Australasian College For Emergency Medicine Research Articles

Vital signs monitoring in Australasian emergency departments: Development of a consensus statement from ACEM and CENA

BackgroundEmergency Department (ED) care is provided for a diverse range of patients, clinical acuity and conditions. This diversity often calls for different vital signs monitoring requirements. Requirements often change depending on the circumstances that patients experience during episodes of ED care. AimTo describe expert consensus on vital signs monitoring during ED care in the Australasian setting to inform the content of a joint Australasian College for Emergency Medicine (ACEM) and College of Emergency Nursing Australasia (CENA) position statement on vital signs monitoring in the ED. MethodA 4-hour online nominal group technique workshop with follow up surveys. ResultsTwelve expert ED nurses and doctors from adult, paediatric and mixed metropolitan and regional ED and research facilities spanning four Australian states participated in the workshop and follow up surveys. Consensus building generated 14 statements about vital signs monitoring in ED. Good consensus was reached on whether vital signs should be assessed for 15 of 19 circumstances that patients may experience. ConclusionThis study informed the creation of a joint position statement on vital signs monitoring in the Australasian ED setting, endorsed by CENA and ACEM. Empirical evidence is needed for optimal, safe and achievable policy on this fundamental practice.

Power and politics of leading change in emergency departments: A qualitative study of Australasian emergency physicians.

The ability to lead change is well recognised as a core leadership competency for clinicians, including emergency physicians. However, little is known about how emergency physicians' think about change leadership. The present study explores Australasian emergency physicians' beliefs about the factors that help and hinder efforts to lead change in Australasian EDs. An online modified Delphi study was conducted with 19 Fellows of the Australasian College for Emergency Medicine. To structure the process, participants were sorted into four panels. Using a three-phase Delphi process, participants were guided through a process of brainstorming, narrowing down and ranking the factors that help and hinder attempts to lead change. Reflexive thematic analysis was used to code and interpret the qualitative data set emerging from participants' responses through the final ranking phase. A wide array of self-, ED- and hospital-related enablers and barriers of leading change were identified, the relative importance of which varied as a function of panel. Five core themes characterised emergency physicians' conceptions of change leadership in hospitals: challenging environments of competing interests and tribalism; need for trust and psychological safety to sustain collaboration; challenges of navigating complex hierarchies; need to garner executive leadership support and; need to maintain a growth mindset and motivation to practice change leadership. The findings of our study provide new insight into emergency physicians' conceptions of the nature, barriers to and enablers of change and point to new directions in leadership development to support emergency physicians' aspirations in the context of quality, organisation and health systems improvement.

Introducing Australia's clinical care standard for low back pain.

Introducing Australia's clinical care standard for low back pain.

Are emergency department nurse practitioners homeless?

The professional body for nurses working in emergency medicine is the College of Emergency Nursing Australasia. The professional body for doctors working in emergency medicine is the Australasian College for Emergency Medicine (ACEM). There is no professional body for nurse practitioners working in emergency medicine. The clinical role of nurse practitioners in emergency medicine more closely resembles that of doctors rather than nurses. Associate membership in ACEM would recognise their role in treating patients and would enhance their access to relevant continued professional development as has been endorsed by ACEM. It would also facilitate their further integration into the body of those who autonomously treat patients in the ED.

Emergency medicine trainees' perceived barriers to training and credentialing in point-of-care ultrasound: A cross-sectional study.

Point-of-care ultrasound (POCUS) is an important tool in emergency medicine (EM), with the Australasian College for Emergency Medicine (ACEM) recommending core modalities as part of fellowship training. In Australia, acquisition of these skills is certified via credentialing but is currently poorly undertaken by EM trainees. We performed a cross-sectional survey of EM trainees across two academic teaching hospitals in Gold Coast, Queensland, between December 2018 and January 2019, to determine the current state of training and perceived barriers to credentialing in POCUS. Fifty-two (59%) eligible EM trainees participated. Although credentialing rates (15%) were low amongst respondents, the majority agreed that it was necessary (69%) and should form part of ACEM training (88%). Amongst these trainees, we identified the desire for increased POCUS training and several barriers including time constraints and the credentialing process itself. Although there is general agreement amongst EM trainees for POCUS credentialing, barriers such as time limitations and technical difficulties were prohibitive for many. We propose the development of an internal structured POCUS training programme within mandatory training time to address these issues.

Emergency department staff perceptions of their roles in providing end of life care

BackgroundEnd of life care in the emergency department is environmentally and culturally challenging. The aim of this study was to determine Australian emergency department doctors and nurses’ perceptions of their roles in providing end of life care in this environment. MethodsPerceptions of end-of-life care roles were identified through semi-structured interviews with doctors and nurses using Dieklemann’s seven interpretative stages of analysis guided by phenomenological interpretive underpinnings (hermeneutics). Nine nurses and seven doctors were recruited using purposive sampling. Organisations for emergency doctors (Australasian College for Emergency Medicine: ACEM) and emergency nurses (College of Emergency Nursing Australasia: CENA) were approached to advertise the study and recruit participants across Australia via email. ResultsResults were categorised into four themes namely: role perception; the intensive nature of the role; emotional burden; and role integration. The participants stated that end of life care was provided according to their professional roles and responsibilities. Doctors and nurses had distinct tasks, some of which overlapped. The accounts of the participants in relation to their understanding of each other’s roles highlighted differences in how nurses perceived the role of doctors, and vice versa. The participants spoke about aspects that had an impact on their role of practicing end of life care in the emergency department setting. ConclusionsIn this study, all participants expressed concern for dying patients in the emergency department. The delivery of quality end of life care was believed to be paramount and required staff to work together to achieve the best outcome for the dying patient and their families. Regardless of the similarities and differences that were perceived within their roles, the nurses and doctors believed that their main objective was to ensure that comfort care was provided to dying patients.

Updated guideline on equipment to manage difficult airways: Australian and New Zealand College of Anaesthetists.

The Australian and New Zealand College of Anaesthetists (ANZCA) recently reviewed and updated the guideline on equipment to manage a difficult airway. An ANZCA-established document development group, which included representatives from the Australasian College for Emergency Medicine and the College of Intensive Care Medicine of Australia and New Zealand, performed the review, which is based on expert consensus, an extensive literature review, and bi-nationwide consultation. The guideline (PG56(A) 2021, https://www.anzca.edu.au/getattachment/02fe1a4c-14f0-4ad1-8337-c281d26bfa17/PS56-Guideline-on-equipment-to-manage-difficult-airways) is accompanied by a detailed background paper (PG56(A)BP 2021, https://www.anzca.edu.au/getattachment/9ef4cd97-2f02-47fe-a63a-9f74fa7c68ac/PG56(A)BP-Guideline-on-equipment-to-manage-difficult-airways-Background-Paper), from which the current recommendations are reproduced on behalf of, and with the permission of, ANZCA. The updated 2021 guideline replaces the 2012 version and aims to provide an updated, objective, informed, transparent, and evidence-based review of equipment to manage difficult airways.

Who should provide expert opinion in emergency medicine-related medical litigation?

Expert evidence plays a central role in establishing the relevant standard of care in medical litigation. In Australia, little is known about the expert witnesses who provide evidence about the standard of care provided in ED. A sample of recent published case law suggests that a proportion of expert evidence about breach of the standard of reasonable care in ED is provided by medical practitioners who are not emergency physicians and/or have no recent practice experience in an ED. This may potentially distort the identification of the relevant standard of care. In the United States, the American College of Emergency Physicians has attempted to address this issue by developing and promulgating expert witness guidelines. Is there a case for the Australasian College for Emergency Medicine to assume an advocacy role and/or develop standards in this area?

Is racism in emergency care contributing to higher Māori mortality rates?

Is racism in emergency care contributing to higher Māori mortality rates?

Gender equity in emergency medicine: Five years on, where are we headed?

The challenge of addressing gender inequality was highlighted in the 2016 Trainee Focus of Emergency Medicine Australasia. Despite increasing numbers of female medical graduates, including increasing female trainees in emergency medicine (EM), this has not yet translated to equal representation in formal leadership roles. Five years later, as the Australasian College for Emergency Medicine (ACEM) welcomes the second female college president, this article explores the gendered leadership gap in EM from an organisational and intersectional feminist perspective and recommends high-level strategies for change. Notably, ACEM has demonstrated committed engagement with gender equity, such as the establishment of the Advancing Women in Emergency Section. It has also achieved gender parity in provisional trainees and improved women's representation on the ACEM Board. However, broader organisational processes that ensure work-life integration, transparent leadership development pathways and equitable recruitment, promotion, retention and evaluation remain critical. Creating a local evidence-base to support diversity in leadership development remains a priority.

Australasian emergency ultrasound: A survey on the current status.

Emergency ultrasound (EUS) has become an integral part of emergency medicine, and the core pillars of governance, infrastructure, administration, education and quality assurance (QA) are vital for its quality and continued growth. We aimed to assess the status of these vital pillars among Australasian EDs. A survey among the clinical leads in ultrasound (CLUS) in Australasian EDs from November 2020 to April 2021. We analysed a total of 98 responses from CLUS representing 98 EDs. Most CLUS (85%) held EUS qualifications (CCPU 57%, DDU 18%, other 9%) but 15% had none. Only 66% of CLUS had dedicated clinical support time, and a mere 5% had administrative personnel support. Up to three ultrasound machines in 62% of EDs, but only 26% of EDs had secured image archiving facilities. In-house credentialing and the Australasian College for Emergency Medicine (ACEM) trainee special skills placement were available in 50% and 32% of EDs, respectively. Only 11% of EDs had regular EUS training for FACEMs, and only 66% of EDs had regular EUS education for emergency medicine trainees. Only 20 EDs had sonographer educators. Regarding EUS QA, only 33% of EDs provided formal EUS report, 23% of EDs conducted regular image reviews and 37% of EDs audited EUS performance. Only 35% of EDs had high-level disinfection equipment, and 56% of EDs had formal transducer disinfection protocols. Despite ACEM recommendations for the practice of EUS, Australasian EDs still lack vital governance, administrative support, infrastructure, education and QA processes. Prompt actions such as ACEM mandating these recommendations are required to improve resource allocation by health services.

Effects of staff grade, overcrowding and presentations on emergency department performance: A regression model.

To examine the effect of staffing levels by experience of medical officers and overcrowding on ED key performance indicators (KPIs). Presentations to Nepean ED from 6 May to 3 November 2019 were examined. Staff were designated either Fellows of the Australasian College for Emergency Medicine (FACEMs), non-FACEM senior decision-makers (SDMs), non-senior decision-makers greater than 2 years postgraduate (non-SDMs) and junior medical officers up to 2 years postgraduate (JMOs). The number of admitted patients boarded in the ED waiting for a ward bed at 8am was used as a marker for overcrowding. Multivariable regression analysis was performed using staffing levels, number of admissions at 8am and total presentations as the independent variables and various ED KPIs as the dependent variables. FACEM and SDM had a significant effect on most ED KPIs, with the effect of FACEM consistently larger than the effect of SDM. There was minimal effect on performance by non-SDM and JMO staffing. There was significant effect of overcrowding as measured by the number of admitted patients in ED at 8am on most ED KPIs. Almost no variables had an effect on Emergency Treatment Performance (4-h target) for admitted patients, suggesting poor performance was caused by factors outside of the ED. Increasing numbers of FACEM and non-FACEM SDM, but not junior staff, and a reduction in overcrowding as measured by the number of admitted patients boarded in the ED at 8am, were associated with improvements in the ED performance.

In this October issue

Intubation is arguably the most important intervention done in an ED. We publish papers that discuss it in some detail. (a) A group from Melbourne conclude that structured and targeted debriefing after intubating children in the ED is feasible and contributes to measurable and qualitative improvements in patient safety. (b) A group from NSW describe current airway management practices after a failed intubation attempt in Australian and NZ EDs as well as factors associated with second attempt success. (c) A group from Queensland report that implementation of an evidence-based care bundle and audit of practice has created a safe environment for trainees to learn the core critical care skill of rapid sequence intubation in the ED. In an editorial linked to the above paper from Melbourne, Victoria Brazil and her colleagues highlight the importance of hot debriefing in the ED. Staff are enthusiastic about team conversations after clinical encounters – to defuse high emotion, promote learning and reflect on ways to improve future care. They argue that clinical event debriefing should be a cornerstone of healthcare team reflexivity but can only result in change if embedded within a larger ‘improvement ecosystem’ that synthesises, analyses and reacts to the data from the coal face. The topic of debriefing is also discussed in detail in the Trainee Focus section. Every year 25 000 Australians experience a cardiac arrest in the community, but only 12% survive. The faster CPR and defibrillation starts, the greater the chance of survival. Currently, only half of Australian adults are trained in Basic Life Support (BLS). The Australian Resuscitation Council and key stakeholder organisations believe the best way to ensure all Australians know how to save a life is by mandating BLS education and training in schools. We publish an ‘Aussie KIDS SAVE LIVES’ Position Statement outlining a strategy to help facilitate the introduction of a programme of regular BLS training into the Australian school curriculum. The August issue profiled this paper on its front cover. In doing so we inadvertently used an acronym for Aboriginal and Torres Strait Islander peoples that is disrespectful and does not embrace cultural diversity. Once we realised the problem, the acronym was changed immediately online; unfortunately, it was too late to change the cover of the print edition. No disrespect or offence was intended. We apologise unreservedly. A group from South Australia give us a retrospective analysis assessing whether the introduction of point of care Rotational Thromboelastometry (ROTEM) influenced blood product transfusion and coagulation management in an Australian level 1 trauma centre. The authors conclude that ROTEM introduced in the ED, altered blood product transfusion practices for major trauma patients with an ISS >12, leading to a potentially safer transfusion strategy and cost savings for key blood products. Another paper from South Australia reports the incidence of Acute Traumatic Coagulopathy (ATC) in trauma patients presenting to the Royal Adelaide Hospital. The conclusion is that prehospital blood transfusions are given to the most severely injured trauma patients and the incidence of ATC in this group is more than 80%. There is an association with prehospital blood transfusion and increased ATC in part related to patient selection and severity of trauma, with the contribution of red cell transfusions to ATC unclear. This association should allow earlier identification of patients at increased risk of ATC to ensure rapid correction of coagulopathy to decrease the morbidity and mortality of trauma. Since 2018, the Australasian College for Emergency Medicine has collaborated with Swinburne University of Technology on a research project to understand and enhance the leadership capacity of emergency physicians, beginning with Australasian Directors of Emergency Medicine (DEMs). This research has revealed the complexity of leadership in emergency medicine, illuminating the strengths and limitations of extant research and suggesting promising new directions for emergency medicine leadership and leadership development research. This program has also shed new light on the knowledge, skills and abilities that DEMs need to develop to catalyse change in the systems where they work. The authors argue that an approach to leadership development that reflects the complexity of leadership in emergency medicine will go a long way to enhancing the sophistication, effectiveness and impact of leadership in emergency medicine.

Evaluation of a Novel Field Suction Unit (SÜPEVAC): A Mannequin Crossover Trial

ObjectiveThe purpose of this study was to obtain a quantitative and qualitative assessment of the SÜPEVAC unit (German Malaysian Medical Industries, Selangor, Malaysia), a novel field suction unit powered by a positive pressure gas source and capable of hospital-grade suction levels and rates. MethodsThis was a randomized crossover trial in a simulated clinical setting to compare the SÜPEVAC unit with standard hospital wall suction. Twenty-two fellows of the Australasian College for Emergency Medicine, the Australian and New Zealand College of Anaesthetists, or the College of Intensive Care Medicine were recruited. Outcomes were assessed via a structured survey and measuring the time to view the glottis. ResultsThis study found there was no significant difference between the SÜPEVAC unit and wall suction with regard to suction time (P = .762; 95% confidence interval, −0.683 to 0.338) or qualitative assessment via the survey. ConclusionsThe SÜPEVAC unit is comparable with wall suction in a clinical setting. Further research is warranted.

The Australasian College for Emergency Medicine's paediatric requirement provides an emergency medicine trainee with adequate paediatric experience: Yes.

The Australasian College for Emergency Medicine's paediatric requirement provides an emergency medicine trainee with adequate paediatric experience: Yes.

The Australasian College for Emergency Medicine's paediatric requirement provides an emergency medicine trainee with adequate paediatric experience: No.

The Australasian College for Emergency Medicine's paediatric requirement provides an emergency medicine trainee with adequate paediatric experience: No.

Audit of ultrasound usage in emergency departments in greater metropolitan Brisbane.

The Australasian College for Emergency Medicine identifies five ultrasound applications which the College deem core to the practice of emergency medicine but there is scant information as to the uptake of ultrasound or the qualification of users. This study aims to determine the percentage of ED physicians in one metropolitan area who utilise ultrasound for core diagnostic and procedural applications in participating hospitals and the percentage of users who have been formally assessed in any ultrasound application. The EDs of eight major public hospitals in greater metropolitan Brisbane area participated in this audit. Data-collectors at each participating ED approached every senior house officer, registrar and senior medical officer in the department and, after obtaining informed consent, asked the participant six questions pertaining to their use of ultrasound for five core applications and about ultrasound training and recorded the answers without information as to the identity of the participant. 94.4% of the physicians participated. Of those participating, 90% used ultrasound for venous access, with progressively fewer using E-FAST (69%), AAA (51%), Lung (40%) and BELS (29%) for diagnostic purposes. Ninety-eight percent of participants were in favour of enhanced departmental training. Only 33% of participants had their ultrasound skills assessed by a qualified person for even one application. While use of ultrasound in some applications is widespread, few users have had their skills assessed. Assessment being a routine part of structured training, it cannot be assumed that these users can competently use ultrasound for procedural or diagnostic applications.

Advancing leadership in Australasian emergency medicine: Taking stock and looking ahead.

Since 2018, the Australasian College for Emergency Medicine has collaborated with the Swinburne University of Technology on a research project to understand and enhance the leadership capacity of emergency physicians, beginning with Australasian Directors of Emergency Medicine (DEMs). Over the last 3 years, this research programme has revealed the complexity of leadership in emergency medicine, illuminating the strengths and limitations of extant research and suggesting promising new directions for emergency medicine leadership and leadership development research. This programme has also shed new light on the knowledge, skills and abilities that DEMs need to develop to catalyse change in the systems where DEMs practice both medicine and leadership. We propose that an approach to leadership development that reflects the diversity of DEMs' leadership challenges and the complexity of leadership in emergency medicine would go a long way to enhancing the sophistication, effectiveness and impact of the leadership in emergency medicine.

Identifying and quantifying general practice-type emergency department presentations.

This research aims to (i) identify general practice-type (GP-type) presentations to EDs in South-East Queensland, Australia and (ii) compare and quantify the clinical, socio-demographic and time-varying characteristics between GP-type and non-GP-type presentations. Data were collected from presentations to four EDs in Queensland from 2009 to 2014. A modified version of the Australasian College for Emergency Medicine (ACEM) method for identifying GP-type ED presentations was used. The four EDs have different proportions of GP-type presentations, between 7% and 33%. Between 2009 and 2014, the amount of GP-type presentations increased in three EDs, by between 5% and 16%, and decreased by 30% in the other ED. Different holidays, for example, the public holidays over the Christmas to New Year period, impact GP-type presentations. Over 50% of GP-type presentations occurred in those aged 0-34 years, and <1% were aged 85+ years. Injury-related diagnoses made up around 37% of the GP-type presentations, and around 13% did not wait for a diagnosis, averaged over the EDs. GP-type presentations are more likely to present to EDs outside standard general practitioner hours. Existing methods for identifying GP-type presentations have drawbacks, and modified methods are required to better identify these types of presentations. Temporal effects not previously investigated in Australian studies, such as holidays, are significantly associated with GP-type presentations. These findings aid strategic planning and interventions to support review of GP-type presentations, instead, in primary-care facilities, and such interventions may be assistive in some EDs more than others.

Emergency clinicians’ knowledge, preparedness and experiences of managing COVID-19 during the 2020 global pandemic in Australian healthcare settings

BackgroundEmergency clinicians have a crucial role during public health emergencies and have been at the frontline during the COVID-19 pandemic. This study examined the knowledge, preparedness and experiences of Australian emergency nurses, emergency physicians and paramedics in managing COVID-19. MethodsA voluntary cross-sectional study of members of the College of Emergency Nursing Australasia, the Australasian College for Emergency Medicine, and the Australasian College of Paramedicine was conducted using an online survey (June-September 2020). ResultsOf the 159 emergency nurses, 110 emergency physicians and 161 paramedics, 67.3–78% from each group indicated that their current knowledge of COVID-19 was ‘good to very good’. The most frequently accessed source of COVID-19 information was from state department of health websites. Most of the respondents in each group (77.6–86.4%) received COVID-19 specific training and education, including personal protective equipment (PPE) usage. One-third of paramedics reported that their workload ‘had lessened’ while 36.4–40% of emergency nurses and physicians stated that their workload had ‘considerably increased’. Common concerns raised included disease transmission to family, public complacency, and PPE availability. ConclusionsExtensive training and education and adequate support helped prepare emergency clinicians to manage COVID-19 patients. Challenges included inconsistent and rapidly changing communications and availability of PPE.