Yusuf Nagree

Access block causes emergency department overcrowding and ambulance diversion in Perth, Western Australia

Objective: Access block refers to the situation where patients in the emergency department (ED) requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame. We systematically evaluated the relationship between access block, ED overcrowding, ambulance diversion, and ED activity. Methods: This was a retrospective analysis of data from the Emergency Department Information System for the three major central metropolitan EDs in Perth, Western Australia, for the calendar years 2001–2. Bivariate analyses were performed in order to study the relationship between a range of emergency department workload variables, including access block (>8 hour total ED stay for admitted patients), ambulance diversion, ED overcrowding, and ED waiting times. Results: We studied 259 580 ED attendances. Total diversion hours increased 74% from 3.39 hours/day in 2001 to 5.90 hours/day in 2002. ED overcrowding (r = 0.96; 95% confidence interval (CI) 0.91 to 0.98), ambulance diversion (r = 0.75; 95% CI 0.49 to 0.88), and ED waiting times for care (r = 0.83; 95% CI 0.65 to 0.93) were strongly correlated with high levels of ED occupancy by access blocked patients. Total attendances, admissions, discharges, and low acuity patient attendances were not associated with ambulance diversion. Conclusion: Reducing access block should be the highest priority in allocating resources to reduce ED overcrowding. This would result in reduced overcrowding, reduced ambulance diversion, and improved ED waiting times. Improving hospital inpatient flow, which would directly reduce access block, is most likely to achieve this.

Quantifying the proportion of general practice and low-acuity patients in the emergency department

Objective: To accurately estimate the proportion of patients presenting to the emergency department (ED) who may have been suitable to be seen in general practice.

The impact of early emergency department allied health intervention on admission rates in older people: a non-randomized clinical study

BackgroundThis study sought to determine whether early allied health intervention by a dedicated Emergency Department (ED) based team, occurring before or in parallel with medical assessment, reduces hospital admission rates amongst older patients presenting with one of ten index problems.MethodsA prospective non-randomized trial in patients aged sixty five and over, conducted in two Australian hospital EDs. Intervention group patients, receiving early comprehensive allied health input, were compared to patients that received no allied health assessment. Propensity score matching was used to compare the two groups due to the non-randomized nature of the study. The primary outcome was admission to an inpatient hospital bed from the ED.ResultsOf five thousand two hundred and sixty five patients in the trial, 3165 were in the intervention group. The admission rate in the intervention group was 72.0% compared to 74.4% in the control group. Using propensity score probabilities of being assigned to either group in a conditional logistic regression model, this difference was of borderline statistical significance (p = 0.046, OR 0.88 (0.76-1.00)). On subgroup analysis the admission rate in patients with musculoskeletal symptoms and angina pectoris was less for those who received allied health intervention versus those who did not. This difference was significant.ConclusionsEarly allied health intervention in the ED has a significant but modest impact on admission rates in older patients. The effect appears to be limited to a small number of common presenting problems.

Neutrophil Gelatinase-Associated Lipocalin (NGAL) predicts renal injury in acute decompensated cardiac failure: a prospective observational study

BackgroundAcute Decompensated Cardiac Failure (ADCF) is frequently associated with deterioration in renal function. Neutrophil gelatinase-associated lipocalin (NGAL) is an early marker of kidney injury. We aimed to determine if NGAL measured at admission predicts in-hospital acute kidney injury (AKI) in ADCF.MethodsA prospective observational study measured NGAL and B-natriuretic peptide (BNP) from patients with ADCF presenting to two tertiary hospitals. Patients received standard care and were followed up daily as inpatients. ADCF was defined by PRIDE score ≥ 6 and AKI by RIFLE criteria.ResultsOne hundred and two patients (median age 80, IQR 69-84 years, 52% male) were enrolled. AKI developed in 22 (25%) of 90 for whom outcome data was available. Seven patients died. NGAL was significantly elevated in those who developed AKI versus those who did not (median 130 ng/ml vs 69 ng/ml, p = 0.002). NGAL was also higher in those who died (median 136 ng/ml vs 68 ng/ml, p = 0.005). AKI was significantly associated with risk of death (5/22 (23%) vs 1/68 (1.5%), p = 0.001), but not length of hospital stay. NGAL significantly correlated with admission eGFR but not BNP. For prediction of AKI, NGAL > 89 ng/ml had sensitivity of 68% and specificity of 70% with area under the receiver operator characteristic (ROC) curve of 0.71 (0.58-0.84). After adjustment for baseline renal function, the odds ratio (OR) for AKI was 3.73 (1.26-11.01) if admission NGAL > 89 ng/ml.ConclusionsElevated NGAL at admission is associated with in-hospital AKI and mortality in patients with ADCF. However, it has only moderate diagnostic accuracy in this setting.

A randomised controlled trial of intramuscular vs. intravenous antivenom for latrodectism—the RAVE study

BACKGROUND Widow spider-bite causes latrodectism and is associated with significant morbidity worldwide. Antivenom is given by both the intravenous (IV) and intramuscular (IM) routes and it is unclear which is more effective. AIM To compare the effectiveness of IV vs. IM redback spider antivenom. DESIGN Randomized controlled trial. METHODS Patients with latrodectism were given either IV or IM antivenom according to a randomized double-dummy, double-blind protocol. The first antivenom treatment was followed by another identical treatment after two hours if required. The primary outcome was a clinically significant reduction in pain two hours after the last treatment. A fully Bayesian analysis was used to estimate the probability of the desired treatment effect, predetermined as an absolute difference of 20%. RESULTS We randomly allocated 126 patients to receive antivenom IV (64) and IM (62). After antivenom treatment pain improved in 40/64(62%) in the IV group vs. 33/62(53%) in the IM group (+9%; 95% Credible Interval [CrI]: -8% to +26%). The probability of a difference greater than zero (IV superior) was 85% but the probability of a difference >20% was only 10%. In 55 patients with systemic effects, these improved in 58% after IV antivenom vs. 65% after IM antivenom (-8%; 95% CrI: -32% to +17%). Twenty-four hours after antivenom pain had improved in 84% in the IV group vs. 71% in the IM group (+13%; 95% CrI: -2% to +27%). A meta-analysis including data from a previous trial found no difference in the primary outcome between IV and IM administration. DISCUSSION The difference between IV and IM routes of administration of widow spider antivenom is, at best, small and does not justify routinely choosing one route over the other. Furthermore, antivenom may provide no benefit over placebo.

Ambulance diversion is not associated with low acuity patients attending Perth metropolitan emergency departments

Objective:  To examine the relationship between ambulance diversion and low acuity patient (LAP) attendances to EDs.

Consensus guidelines for the investigation and management of encephalitis in adults and children in Australia and New Zealand

Encephalitis is a complex neurological syndrome caused by inflammation of the brain parenchyma. The management of encephalitis is challenging because: the differential diagnosis of encephalopathy is broad; there is often rapid disease progression; it often requires intensive supportive management; and there are many aetiologic agents for which there is no definitive treatment. Patients with possible meningoencephalitis are often encountered in the emergency care environment where clinicians must consider differential diagnoses, perform appropriate investigations and initiate empiric antimicrobials. For patients who require admission to hospital and in whom encephalitis is likely, a staged approach to investigation and management is preferred with the potential involvement of multiple medical specialties. Key considerations in the investigation and management of patients with encephalitis addressed in this guideline include: Which first-line investigations should be performed?; Which aetiologies should be considered possible based on clinical features, risk factors and radiological features?; What tests should be arranged in order to diagnose the common causes of encephalitis?; When to consider empiric antimicrobials and immune modulatory therapies?; and What is the role of brain biopsy?

A multi-faceted intervention to implement guideline care and improve quality of care for older people who present to the emergency department with falls

BackgroundGuidelines recommend that older people should receive multi-factorial interventions following an injurious fall however there is limited evidence that this is routine practice. We aimed to improve the delivery of evidence based care to patients presenting to the Emergency Department (ED) following a fall.MethodsA prospective before and after study was undertaken in the ED of a medium-sized hospital in Perth, Western Australia. Participants comprised 313 community-dwelling patients, aged 65 years and older, presenting to ED as a result of a fall. A multi-faceted strategy to change practice was implemented and included a referral pathway, audit and feedback and additional falls specialist staff. Key measures to show improvements comprised the proportion of patients reviewed by allied health, proportion of patients referred for guideline care, quality of care index, all determined by record extraction.ResultsAllied health staff increased the proportion of patients being reviewed from 62.7% in the before period to 89% after the intervention (P < 0.001). Before the intervention a referral for comprehensive guideline care occurred for only 6/177 (3.4%) of patients, afterwards for 28/136 (20.6%) (difference = 17.2%, 95% CI 11-23%). Average quality of care index (max score 100) increased from 18.6 (95% CI: 16.7-20.4) to 32.6 (28.6-36.6).ConclusionsA multi-faceted change strategy was associated with an improvement in allied health in ED prioritizing the review of ED fallers as well as subsequent referral for comprehensive geriatric care. The processes of multi-disciplinary care also improved, indicating improved care received by the patient.

Comparison of two clinical scoring systems for emergency department risk stratification of suspected acute coronary syndrome

Objective: To compare two methods of risk stratification for suspected acute coronary syndrome (ACS) in the ED.

Rapid risk stratification in suspected acute coronary syndrome using serial multiple cardiac biomarkers: A pilot study

Objective:  To determine the feasibility of using a biomarker panel of myoglobin, creatinine kinase MB (CK‐MB) and cardiac troponin I (cTnI) to identify patients with suspected acute coronary syndrome (ACS) who are suitable for discharge within 2 h.