Diana Egerton-Warburton

Survey of alcohol-related presentations to Australasian emergency departments

Objective: To determine the proportion of alcohol‐related presentations to emergency departments (EDs) in Australia and New Zealand, at a single time point on a weekend night shift.

Antiemetic use for nausea and vomiting in adult emergency department patients: randomized controlled trial comparing ondansetron, metoclopramide, and placebo.

STUDY OBJECTIVE We compare efficacy of ondansetron and metoclopramide with placebo for adults with undifferentiated emergency department (ED) nausea and vomiting. METHODS A prospective, randomized, double-blind, placebo-controlled trial was conducted in 2 metropolitan EDs in Melbourne, Australia. Eligible patients with ED nausea and vomiting were randomized to receive 4 mg intravenous ondansetron, 20 mg intravenous metoclopramide, or saline solution placebo. Primary outcome was mean change in visual analog scale (VAS) rating of nausea severity from enrollment to 30 minutes after study drug administration. Secondary outcomes included patient satisfaction, need for rescue antiemetic treatment, and adverse events. RESULTS Of 270 recruited patients, 258 (95.6%) were available for analysis. Of these patients, 87 (33.7%) received ondansetron; 88 (34.1%), metoclopramide; and 83 (32.2%), placebo. Baseline characteristics between treatment groups and recruitment site were similar. Mean decrease in VAS score was 27 mm (95% confidence interval [CI] 22 to 33 mm) for ondansetron, 28 mm (95% CI 22 to 34 mm) for metoclopramide, and 23 mm (95% CI 16 to 30 mm) for placebo. Satisfaction with treatment was reported by 54.1% (95% CI 43.5% to 64.5%), 61.6% (95% CI 51.0% to 71.4%), and 59.5% (95% CI 48.4% to 69.9%) for ondansetron, metoclopramide, and placebo, respectively; rescue medication was required by 34.5% (95% CI 25.0% to 45.1%), 17.9% (95% CI 10.8% to 27.2%), and 36.3% (95% CI 26.3% to 47.2%), respectively. Nine minor adverse events were reported. CONCLUSION Reductions in nausea severity for this adult ED nausea and vomiting population were similar for 4 mg intravenous ondansetron, 20 mg intravenous metoclopramide, and placebo. There was a trend toward greater reductions in VAS ratings and a lesser requirement for rescue medication in the antiemetic drug groups, but differences from the placebo group did not reach significance. The majority of patients in all groups were satisfied with treatment.

Sub-dissociative-dose intranasal ketamine for moderate to severe pain in adult emergency department patients.

There are currently no studies assessing effectiveness of sub‐dissociative intranasal (IN) ketamine as the initial analgesic for adult patients in the ED.

Treatment and assessment of emergency department nausea and vomiting in Australasia: a survey of anti-emetic management.

Objective: To describe the treatment and assessment of emergency department nausea and vomiting (EDNV) in Australasia by Fellows of the Australasian College for Emergency Medicine (FACEM). To determine the influence of various factors on FACEM anti‐emetic choice. To compare the influence of drug effectiveness, side effects, cost and pharmacy directives on adult EDNV anti‐emetic choice between FACEM choosing the two most common first‐line agents.

Ultrasound guidance for central venous catheter placement in Australasian emergency departments: Potential barriers to more widespread use

Objectives:  To survey Fellows of the Australasian College for Emergency Medicine (FACEMs) in order to describe current ultrasound (US) usage during central venous catheter (CVC) placement and to compare practice and opinions between FACEMs routinely using US and those not.

Review article: Effectiveness of ultra-brief interventions in the emergency department to reduce alcohol consumption: A systematic review

To assess the effectiveness of ultra‐brief interventions (ultra‐BI) or technology‐involved preventive measures in the ED to reduce alcohol harm and risky drinking. Medline, Embase, PsycINFO, CINAHL and EBM reviews were searched for articles published between 1996 and 2015. Randomised controlled trials and quasi‐randomised trials, which compared an ultra‐BI with screening, standard care or minimal intervention for adults and adolescents at risk for alcohol‐related harm presenting to an ED, were included. Outcomes of interest were frequency of alcohol consumption, quantity of alcohol consumed, binge drinking and ED representation. Thirteen studies (nine single centre and four multicentre) were included. Six studies showed a significant reduction in the quantity consumed with intermediate effect size at 3 months (d = −0.40) and small effect size at 12 months (d = −0.15). Two studies showed a significant reduction in binge drinking with small effect size at 3 months (d = −0.12) and 12 months (d = −0.09). No studies showed an effect on frequency of alcohol consumption or ED representation. Heterogeneity in study design, definition of risky, harmful or hazardous alcohol use, intervention types, outcomes, outcome timeframes and outcome measures prevented the performance of quantitative meta‐analysis. Despite its limited effectiveness in reducing alcohol use in the short‐term, with the large number of people attending EDs with risky drinking, the use of an effective ultra‐BI would have the potential to have a measurable population effect.

Ultrasound use in Australasian emergency departments: A survey of Australasian College for Emergency Medicine Fellows and Trainees

To describe current practice of EDUS by ACEM Trainees and Fellows; to describe potential barriers to US use in the Australasian setting; to determine compliance with current college guidelines regarding US credentialing.

Perceptions of Australasian emergency department staff of the impact of alcohol-related presentations

Objectives: To survey emergency department (ED) clinical staff about their perceptions of alcohol‐related presentations.

When is peripheral intravenous catheter insertion indicated in the emergency department

has been successfully employed at the Royal Hobart Hospital and the University of Tasmania (A/Prof. G. Couser, pers. comm., 2014). Issues relating to the TRP require more thorough consideration and review. Clearly, access to quality supervision, mentoring and support are areas that require attention. Quarantined time for research is also likely to impact positively on the experience. The CP appears to be providing an efficient and effective means of meeting the relevant ACEM learning objectives. However, more work is required to improve access to CP subjects, and ensure that the TRP remains a viable and attractive option for those trainees interested in research. Enhancements to both pathways will improve the overall image and perception of the TRR.

Don't just do something, stand there! The value and art of deliberate clinical inertia: DELIBERATE CLINICAL INERTIA: MASTERLY INACTIVITY

It can be difficult to avoid unnecessary investigations and treatments, which are a form of low‐value care. Yet every intervention in medicine has potential harms, which may outweigh the potential benefits. Deliberate clinical inertia is the art of doing nothing as a positive response. This paper provides suggestions on how to incorporate deliberate clinical inertia into our daily clinical practice, and gives an overview of current initiatives such as ‘Choosing Wisely’ and the ‘Right Care Alliance’. The decision to ‘do nothing’ can be complex due to competing factors, and barriers to implementation are highlighted. Several strategies to promote deliberate clinical inertia are outlined, with an emphasis on shared decision‐making. Preventing medical harm must become one of the pillars of modern health care and the art of not intervening, that is, deliberate clinical inertia, can be a novel patient‐centred quality indicator to promote harm reduction.