency for violence were between 24–30 ages, male and with a low level of education (p < 0.001). 10.5% of the people agreeing with violence being a method for avocation and 22.2% of the people agreeing that doctors should be beaten/killed for the patients not being able to be saved were people who never had any arguments with health workers. 16.6% of the participants indicated that health workers including doctors and nurses exercised violence towards themselves.

Conclusion: An important portion of the population viewed violence towards the health workers as a way of advocacy, approved violence and were pleased by these events. Mostly not being taken into consideration, the media's and the politicians actions against the health workers were blamed for violence.

Key words: Health worker, violence, public view, media, politician, education.

Performance targets in emergency medicine – how about one for education?

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Greta Perovic,1 Don Liew MBBS FACEM2

1St Vincent's Hospital, Melbourne, Victoria, Australia; 2Teemwork Pty Ltd, Victoria, Australia

Background: Older amongst us will recall medicine's “See One, Do One, Teach One” teaching paradigm. An illustrative example of Kolb's Experiential Learning Cycle, it potently facilitated trainee learning, but came at a cost of safety and acceptability. Society and our fraternity rightly expect requisite degrees of competence before a practitioner performs any intervention on real patients, let alone teach it. “Learn One” commands a position in the modern teaching paradigm. With high demand for service provision and a national obsession with time-based targets, how then can training institutions fulfill their teaching obligations?

Methods: Simulation based education and workplace based assessments (WBAs) represent current tools in our teaching armoury. Both are resource-intensive. The former precludes floor-based activity; whether or not the latter is likewise is currently subject to heated debate! One reason is the perceived shortage of required time to effectively facilitate WBAs. Will WBAs compromise service provision and education? Or is it the ideal tool to simultaneously cater for both?

Conclusion: Measuring education deliverables may assist this conundrum and emerges as an important endeavour for our fraternity. Newer educational strategies in addition to simulation and WBAs – including private hospitals, online resources and courses – characterise the modern educational landscape. Robust, reliable measures of education may help determine efficacy of these tools. After all, we remain accountable for the lasting imperative, that our future specialists are appropriately trained.

Round the table teaching: a novel method for small group teaching using a simulated learning environment

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Fenton O'Leary MBBS FACEM,1,2,3 Kathryn McGarvey RN MMedEd,2,3 Francis Lockie MBBS FRACP,4 Karen M Scott BEd MA PhD2

1Emergency Department, The Children's Hospital at Westmead, Westmead, New South Wales, Australia; 2Sydney Medical School, University of Sydney, New South Wales, Australia; 3RESUS4KIDS, NSW Child Health Networks, New South Wales, Australia; 4Emergency Department, Women's and Children's Hospital, Adelaide, South Australia, Australia

This presentation describes a novel small group teaching methodology which combines a number of evidence-based, small group teaching methods into an engaging, practical format for teaching the sequential approach to common emergency department presentations. The instructor-to-student ratio is 1:6–8 ensuring all participants can engage with the course content and the group, and have ample hands-on practical time. Rather than teaching clinical skills in isolation, a low fidelity simulated learning environment is used, with a ‘pause and discuss’ format, allowing the instructor to enhance and direct learning and provide regular feedback. Round the Table Teaching utilises an approach similar to the Fishbowl method, enabling participants to learn from watching each other and undertaking individual practice. Using a blended learning approach, with e-learning or printed material as pre-learning, the knowledge participants acquire prior to the face-to-face component is tested when they apply it to practical skills during the simulated learning scenarios. Through the ‘testing effect’, students learn more and retain knowledge and skills longer when tested on recently studied material. The Round the Table Teaching method can be applied to any topic where participants have to demonstrate understanding of a sequential approach to a clinical skill or clinical condition. Examples of possible topics include the sequential approach to a trauma patient and the insertion of a central venous catheter. The method is particularly engaging in an interprofessional environment or where different grades learn together within one profession as the emphasis is on learners participating individually and as a group.

The neurocognitive effects of simulated use-of-force scenarios

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Donald Dawes,1,2 Jeffrey Ho,3,4 Andrea Vincent,5 Paul Nystrom,3,4 Johanna Moore,3 Mike Brave,6 James Miner3

1Lompoc Valley Medical Center, Lompoc, California, USA; 2Santa Barbara Police Department, Santa Barbara, California, USA; 3Hennepin County Medical Center, Minneapolis, Minnesota, USA; 4Meeker County Sheriff's Office, Litchfield, Minnesota, USA; 5University of Oklahoma, Norman, Oklahoma, USA; 6LAAW International, LLC, Scottsdale, Arizona, USA

Introduction: While the physiologic effects of conducted electrical weapons (CEW) have been the subject of numerous studies, the effect on neurocognitive functioning is less well understood. We compared the neurocognitive effects of an exposure from a TASER® X26™ CEW to four other use-of-force scenarios during a law enforcement training exercise.

Methods: Data were collected on subjects undergoing one of five use-of-force scenarios: 1) a 5-second TASER X26 CEW exposure, 2) a sprint of 100 yards with obstacles, 3) a 45-second simulated fight, 4) a K-9 search and bite exercise, and 5) a spray of oleoresin capsicum to the face. The neurocognitive testing consisted of a computer-based programme, the Automated Neuropsychological Assessment Metrics, a well-established neurocognitive metric using three subtests. Once the subject completed the practice session, a baseline, pre-scenario session was administered. The subject then completed the scenario. Vital signs and the battery were repeated immediately post-scenario. The battery was repeated again at 15 minutes, and at one hour. Performance across the three tests was examined using a summary score, the Index of Cognitive Efficiency (ICE).

Results: We enrolled 57 subjects. There were no differences in cognitive performance according to exposure group (F (4, 51) = 1.13, p = 0.36) and no interaction between exposure group and session (Λ = 0.81, F (12, 130) = 0.90, p = 0.55). However, the main effect for session was significant (Λ = 0.61, F (3, 49) = 10.28, p < 0.0001). Follow-up contrasts indicated overall decrements in baseline performance at sessions 3 and 4 (ps < 0.002) that recovered to baseline levels by session 5 (p = 0.38).

Conclusion: We did not find a difference between the neurocognitive effects of the five use-of-force scenarios. The use-of-force scenarios lead to a decline in neurocognitive functioning but this effect was transient and may not have reached the level of important clinical significance.

Markers of acidosis and stress in a sprint versus a conducted electrical weapon

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Donald Dawes,1,2,3,4 Jeffrey Ho,5,6 Paul Nystrom,5,6 Johanna Moore,5 James Miner5

1Lompoc Valley Medical Center, Santa Barbara, CA, USA; 2Hennepin County Medical Center, Minneapolis, MN, USA; 3Lompoc Valley Medical Center, Lompoc, California, USA; 4Santa Barbara Police Department, Santa Barbara, California, USA; 5Hennepin County Medical Center, Minneapolis, Minnesota, USA; 6Meeker County Sheriff's Office, Litchfield, Minnesota, USA

Introduction: Acidosis and catecholamine excess have been proposed as underlying physiologic derangements in subjects at high risk for arrest related death. The effect of conducted electrical weapons (CEW) on these variables has been studied, but there has not been an attempt to find an “equivalency” with exercise.

Methods: Blood was drawn immediately before the intervention, and then at 0, 2, 4, 6, 8 and 10 minutes after and analysed for pH, lactate, and serum catcholamines. Sprint subjects were split into 3 groups for analysis, 20 yard sprint (group one), 30–50 yard sprint (group 2), and >50 yard sprint (group 3), and compared to a 5-second TASER X26 exposure (group 4). Medians of each group were compared at set time points after sprinting or exposure using the K-sample equality of medians test. Differences within each group were compared across set time points using the Wilcoxon sign-rank test.

Results: 37 subjects were enrolled. At baseline, the median pH medians in the four groups were not different (p = 0.715). At all subsequent time points the median pH was different between the groups (p < 0.001). The pH had decreased at 0, 2, 4, and 8 minutes in groups 1, 2, and 3 (p < 0.001). At 6 minutes all the groups were significantly different than baseline (p < 0.001). At 10 minutes, the pH of groups 2 and 3 was significantly different than baseline (p < 0.01). At baseline total catecholamines were not different between the groups (p = 0.381). At 0 and two minutes after the exposure, the total catecholamine medians across groups were significantly different (p = 0.025). There was no difference in catecholamines at 4, 6, 8 or 10 minutes. At 0 and two minutes after exposure total catecholamines were elevated from baseline in groups 2 and 3 (p < 0.001).

Conclusion: A 5-second CEW exposure effects markers of acidosis and stress less than or equal to a 20-yard sprint.

Does CSF spectrophotometry provide benefit in the assessment of CT negative suspected subarachnoid haemorrhage?

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Angus Hann MBBS (Hons),1 Kevin Chu MBBS FACEM,1,2 Jaimi Greenslade PhD,1,2 Anthony Brown MBChB FACEM1,2

1School of Medicine, University of Queensland, Brisbane, Queensland, Australia; 2Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia

Background: Both visual inspection and spectrophotometry of the CSF are performed following a LP in the study hospital for patients with suspected subarachnoid haemorrhage (SAH) and a normal head CT.

Objective: To determine whether spectrophotometry plus visual inspection (combined examination) identifies more aneurysmal SAH than visual inspection alone.

Methods: A retrospective study of ED patients who had a headache-related diagnosis on EDIS and CSF examined for xanthochromia from June 2005 to July 2012 was conducted. Aneurysmal SAH was defined as angiographic evidence of a cerebral aneurysm within 30 days of presentation in a patient being investigated for non-traumatic SAH. Patients not undergoing angiography were followed up clinically to determine whether they represented with SAH to the study hospital. The combined examination result was considered positive if either test revealed xanthochromia. Inconclusive results were considered positive.

Results: 409 patients (mean ± SD age 37.8 ± 13.6 years, female 56.2%) with a normal head CT had a LP performed. Six (1.5%) had a cerebral aneurysm detected on angiography which was coiled or clipped. Visual inspection and the combined examination identified five and six of these aneurysms respectively [sensitivity 83.3% (95%CI:36.1-97.2%) vs 100% (95%CI:54.1-100%), specificity 95.0% (95%CI:92.4-96.0%) vs 78.2% (95%CI:73.8-82.1%)]. The sensitivity of the combined examination was not statistically different to that of visual inspection alone. Visual inspection had a significantly higher specificity than the combined examination.

Conclusion: The combined examination detected more cases of aneurysmal SAH than visual inspection alone. Caution should be applied when using only visual inspection of the CSF to exclude this diagnosis.

Students’ perspectives on clinical practice in medical assistant education in Malaysia

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Alias Mahmud DipMA BSc Med,1 Nor Hayati Alwi Bsc MSc PhD,2 Tajularipin Sulaiman BSc MeD PhD,2 Aminuddin Hassan BSc Msc PhD2

1Training Management Division, Ministry Of Health, Malaysia; 2Faculty of Educational Studies, University Putra, Malaysia

Introduction: Clinical practice serves as the main component in the curriculum of Diploma in Medical Assistant in Malaysia. The purpose of this clinical practice is to provide the actual experiences to students in the aspect of patient care and also enhance the integration between theoretical learning with practice.

Objective: To obtain student perspectives on the Diploma in Medical Assistant undergoing clinical practice in several hospitals in the state of Negeri Sembilan. Several perspectives have been explored from the students which are in terms of confidence, clinical learning and the use of clinical equipment.

Methods: This study adopts the survey method on 67 fourth-semester students of the Diploma in Medical Assistant course, at the Medical Assistant College, Seremban who have undergone clinical practice in several hospitals. The study instrument used is the questionnaire form containing 20 items and which uses the 5-point Likert Scale. Data have been analysed descriptively as to gain the students’ perspectives in the aspects of confidence, clinical learning and the use of clinical equipment.

Results: The study outcome shows that there is a degree of concern among the students who undergo the clinical practice. Other than that, there are several issues that emerge in the clinical implementation which is the gap that exists between theory and practice such as the different equipment used in the college compared to the clinical placement where they are placed.

Conclusion: Practical exposure in college needs to be optimised so that it can enhance students’ confidence before they undertake clinical practice. Other than that, the implementation of theoretical teaching and practice should be integrated as to prevent the gap from forming between theory and practice.

2013: The establishment of emergency medicine in Norway

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Gayle Galletta MD, Kåre Løvstakken MD

Akershus University Hospital, Lørenskog, Norway

Study objective: Norway (population five million) is one of the wealthiest countries in the world. Healthcare is considered a universal human right, and each resident is covered by the national health plan and assigned a primary care physician (PCP). Despite this progressive healthcare system, the specialty of emergency medicine does not exist. Patients who are not critically ill or injured, are first evaluated by their PCP or, if after hours, the urgent care centre associated with the PCP's office. Patients who require more extensive evaluation, treatment, or hospital admission are sent to the hospital's Acute Receiving Area, which typically has separate areas for medicine, surgery, neurology, and paediatrics. Most patients are initially evaluated by interns or other inexperienced physicians.

Methods: In February 2013, Norway's first emergency department (annual census 45,000) was established at Akershus Universitetssykehus (AHUS), located near Oslo. By September 2013, eight full-time attending physicians (3 American trained emergency medicine physicians, two Norwegian anaesthesiologists, one Norwegian paediatrician, one Norwegian internist, and one Norwegian surgeon) will be staffing the emergency department around the clock to provide triage, patient care and supervision to physicians in training.

Results: Less than one year from its inception, the ED at AHUS will be providing 24/7 attending physician coverage, training future emergency physicians and contributing to EM research.

Conclusion: Norway is, in 2013, experiencing the development of emergency medicine, in much the same way as the United States, Australia, and other developed countries did 30–50 years ago.

Development and maintenance of a continuing medical education programme for a pre-hospital service in the UAE

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Nathan Puckeridge BSc MParaSC(CritCare),1,2,3 Fergal Cummins FCEM FACEM1,3,4,5

1Clinical Education & Research, National Ambulance, Abu Dhabi, United Arab Emirates; 2School of Medical Science, Edith Cowan University, Perth, Western Australia, Australia; 3School of Biomedical Science, Charles Sturt University, Bathurst, New South Wales, Australia; 4REDSPoT Retrieval, emergency Disaster Medicine Research and Development Unit, Dublin, Ireland; 5Graduate Entry Medical School, University of Limerick, Limerick, Ireland

Objective: National Ambulance commenced operations in the UAE to assist the government to provide pre-hospital care services in urban, remote and hostile environments. Clinical staff were chosen from various international pre-hospital systems with varying educational backgrounds and clinical practice capabilities. The Health Authority Abu Dhabi (HAAD) regulate within a tiered licensure system to assess, credential and license staff. This necessitated the development of an education system to draw multiple curriculum frameworks and regulatory systems into a singular body of science knowledge and skill-base aligned to accepted clinical practice and fulfill regulatory measurables yet ensure clinicians fulfill community safety expectations and develop evidence of ongoing clinical competence.

Methods: 1) Consultation with HAAD where pre-hospital professionals are mandated to hold certification in life-support programmes demonstrating algorithmic approach to common life threats. 2) Curriculum standards from five major developed pre-hospital systems were compared for continuous education content and suitability for use within the context of Joint Royal College Ambulance Liaison Committee CPGs (HAAD standard).

Results: To date, 250 staff have presented to HAAD for credentialing assessment and licensure. None have failed to meet the requirements for licensing examinations, none have been deficient in CME credits and all have met safe clinical practice competency standards.

Conclusion: An objective, structured clinical education framework including a revolving continuous education plan which exceeds the mandated clinical specification for tiered measurable levels of pre-hospital professionals has coveted National Ambulance as a clinical leader in terms of clinical delivery, service provision and future sustainability for the UAE.

Developing a training programme for a de novo HEMS service in the UAE

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Hugo Goodson BHSc,1 Nathan Puckeridge BSc MParaSc(CritCare),1,2,3 Fergal Cummins FCEM FACEM1,3,4,5

1Clinical Education & Research, National Ambulance, Abu Dhabi, United Arab Emirates; 2School of Medical Science, Edith Cowan University, Perth, Western Australia, Australia; 3School of Biomedical Science, Charles Sturt University, Bathurst, New South Wales, Australia; 4REDSPoT Retrieval, Emergency Disaster Medicine Research and Development Unit, Dublin, Ireland; 5Graduate Entry Medical School, University of Limerick, Limerick, Ireland

Background: National Ambulance has been a provider of pre-hospital emergency care in Abu Dhabi and other regions of the United Arab Emirates (UAE) since November 2010. In addition to helping to develop the public ambulance system in Abu Dhabi and provide medical personnel for other contracts, the company is also contracted to provide a new helicopter emergency medical service (HEMS) catering for onshore and offshore oil and gas operations. Prior to commencement of operations, The National Ambulance Education Department was tasked with creating and delivering a training package that equipped experienced paramedics, some of whom had not worked in an aeromedical environment before, with sufficient knowledge and understanding to work safely and effectively as flight paramedics.

Methods: As part of the process the following resources were reviewed: international standards, aeromedical retrieval guidelines and protocols, HEMS experts, and existing HEMS systems publications. A training programme was constructed with consideration for its appropriateness for the UAE's unique cultural and geographical requirements.

Results: The programme comprises multiple blended learning components: online/self-directed learning provides the clinical knowledge, practical airframe orientation and safety training ensures familiarity and operational awareness. In addition, practical scenario sessions maximise crew resource management learning and risk mitigation while allowing paramedics to consider practical application of their clinical skills.

Conclusion: The National Ambulance HEMS training package is unique for the UAE arena but has utilised experiences of other HEMS services. The importance of cultural awareness has been essential in providing a de novo HEMS service in the UAE.

Emergencies in radiology: a survey of radiologists and radiology trainees

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Simon Craig MBBS (Hons) FACEM MHPE,1,2 Parmanand Naidoo MBBS FRANZCR2,3

1Monash Medical Centre Emergency Department, Monash Health, Clayton, Victoria, Australia; 2Southern Clinical School, Faculty of Medicine, Monash University, Clayton, Victoria, Australia; 3Monash Health Radiology, Monash Health, Clayton, Victoria, Australia

Introduction: Emergencies in radiology are infrequent, but potentially lethal. Australasian radiologists are advised to undergo resuscitation training at least every three years, however, little is known about their experience and confidence in managing common emergencies relevant to their clinical practice. This paper describes the current experience and confidence of Australasian radiologists and radiology trainees in the management of common medical emergencies.

Methods: A cross-sectional online survey of trainees and fellows of the RANZCR collected data on training and learning preferences relating to resuscitation and life-support skills, access to emergency medical care, and knowledge, confidence and ability in managing a variety of medical emergencies.

Results: There were 602 responses to the survey (response rate 23.4%). The majority of respondents were interested in learning more about the management of contrast reactions, cardiac arrest, ischaemic chest pain, and basic life support. Self-rated knowledge, confidence and ability were higher in respondents who had completed life-support training within the previous three years. In this group, however, more than 40% rated their ability at managing contrast reactions as poor or fair, while more than 60% rated their ability as poor or fair for management of cardiac arrest, basic life support, advanced life support, and dosing of adrenaline. Preferred resuscitation training modalities included simulation, small group tutorials, and workshops.

Conclusion: Self-reported level of skill and expertise in the management of potential emergencies in radiology is suboptimal among a large number of respondents. Consideration should be given to addressing this by improving access to specific training.

Fast and Furious: implementing LEAN management in ED

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Abel Wei

Emergency Department, Radboud University Medical Center, the Netherlands

Background: Doctors are scientists. If we manage our department according to best practice like how we practice medicine based on evidence levels, there will be no lengthy waiting time, ED crowding, admission cueing, etc. The best practice might just be LEAN. The idea of LEAN management is to eliminate every step in the process that is not adding value to the end product. By eliminating these steps you try to maximise the efficiency and focus on the important steps in the process to get the best end product in the least amount of time and effort. LEAN management was originally designed by the Toyota motor corporation to make the production of their automobiles more efficient.

Methods: All patients with relatively simple traumatic injuries, patients with ophthalmic, ENT problems and patients with a demand for care that can be solved within 45 minutes are referred to as fast track patients. The objective was to make the process of these patients so efficient that they would be able to leave the hospital within 45 minutes of arrival. Furthermore we wanted the patients to be satisfied about their treatment. We performed a before and after LEAN management study. In July, August and September of 2012, time measurements were made for all patients in the previous benchmark study. Of each patient the time of arrival at the ED and the time of departure were administered. During the 9th of May 2013 until the 3th of July, measurement is made of the fast track patients so it is comparable to the benchmark database. The mean time between arrival and leaving the ED was 58.37 minutes with a SD of 34.24 min in the 54 fast track patients in the benchmark database in 2012. During the measurement in 2013, 375 patients are included. The mean time between arrival and leaving the ED was 46.5 minutes. This means a reduction of 11 minutes and 52 seconds. In the first three weeks we asked all fast track patients to fill in a satisfaction survey. During these weeks 143 patients arrived at the ED of which 99 filled in the form and 85 filled it in completely. In general the patients were very pleased with the courtesy of the personnel and the general treatment, these items almost had a perfect score. Some patients believe the time until treatment by the doctor and the pain treatment can still be improved. 85 of the patients gave a grade of their general appreciation of the ED and judged the ED with a mean grade of 9.0.

Internet use in NSW emergency departments

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Sally McCarthy MBBS FACEM MBA, Victoria Cook, Matthew Murray, Vanessa Evans

Emergency Care Institute, NSW Agency for Clinical Innovation, Sydney, Australia

The principles of evidence based medicine dictate the implementation of the most current evidence for clinical care. Clinicians have cognitive limitations therefore easy access to resources is critical in practicing EBM. These resources are increasingly, and often, exclusively, found online. Access to online resources and the internet has been identified by emergency clinicians as a major issue in NSW emergency departments (ED) with consistent feedback that lack of access impedes clinicians’ ability to deliver quality care. The Emergency Care Institute (ECI) surveyed NSW EDs to explore the use and availability of internet services. The survey, in May 2013, obtained 557 responses, from all local health districts (LHDs). To contextualise, the survey enquired about the clinical questions that drive potential internet needs. One half of respondents reported that their level of internet access available at work was poor or that they had no access (50%). Only 7% reported that internet access was ‘very good’. Use of personal communication devices to access medical resources was widespread, with 69% of respondents using their own device. Internet access barriers identified were blocking firewalls / blocked sites (73%), and a number of other technical or resource factors, including lack of computer/ insufficient computers (51%); slow computer /outdated technology (51%); poor/no wireless access (48%) and volume of staff needing to use shared computers (46%). The majority of respondents (89%) felt that these barriers affected their ability to perform their work. The presentation will report the findings and implications of this research. This survey and report follows initial work by Ms V Cook, ECI undergraduate student.

What do clinicians perceive as a successful trial of fluids? A secondary assessment of a randomised controlled trial

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Sandy Hopper MBBS FACEM FRACP,1,2 Michelle McCarthy MN,1 Chasari Tancharoen MBBS,3,4 Katherine J Lee PhD,2,3 Francesca Orsini MSc,2 Franz Babl MD MPH FRACP1,2

1Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia; 2Murdoch Children's Research Institute, Melbourne, Victoria, Australia; 3Department of Paediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia; 4Junior Medical Staff Department, St Vincent's Hospital, Melbourne, Victoria, Australia

Aim: To explore physician perceptions of the amount of fluid that demonstrates a successful “trial of fluids”, defined as adequate fluid intake in the emergency department (ED) in children who have had insufficient fluid intake at home.

Methods: This is a secondary analysis of a randomised placebo–controlled trial of viscous lignocaine versus placebo in children aged six months to eight years with acute infectious ulcerative mouth conditions (gingivostomatitis, ulcerative pharyngitis or hand foot and mouth disease), and poor oral fluid intake. We measured the amount of fluid ingested in the 60 minutes following administration of the intervention and relate physician perception of adequate intake to measured intake. Given there was little difference in oral intake between the treatment groups, the two arms were pooled for this analysis.

Results: 100 participants were recruited (50 per treatment group) all of whom completed the 60 minute trial period. Clinically, 21% were not dehydrated, 72% mildly dehydrated and 5% moderately dehydrated at ED triage. Overall, clinicians perceived 58% of participants to have an adequate intake within the first hour following intervention. The median consumption of those whose oral intake was deemed as adequate was 12.6 (interquartile range 9.4–18.4) ml/kg; for those whose oral intake was not deemed adequate the median consumption was 2.7 (0.7–5.3) ml/kg (ranksum p < 0.001).

Conclusion: In children undergoing trial of fluids, we found most clinicians perceived a fluid intake greater than 9.4 ml/kg as adequate and lower than 5.3 ml/kg as inadequate.

Normal ranges of heart rate and respiratory rates for infants and children: a cross sectional study of patients attending an Australian tertiary hospital paediatric emergency department

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Fenton O'Leary MBBS FACEM,1,2 Andrew Hayen PhD,3 Francis Lockie MBBS FRACP,4 Gilad Chayen MD,1 Jennifer Peat PhD5

1Emergency Department, The Children's Hospital at Westmead, Westmead, New South Wales, Australia; 2Sydney Medical School, University of Sydney, New South Wales, Australia; 3School of Public Health & Community Medicine, University of New South Wales, New South Wales, Australia; 4Emergency Department, Women's and Children's Hospital, Adelaide, South Australia, Australia; 5Australian Catholic University, Melbourne, Victoria, Australia

Introduction: A key component in the assessment of a child in the emergency department (ED) is their heart rate and respiratory rate. In order to interpret these signs practitioners must know what is normal for a particular age. The aim of this paper was to develop age specific centiles for these parameters and to compare centiles to the previously published work of Fleming and Bonafide and the Advanced Paediatric Life Support (APLS) reference ranges.

Methods: A retrospective cross sectional study of children presenting to the emergency department of the Children's Hospital at Westmead, Australia. Data was restricted to afebrile, triage category five patients aged 0–15 years. Centiles were developed using quantile regression analysis, with cubic B splines to model the centiles. The resulting centile charts were compared with previous studies by concurrently plotting the estimates.

Results: 668,616 records were retrieved and 111,696 heart and respiratory rates included in the analysis. Graphical comparison shows that with heart rate our 50th centile agrees with the results of Bonafide, is significantly higher than the Fleming centiles and fits well between the APLS reference ranges. With respiratory rate our 50th centile was significantly lower than the comparison centiles in infants, becomes higher with increasing age and crosses the lower APLS range in infants and upper range in teenagers.

Conclusion: To our knowledge this is the largest dataset of respiratory and heart rates in children. Clinicians should be aware that there is still some controversy over what represents normal respiratory or heart rates in children.

An evaluation of research capacity among emergency department clinicians

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Jenine Lawlor BPsych (Hons) MPsych,1,2 Jeremy Furyk MBBS MPHTM MSc (Clinical Trials),2 David Plummer AM MBBS PhD,1,3 Richard Franklin BSc MSocSci PhD,1 Linda Shields BAppSci MD PhD,4 Wendy Smyth BA MApp Sci Grad Dip MBus PhD4

1School of Public Health and Tropical Medicine, James Cook University, Townsville, Queensland, Australia; 2Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia; 3Professor of Health Practitioner Research Capacity Development, The Townsville Hospital, Townsville, Queensland, Australia; 4Tropical Health Research Unit for Nursing and Midwifery Practice, The Townsville Hospital and James Cook University, Townsville, Queensland, Australia

Objective: This study aims to assess the baseline research capabilities of Emergency Department (ED) clinicians at The Townsville Hospital (TTH).

Methods: A survey instrument was sent to clinicians working in the ED over a one month period. Participants were asked to provide information on demographics, interest in participating in future research, research experience and support needs, and attitudes and beliefs about research.

Results: Of the 13 allied health, 109 medical and 223 nursing staff working in the ED at the time of the survey, 212 clinicians (13 allied health, 88 medical and 111 nursing) responded yielding an overall response rate of 61.5%. Despite only a minority of clinicians participating in research activities such as publications (11.8%) and conference presentations (12.3%) in the preceding 3 years, the majority of clinicians (68.3%) were interested in getting involved in future research. In general clinicians reported having more experience and requiring less support with earlier stages of the research process such as searching and critically reviewing the literature. The four barriers identified as most influencing research involvement were insufficient time (71.2%), lack of support requirements such as training or supervision (61.8%), not having a topic that was interesting or relevant (42.0%), and being unable access to adequate funding or resources (23.6%).

Conclusion: Research involvement of ED clinicians at TTH was only small, with more support required for more complex research tasks. Attitudes towards research were generally positive with reported interest in future involvement likely to facilitate research capacity building efforts in the ED.

Foreign language speaking patients- satisfaction with emergency department service at a tertiary hospital in Brisbane

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Ibrahim Mahmoud MBBS MSc MPH Gcert (Epi) PhD,1 Xiang-Yu Hou MD PhD,1 Kevin Chu MBBS,1,2 Michele Clark PhD,1 Rob Eley MBBS3

1School of Public Health, Queensland University of Technology, Brisbane, Australia; 2Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; 3The University of Queensland – Princess Alexandra Hospital, Brisbane, Australia

Objective: To compare the satisfaction with hospital emergency department (ED) service among patients from Non-English speaking backgrounds (NESB) to those from English speaking backgrounds (ESB).

Methods: A cross-sectional survey was conducted at the ED of an adult tertiary-referral hospital in Brisbane with 828 patients of ATS 3, 4 or 5 over a four-month period. Pearson X2-test and multivariate logistic regression analyses were performed to examine the differences in patient reported satisfaction between the ESB and NESB groups.

Results: Despite the fact that both NESB patients and ESB patients are fairly satisfied with the ED service (63.2% and 80.7% satisfaction rate respectively), the NESB patients were less satisfied with their ED service than the ESB patients (OR 0.4, 95% CI 0.3–0.6, p < 0.05). The promptness of service received the lowest satisfaction rates (ESB 64.7%, NESB 51.1%, p < 0.05), followed by the attention given to spiritual and emotional needs (ESB 68.2%, NESB 55.0%, p < 0.05). The two groups reported that the most important elements of their ED service are the promptness of service (18.1%), quality and professional care (10.0%), communication (9.5%), and staff (5.2%).

Conclusion: Despite the high satisfaction rates with ED service, patients from NESB were significantly less satisfied than the ESB patients. Further research is required to examine the possible reasons including their expectations from ED service.

A three year retrospective study on dermatological conditions presenting to a tertiary emergency department in Australia

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Julia Lai-Kwon MBBS,1 Tracey J Weiland PhD,2,3 George A Jelinek FACEM,2,3 Alvin H Chong FACD1

1Department of Medicine (Dermatology), St. Vincent's Hospital, Melbourne, Australia; 2Emergency Practice Innovation Centre, St. Vincent's Hospital, Melbourne; 3Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia

Introduction: Dermatology is primarily an outpatient-based specialty in Australia. However, Hamilton et al.1 report that 5–8% of ED presentations are for dermatological complaints. Identification of the type and frequency of dermatological conditions presenting to a tertiary Australian ED would have implications for curriculum design for junior doctors and emergency physicians.

Objective: To provide demographic and clinical data on the types of dermatological problems that present to a tertiary ED in Australia (St Vincent's Hospital Melbourne) over a three year retrospective period.

Methods: All ED visits between 1 January 2009 and 31 December 2011 were extracted from the hospital database. Dermatological presentations were identified by searching for keywords in the ‘Presenting Complaint’ and ‘Triage Notes’ fields, and by searching for specific ICD10 diagnosis codes. These lists were merged and traumatic skin injuries, burns, post-operative wound complications and repeat presentations were excluded. The characteristics and patient demographics were then analysed.

Results: 4817 patients presented with a dermatological complaint (3.9%). The most common conditions were cellulitis (36.1%), allergy with skin involvement including urticaria and angioedema (19.5%), boils/ abscesses/furuncles/pilonidal sinuses (11.1%), eczema (5.7%), and varicella zoster (3.3%). 937 (19.4%) patients required admission for cellulitis (56.0%), boils/ abscesses/furuncles/pilonidal sinuses (19.2%), non-specific skin infections (3.4%), psoriasis (3.3%) and eczema (2.9%).

Conclusion: Skin conditions represent a small proportion of ED presentations. High prevalence conditions such as cellulitis, abscesses and urticaria/ angioedema should the focus of emergency medicine dermatological curricula to improve the recognition and initial management of common skin complaints.


1 Trott AT. Rash. In: Hamilton GC, Sanders A, Strange GS, editors. Emergency Medicine: an approach to clinical problem solving, 2nd ed. Philadelphia, PA. Saunders; 2003.

Acute coronary syndrome diagnosis. How often do we get it right in the ED?

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George Braitberg MBBS FACEM1,2

1Department of Emergency Medicine Monash Health, Clayton, Victoria, Australia; 2Southern Clinical School, Monash University, Clayton, Victoria, Australia

Objective: Acute coronary syndrome (ACS) encompasses unstable angina (UA), non ST elevation myocardial infarction (NSTEMI) and ST segment elevation myocardial infarction (STEMI). In 2007–2008 in Australia there were 95,000 hospitalisations for ACS. There is limited data about the level of agreement between the emergency department (ED) and hospital discharge diagnosis. The objective of this study is to describe the proportion of ED patients with a concordant ACS hospital discharge diagnosis and determine factors associated with this.

Methods: This study was a retrospective case series of consecutive presentations of patients with acute coronary syndrome to the EDs of Southern Health, Victoria, Australia, during a six-month period between August 2011 and January 2012.

Results: 1028 patients diagnosed with ACS in the ED were identified. Hospital discharge diagnosis was recorded for 704 cases. The mean age was 63 years (SD 14.5) and 69% were male. 119 patients (16.9%) were diagnosed with a STEMI, 322 (45.7%) with a NSTEMI and 263 (37.4%) with UA. 68.3% had a concordant discharge diagnosis of ACS. An ED diagnosis of STEMI (87.4%), English as the primary language (OR 1.81 (1.13 – 2.89) and chest pain as the presenting complaint [OR 2.70 (1.72–4.23) were associated with a concordant diagnosis of ACS.

Conclusion: Almost one third of patients who are admitted to the hospital with ACS have a different hospital discharge diagnosis. English language, chest pain and STEMI ECG changes are associated with a more concordant diagnosis. Further research needs to be performed to better understand these findings.

Is apnoeic oxygenation safe for one hour?

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Burkard Rudolf

Cellitinnen, Sprockhoevel, Germany

Introduction: Apnoeic oxygenation is often used, when endotracheal intubation is not possible. Oxygenation is performed via facemask, transcricoidal needle, small hypopharyngeal catheters and others. It is very well known that this enables oxygenation over several hours. Not much is known about the problem of rising carbon dioxide tension on cerebral and cardiac function.

Material and Methods: 50 patients who underwent a panendoscopy in apnoeic oxygenation for more than 30 minutes were investigated. Beside the routine monitoring, a 12 channel ECG with automatic ST-level monitoring was installed. After anaesthesia the patients’ behaviour was proofed in the recovery room.

Results: Apnea times ranged between 28 and 67 minutes. There was no lack of oxygenation. Changes in ST-level could not be observed even in patients with pre-existing CHD. Anaesthetist couldn′t find any difference in the behaviour during waking up. The waking up scores in the recovery room were not different from patients without apnea.

Conclusion: Apnoeic oxygenation is a safe method for oxygenation even over one hour. The rise in carbon dioxide tension does not affect cerebral or cardiac function.

Perforation of the esophagus: analysis of 68 cases

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Pai-Chun Yen MD,1,2 Ewai Zhang MD,1,2 Tsung-Cheng Tsai MD,1,2 Chao-Jui Li MD1,2

1Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaoshiung, Taiwan; 2Chang Gung University College of Medicine, Taiwan

Background: Esophageal perforation is a surgical emergency with high morbidity and mortality rates, and there is no consensus regarding the appropriate management. We evaluated the outcome of patients with esophageal perforation.

Methods: A retrospective review was made of 68 patients with esophageal perforations treated at Kaohsiung Chang Gung Memorial Hospital during January 2001 to June 2012. Patients suffering from perforation secondary to surgical procedures were ruled out.

Results: Twenty-seven (40%) perforations were due to traumatic causes including foreign body ingestion and caustic injury. Iatrogenic perforations occurred in 10 patients (15%). Spontaneous perforations in nine (13%), followed by malignancy in eight (12%) and undetermined in 14 patients. A total of 35 (52%) patients had cervical injury, 13 (19%) patients had thoracic, and 20 patients had abdominal esophageal injury. Thirty-two (47%) patients underwent surgical intervention, whereas 36 patients were managed by non-operative treatment. The global survival rate was 71% for all patients, with 20 deaths.

Conclusion: Esophageal perforation is a life-threatened condition and needs aggressive treatment. Malignancy perforation had the highest mortality (75%). Other factors influencing the mortality rate are age of the patient, location of perforation and delay diagnosis – more than 24 hours after the perforation event. Charlson Comorbidity Index (CCI) is also a useful tool to evaluate the outcome of patients with esophageal perforation.

Diagnosing subarachnoid haemorrhage: how many more lumbar punctures do I have to do?

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Thomas Cheri FCEM FACEM DMCC DipMedTox, Saptarshi Mukerji MBChB, George Marchant MBChB

Emergency Department, Palmerston North Hospital, Palmerston North, New Zealand

Introduction: Subarachnoid haemorrhage (SAH) is a diagnosis that no clinician wants to miss. Most international guidelines recommend the use of computed tomography (CT) and lumbar puncture (LP) as initial investigations for the diagnosis of SAH. Some authors quote that in patients who are CT negative for SAH; around 2–10% of them would be LP positive for SAH.

Objective: The objective of this study was to review the current pick up rate of SAH by LP in patients who were CT negative in a regional hospital in New Zealand.

Methods: A retrospective review of all CSF samples tested for xanthochromia over a two year period (2011–2013) was completed. For those patients, we also reviewed their CT scan reports.

Results: A total of 107 LP's were done of which six were inconclusive/had insufficient sample. Of the 101 samples, all those patients had undergone a CT head and were negative for SAH. Ninety seven (96%) were negative & four (4%) positive for xanthochromia. Out of the four positive, three underwent MRA, and one had CTA performed. Of these only one was positive for a bleed.

Conclusion: The results of our study shows that in our hospital practice we have a less than 1% pick up rate of SAH by LP if the initial CT was negative.

Emergency department management of acute nerve injury pain: a review

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Emergency Department, Sutherland Hospital, Sydney, New South Wales, Australia

Aim: The aim of this study was to evaluate published research regarding the use of antidepressants and anticonvulsants in the emergency department management of acute nerve injury pain.

Background: Patients with acute nerve injury often have severe pain which is unresponsive to conventional analgesia. No drugs used for neuropathic pain are licensed specifically for first line use in acute nerve injury pain in Australia. The pathophysiology of acute nerve injury pain differs from that of chronic neuropathic pain because peripheral nerve damage leads to changes in the spinal cord over a period of several days, mediated by activated microglial cells.

Methods: A literature review was conducted using Embase and PubMed searches with the keywords ‘peripheral nerve injury’, ‘neuropathic pain’, ‘anticonvulsant’, ‘pregabalin’, ‘antidepressant’ and ‘emergency ward’. The guidelines from the major pain research organisations were also reviewed. The level of evidence provided by each article was evaluated.

Results: 529 articles were assessed, of which none directly addressed the management of acute nerve injury pain. For chronic neuropathic pain the best performing drugs were tricyclic antidepressants and calcium channel ligands (gabapentin and pregabalin). Venlafaxine and duloxetine were less effective than tricyclics and caused more adverse effects.

Implication: In the absence of any studies regarding the management of acute nerve injury pain the best available evidence comes from studies of chronic pain. Calcium channel ligands have a similar efficacy to tricyclics antidepressants, but with less serious side effects. There is a need to research the use of drugs for acute nerve injury pain.

Rocuronium versus Suxamethonium: a survey of first line muscle relaxant use in UK pre-hospital rapid sequence induction

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Emma Louise Hartley MBChB MCEM, Roger Alcock MBChB BSc (Hons) MRCP DCH FCEM

Emergency Department, Forth Valley Royal Hospital, Larbert, Scotland, UK

Introduction: Pre-hospital anaesthesia in the UK is provided by Helicopter Emergency Medical Service (HEMS) and British Association for Immediate Care (BASICS), a road based service. Muscle relaxation in rapid sequence induction (RSI) has traditionally been undertaken with the use of Suxamethonium, however Rocuronium, at higher doses, has comparable intubating conditions with fewer side effects. The aim of this survey was to establish how many pre-hospital services in the UK are now using Rocuronium as first line in RSI.

Methods: An online survey was constructed identifying choice of first line muscle relaxant for RSI and emailed to lead clinicians for BASICS and HEMS services across the UK. If Rocuronium was used further questions regarding optimal dose, Sugammadex, contraindications and difference in intubating conditions were asked.

Results: A total of 29 full responses (93.5%) were obtained from 31 services contacted. Suxamethonium was used first line by 17 pre-hospital services (58.6%) and Rocuronium by 12 (41.4%). In 11 services (91.7%) a dose of 1mg/kg of Rocuronium was used and in one service 1.2mg/kg (8.3%) used. No services using Rocuronium carry Sugammadex. In five services slower relaxation time was found using Rocuronium, (41.7%) and in seven services no difference in intubation conditions were noted (58.3%). Contraindications to Rocuronium use included high probability of difficult airway and anaphylaxis.

Conclusion: Use of Rocuronium as first line muscle relaxant in pre-hospital RSI is increasing. Continued auditing of practice will ascertain which services have adopted change and identify if complications of failed intubation increase as a result.

Video vs direct laryngoscopy: assessment of the first 100 day run-in period for ems

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Mark E A Escott BMBS MPH FACEP,1,3 Guy R Gleisberg MBA BSEE NREMTB,1 Kevin Traynor LP NREMTP,2 Levon Vartanian MD FAAEM,2 Shane Jenks MD,2,3 Brett J Monroe MD,1,3 Michael G Gonzalez MD FACEP FAAEM3

1Montgomery County Hospital District Emergency Medical Services, USA; 2Cypress Creek Emergency Medical Services, USA; 3Baylor College of Medicine, Section of Emergency Medicine, USA

Introduction: Video laryngoscopy (VL) utilisation is becoming more frequent within the pre-hospital setting. A paucity of literature exists comparing video laryngoscopy success rates to direct laryngoscopy (DL) as the primary technique for intubation by emergency medical services (EMS).

Objective: To compare the view during laryngoscopy and first-attempt success rates (FASR) with DL and VL as the primary method of intubation in the pre-hospital environment.

Methods: This prospective study includes consecutive intubations between March 18 – June 26, 2013 employing a standardised protocol. The KingVISION video laryngoscope (KVL) was utilised as the primary device with DL as back-up within two suburban EMS systems on 50% of the ambulances and rotated monthly. FASR, Cormack-Lehane (C-L), Percentage of Glottic Opening (POGO), and primary failures (PF) were recorded.

Results: A total of 155 intubations with 84 KVL (54%) were performed by 118 paramedics who had a mean experience with DL of nine years, and 0.25 years with KVL. FASR: KVL 60(71%) and DL 48(68%) (95% CI: – 0.107- 0.185). C-L grade I or II view: KVL 65(77%) and DL 42(59%). POGO scores of ≥80%: KVL 61(73%) and DL 34(71%). Most frequent PF: DL 8(42%) inability to expose vocal cords and KVL 9(38%) secretions/blood/vomit.

Conclusion: During the first 90 days of the run-in period, the paramedics were able to achieve equivalence in FASR with the novel device (KVL). Further studies are warranted to evaluate KVL as a primary technique for intubation in the pre-hospital setting following a run-in period.

An analysis of emergency department clinician opinion on the investigation of suspected subarachnoid haemorrhage

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Andrew Rogers BMBCh BA, Jeremy Furyk MBBS MPHTM MSc FACEM, Colin Banks MBBS FACEM

Emergency Department, Townsville Hospital, Townsville, Queensland, Australia

Objective: The emergency department (ED) investigation of suspected a traumatic subarachnoid haemorrhage (SAH) is a hotly debated topic. This study aims to evaluate current ED clinician opinion on the optimal investigation of suspected SAH.

Methods: An electronic survey was distributed to ED registrars and consultants via ACEM. Responses were analysed according to level of experience, access to a neurosurgical service, state and department setting (metropolitan versus rural).

Results: There were 878 survey respondents (response rate 24%). A total of 383 respondents (44%) agreed or strongly agreed with the statement, “A normal non-contrast CT (3rd generation or later) reliably excludes SAH if performed within six hours of headache onset”, compared to 341 (39%) who disagreed or strongly disagreed. However, only 116 clinicians (13%) agreed or strongly agreed that non-contrast CT was able to exclude SAH if performed within 12 hours of headache onset. A narrow majority of respondents (n = 444, 51%) disagreed or strongly disagreed that CTA can reliably replace lumbar puncture for diagnosis of SAH, with 185 clinicians (21%) who were “unsure”. A majority of clinicians (n = 587, 67%) disagreed that “a decreasing red cell count excludes SAH”, versus the 14% (119) who agreed with the statement.

Conclusion: Advances in CT imaging technology have increased the sensitivity for detecting a bleed on non-contrast CT head. This study demonstrates a high level of disagreement concerning the optimal investigation of suspected SAH, particularly regarding the reliability of non-contrast CT for excluding a bleed, and highlighting the need to work towards a consensus approach.

Final lumbar puncture tube and absolute percentage change in red blood cell count in the diagnosis of aneurysmal SAH

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Kevin Chu MBBS FACEM,1,2 Angus Hann MBBS (Hons),1 Juliana Yee MBBS,2 Jaimi Greenslade PhD,1,2 Anthony Brown MBChB FACEM1,2

1School of Medicine, University of Queensland, Brisbane, Queensland, Australia; 2Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia

Background: Final lumbar puncture (LP) tube red blood cell (RBC) count >10,000 and a percentage change in RBC count <63% (absolute differential RBC count between last and first tubes divided by mean RBC count of the two tubes) has been reported to help distinguish subarachnoid haemorrhage (SAH) from traumatic tap.

Objective: To evaluate the final tube RBC count and percentage change in RBC count in the diagnosis of aneurysmal SAH.

Methods: A retrospective study of ED patients who had a headache-related diagnosis, negative head CT and CSF RBC count reported from June 2005 to July 2012 was conducted as part of a programme of studies on SAH. We defined aneurysmal SAH as angiographic evidence of a cerebral aneurysm in a patient being investigated for SAH. A positive LP RBC count result was defined as a final LP tube RBC count >10,000 plus percentage change in RBC count <63%.

Results: 409 patients with a normal head CT had a LP performed. Six (1.5%) had a cerebral aneurysm detected of which all were coiled or clipped. There were four true positive, two false positive, 401 true negative and two false negative LP RBC count results giving a positive likelihood ratio of 134 (95%CI:39-472) and a negative likelihood ratio of 0.34 (95%CI:0.13-0.89). With a 1.5% prevalence, the post-test probability of aneurysmal SAH after a positive and negative result was 66% and 0.5% respectively.

Conclusion: The use of final tube RBC count >10,000 plus percentage change in RBC count <63% shows promise in this preliminary study.

Career satisfaction among Australian emergency medicine staff: a two centre cross sectional study

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Stephen Asha FACEM PhD,1,2 Manit Arora MBBS (Hons) MS Ortho,1,2 Ashish Dhar Diwan FRACS PhD1,2

1St George Public Hospital, Sydney, Australia; 2University of New South Wales, Sydney, Australia

Aim: To study career satisfaction among health staff in two emergency departments, and the factors associated with it

Methods: We conducted a two centre cross-sectional observational study using a 36-question survey consisting of a self-developed item set of 14 questions and a 22 question validated instrument (Maslach burnout inventory – human services survey). Satisfaction with choice of emergency medicine as a career was assessed using a single item scored on a 5 point Likert scale. The survey was emailed to 381 health personnel at the two institutions.

Results: Three hundred and eighty one staff members were invited to participate in the survey; the response rate was 31%. Overall career satisfaction with emergency medicine was high (79%). Satisfaction was higher in nurses (95%) than administrative staff (70%) and doctors (71%). The career satisfaction in emergency medicine rate for doctors is similar with comparable literature. Career satisfaction was higher with increasing seniority (OR 25.7 multivariate analysis), satisfaction with work life balance (OR 2.1) and higher personal accomplishment scores (OR 1.1). Significant trends were also identified with career satisfaction in emergency medicine and time allocated for non-clinical duties (p < 0.001), personal health (p= 0.03), age (p= 0.001), and emotional exhaustion scores (p = 0.03).

Discussion: Career satisfaction is high among emergency medicine staff at these two Australian emergency departments. Factors associated with career satisfaction need to be targeted to improve career satisfaction including time allocated for non-clinical duties, staff health and work-life balance. Further nationwide study and nursing sub-population study is needed to further identify factors affecting and rates of career satisfaction in emergency medicine.

Patients’ perceptions of emergency department services: better specialised staff, convenient and available services

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Joanna Rego MPH PhD candidate, Gerry FitzGerald MD FACEM FRACMA, Sam Toloo PhD

Queensland University of Technology, Queensland, Australia

Many factors are identified as contributing to the high demand for emergency department (ED) care. Similarly, there have been many initiatives taken to minimise the impact that is placed on EDs. Many of these, however, do not consider the patient's opinions and motivations. The aim of this cross-sectional study was to understand patients’ perspectives and reasons behind their decision to present to EDs.

911 surveys were collected from patients presenting to eight Queensland EDs in 2011. Based on the principal component analysis technique, a six-item scale entitled “Best services at emergency departments” was extracted (α = 0.729) measuring patients’ opinions and perspectives. Further, the independent t-tests were conducted between various groups of ED users.

The results suggest that multiple users more likely viewed EDs as the best place for their conditions than the first-time users (median 10.73 v 11.56, p < 0.001). Moreover, patients who made the decision to present by themselves had a more favourable perception of the ED services than those for whom the decision was made or others were involved (median 11.38 v 10.80, p = 0.003). Method of arrival did not affect the respondents’ perception of ED (median 11.13 v 11.00, p = 0.65).

The results of this research indicate that patients’ perception of ED as the best and most appropriate place for attention to their medical conditions plays an important role in their decision to present and keep returning to ED. Understanding patients’ reasons and decisions enhances the success of planning and implementing alternative services to manage the demand for ED services.

Burnout prevalence and factors associated with burnout among Australian emergency medicine staff: a two-center cross-sectional study

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Stephen Asha FACEM PhD,1,2 Manit Arora MBBS Hons MS Ortho,1,2 Ashish Dhar Diwan FRACS PhD1,2

1St George Public Hospital, Sydney, Australia; 2University of New South Wales, Sydney, Australia

Background: Emergency medicine is emotionally, physically and intellectually challenging. Medical professionals are particularly susceptible to burnout, with adverse consequences to patients, health institutions and health staff. The aim of this study was to assess burnout prevalence among health staff in two emergency departments, and the factors associated with it.

Methods: We conducted a two centre cross-sectional observational study using a 36-question survey consisting of a self-developed item set of 14 questions and a 22 question validated instrument (Maslach Burnout Inventory – Human Services Survey) to assess burnout. The survey was emailed to 381 emergency department staff at the two sub-urban metropolitan teaching hospitals in southeast Sydney.

Findings: One hundred and thirteen responders completed the survey yielding a response rate of 30%. The overall burnout prevalence was 56.6% among responding emergency staff. Satisfaction with choice of emergency medicine as a career (81%), work-life balance (56%) and workload related satisfaction (47%) was high, however, satisfaction with time available for non-clinical duties was low (28%). There was no significant difference for burnout between doctors, nurses and clerical staff. However, burnout prevalence among consultants (42%) was lower than nurses (53%). Junior medical staff were 1.8 times more burned out than consultants (p = 0.03). Burned out staff had poorer self-rated health (p = 0.03) and lower satisfaction for all parameters compared to non-burned out staff (p < 0.05). Older age (p = 0.049), more years worked in emergency medicine (p = 0.01) and more time available for non-clinical duties (p = 0.02) were associated with lower burnout. Older age and satisfaction were also significantly associated with lower emotional exhaustion and depersonalisation scores.

Interpretation: Burnout prevalence is high among emergency medicine staff, despite high career satisfaction. Consultants in our emergency department setting had lower, and nurses higher, burnout prevalence when compared with their global colleagues. This may be due to different demands and stresses on emergency staff in Australian settings. There may be a role for active interventions, such as increased time available for non-clinical duties, aimed at reducing burnout.

Does an airway quality assurance checklist improve complication rates associated with endotracheal intubation in the emergency department? – preliminary data

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Anthony MY Chuang MBBS,1,2 Chau W Ng MBBS,1 Eileen Phuah MBBS,1 Gar M Chan MD FACEM3

1Clinical Management Unit, Launceston General Hospital, Launceston, Tasmania, Australia; 2Launceston Clinical School, Faculty of Health Science, University of Tasmania, Launceston, Tasmania, Australia; 3Department of Emergency Medicine, Launceston General Hospital, Launceston, Tasmania, Australia

Introduction: Despite lack of evidence to suggest quality assurance checklists (QACs) reduce the rate of adverse events (AEs) for endotracheal intubations (EIs), many hospitals have implemented them.

Methods: We are performing a prospective study in a regional hospital emergency department (ED) that performs 100 intubations per-annum. A 2-page checklist based on international, national and regional guidelines was modified for this ED.

Although the QAC included many patient and operator's demographics, we focused on three components: pre-intubation inspection (PII), pre-intubation preparation (PIP), and pre-intubation system-based practice (PISBP). Items in PII include Mallampatti Score and other similar assessments. Items in PIP include positioning, pre-oxygenation, and equipment preparation. PISBP entail the assignment of specific roles.

Completion of these components was compared to the number of AEs as incidence rate ratios using a negative binomial regression.

Results: In a two-month period, 20 EIs occurred with 17 QACs completed (compliance: 85%). There was an average of 1.35 EI attempts per patient (23 attempts, 17 patients). All three components of the pre-intubation assessments were completed in 9/17 QACs (46.67%). Five AEs were reported with no deaths: 3 desaturations (Sat < 90%) associated with incomplete PIP (one case) and PISBP (two cases); two severe desaturations (Sat < 70%) associated with incomplete PIP and PISBP, one case each. However, there is currently insufficient data to perform a binomial regression.

Conclusion: Although there was a correlation between AEs and failure to perform components of the QAC, this is preliminary data and no statistical significant conclusion can be drawn at this time.

Does a screensaver reminder help improve hand hygiene practices? A controlled trial in two emergency departments

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Simon Craig MBBS (Hons) FACEM MHPE,1,2 Rhonda Stuart MBBS FRACP PhD,2,3 Anthony Kambourakis MBBS GradDipHlthServMt MPH FACEM AFRACMA1

1Monash Medical Centre Emergency Department, Clayton, Victoria, Australia; 2Southern Clinical School, Faculty of Medicine, Monash University, Clayton, Victoria, Australia; 3Monash Infectious Diseases, Monash Health, Clayton, Victoria, Australia

Introduction: Improved healthcare worker hand hygiene is likely to reduce the risk of hospital-acquired infections. Existing efforts to achieve this include online training, education sessions, and regular audits. This study describes the impact of introducing screensaver hand hygiene reminders targeted to both staff and patients, to our metropolitan ED, while using a neighbouring ED in the same hospital network as a control.

Methods: ED staff compliance with the “5 moments” of hand hygiene is regularly audited by specifically trained infection control staff. Each audit involves observing departmental staff for 350 moments. Baseline data was collected at both hospitals: Monash Medical Centre (MMC) and Dandenong Hospital (DH) two months prior to the intervention. At MMC (the intervention hospital) a series of screensavers was installed on all computers in clinical work areas. There was no such intervention at DH. Both sites were aware of regular hand hygiene audits, and utilised existing hospital training methods to ensure compliance. Three months after the addition of screensavers to MMC, both emergency departments were re-audited for hand hygiene compliance.

Results: Baseline compliance with hand hygiene practices were 62% at MMC and 63% at DH. After the study period, repeat audit demonstrated a significant improvement at both sites: 73% at MMC and 71% at DH. There was, however, no difference in the improvement between the two sites.

Conclusion: A screensaver intervention does not appear to provide any additional benefit to usual activities aimed at improving hand hygiene compliance in the ED.

Who is working in your emergency department? The Victorian emergency registrar study (VERS) 2013

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Michael Sheridan MBChB FCEM FACEM, Jack Pugh MBChB, Sarah Keating MBBS, Megan Purcell Jones MBBS

Emergency Department, Geelong Hospital, Barwon Health, Geelong, Victoria, Australia

Objective: To investigate the number of Victorian Emergency registrars working during a period of 3 months (February to April 2013) who attained their medical degree out with Australia.

Methods: Initial registrar contact was sought from each DEMT via email or phone call to contact the registrars within their departments and information requested on registrar departmental numbers. An email/internet survey was then sent to each potential participant via the ‘SurveyMonkey’ format. This Victorian Emergency Registrar Study (VERS) asked 10 questions which were logged and recorded. A follow up email at six weeks was sent, and data was then analysed at the conclusion of the three month period.

Results: Of 364 Emergency registrars working in Victoria at the time of our study we received responses from 143 (39%). The largest numbers of responders, 51 (35%), were trained in the United Kingdom and Ireland, followed by Australia with 46 (32%). Registrars educated in Asia made up 16% of the total with 23 responses. The rest of Europe 8 (5.5%), New Zealand 8 (5.5%), Africa 4 (3%) and the Americas/West Indies 4 (3%).

Conclusion: In 2013, Victorian Emergency departments are staffed by significant numbers of international medical graduates. (IMGs). These figures suggest that of those that responded, the largest proportion of these IMGs were trained in the United Kingdom and Ireland. The reliance on IMGs to staff registrar positions is a challenge for Australian EDs and the effects on the health care systems in United Kingdom and Ireland are already being felt with staff shortages.

Paediatric emergency department patients administered a high rate of off-label drugs

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David Taylor MBBS MD MPH DRCOG FACEM,1,2 Paul Joffe MBBS (Hons) BA BSc BMedSci FRACP,3 Simone Taylor PharmD GradCertClinResMeth,4 Alicia Jones MBBS (Hons) BMedSci,5 John A Cheek MBBS FACEM,3,5,6,7 Simon Craig MBBS (Hons) FACEM MHPE,7,8 Andis Graudins. MBBS (Hons) PhD FACEM FACMT,7,9 Reetika Dhir MBBS FRACP,1,3 Franz Babl MD MPH FRACP,2,3,5 David Krieser MBBS FRACP10

1Emergency Department, Austin Hospital, Melbourne, Victoria, Australia; 2Department of Medicine, University of Melbourne, Victoria, Australia; 3Royal Children's Hospital, Melbourne, Victoria, Australia; 4Pharmacy Department, Austin Hospital, Victoria, Australia; 5Murdoch Children's Research Institute, Parkville, Victoria, Australia; 6Emergency Department, Monash Medical Centre, Clayton, Victoria, Australia; 7Monash University, Clayton, Victoria, Australia; 8Emergency Department, Monash Medical Centre, Monash Health; 9Emergency Department, Dandenong Hospital, Dandenong, Victoria, Australia; 10Emergency Department, Sunshine Hospital, Victoria, Australia

Objective: To determine the prevalence and nature of off-label drug administration to paediatric ED patients.

Methods: We undertook a retrospective, observational study in six EDs (July 2011 to June 2012, inclusive). Patients, aged 0–17 years, who were administered a drug in the ED were included. At each site, 50 eligible patients were randomly selected each month of the study period. An explicit review of the medical records of each enrolled patient was undertaken. Medications were classified as on/off-label according to categories of use approved by the Therapeutic Goods Administration.

Results: 3,343 patients were enrolled (56.5% male, mean age 7.2±5.2). Of the 6,786 drug doses administered, 30.8% (95% CI 29.7-31.9%) were off-label. The off-label administrations were attributed to 653 (19.5%) patients. The mean number of off-label doses/patient was 0.63 overall and 3.2 for those who had at least one off-label dose. The ages of patients who were/were not administered an off-label drug were similar (p = 0.45). Salbutamol, ondansetron, ipratropium, oxycodone and fentanyl were the drugs most-commonly administered off-label. In 1,052 cases, the dose/frequency was greater than that approved; in 161, the drug was not approved for the weight or age; in 743, there was an unapproved indication for treatment; in 188, the drug was administered via an unapproved route; in 227, a non-TGA approved product was administered.

Conclusion: The rate of off-label drug administration to paediatric ED patients is high. This has implications for patient safety, drug licensing, medico-legal issues, best practice guidelines and future research.

Blood cultures performed in children aged 3–36 months in the emergency department – are we following recommended clinical practice guidelines?

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Marjolein Slaa MBBS,1 Simona Sabau MBBS FRACP,1 Kathy McMahon MBBS FRACP,1 Pam Rosengarten MBBS FACEM1,2

1Emergency Department, Peninsula Health, Victoria, Australia; 2Monash University, Victoria, Australia

Background: Since the introduction of the conjugate pneumococcal vaccine (PCV-7) the rates of bacteraemia in immunised children have fallen dramatically. Current state approved clinical practice guidelines (CPGs) have been produced by the Royal Children's Hospital Melbourne (RCH) guiding the need to perform blood cultures (BCs) in febrile children aged 3–36 months.

Objective: The study aim was to determine the prevalence of BCs in children aged 3–36 months presenting to Peninsula Health emergency departments (EDs), and whether the decision to perform BCs reflects the current RCH CPG for febrile child.

Methods: Retrospective study of all BCs performed in previously well, fully immunised children aged 3–36 months presenting to the EDs between January 2011 and July 2012. Patients with immunodeficiency, malignancy or indwelling catheters were excluded.

Results: 404 BCs were included in the study, 65 (16.1%) were done in accordance with RCH CPG of which 3 (4.6%) BCs were positive for bacteraemia. 339 (83.9%) BCs did not meet criteria of which two (0.6%) BCs were positive for bacteraemia and 20 (4.9%) BCs were contaminated.

Conclusion: This study demonstrates that in the post vaccination era the incidence of bacteraemia in previously well, immunised children is very low and that applying CPGs has potential to reduce BCs rates by over 80% with resultant clinical and resource implications.