ED Presentations Research Articles

Casemix and performance of Australian emergency departments: A comparison of major city, regional and remote locations.

EDs are an essential service, and higher rates of presentations per population are seen in regional and remote areas compared to major cities. Australia-wide differences in utilisation and performance remain largely unknown. This was a descriptive, retrospective epidemiological study analysing data collected via the National Non-Admitted Patient Emergency Department Care Database managed by the Australian Institute of Health and Welfare. Data from all reporting public hospitals in Australia for the period between 1 July 2018 and 30 June 2019 were analysed. Reporting EDs were geographically categorised using the 2016 Australian Statistical Geography Standard - Remoteness Area. ED presentations for the 293 reporting EDs were 8 352 192 (median 17 904, range 8-113 929), one-third (33.09%, 95% CI 33.06-33.12) were outside major cities. Remote ED presentations were less likely to arrive by ambulance (12.13% [12.01-12.26]; major cites 28.07% [28.03-28.10]; regional 22.55% [22.50-22.60]) but more likely by police/correctional services vehicle (major cities 0.59% [0.58-0.60]; regional 0.71% [0.70-0.72]; remote 1.71% [1.66-1.76]). Presentations to remote EDs were more likely to leave without being attended by a health professional (5.29% [5.21-5.38]; major cities 3.93% [3.92-3.95]; regional 3.53% [3.51-3.55]). A larger proportion of admitted patients stayed at least 8 h in remote (21.83% [21.46-22.20]) and regional (21.52% [21.41-21.62]) EDs compared to major cities (19.82% [19.76-19.88]). Our study highlights ED utilisation, casemix and performance by location. The differences observed, especially areas of inequity and need for interventions, reiterate that imperative regional and remote EDs are appropriately resourced to support the communities they serve.

Assay of macrotroponin I not complexed with troponin T: effect on the performance of troponin T to predict myocardial infarction

Abstract Background Cardiac troponin-immunoglobulin (Ig) complexes (macrotroponin) can interfere with cardiac troponin (cTn) test performance. However, the role of this interference has not been fully explored. We developed a specific, novel, 2-hour prototype immunoassay of monomer IgG-bound TnI (bTnI-IgG). Using this assay, our purpose was to examine the potential contribution of cTnT binding to macro-TnI, and report its effects on the clinical diagnostic and predictive performance of highly sensitive TnT (hs-TnT) and TnI (hs-TnI) assays. Methods Using the bTnI-IgG assay, we evaluated EDTA blood samples taken at presentation (t=0) from two ED acute chest pain studies; SPACE (n=1066) and FAST-TRAC (n=1440), with statistical analysis (logistic regression, ROC curves), to AMI and 1-year outcomes, alone and in combination, with hsTnT (Roche) and hsTnI (Abbott/Beckmann) tests. Pathway analysis was used to identify if single bTnI-IgG measurements improve risk stratification in low and high AMI risk. Results In individual and combined study datasets, bTnI-IgG concentrations in patients with adjudicated acute MI (n=336) were lower than all other diagnoses (p<0.001). Singularly, and in multivariable models containing hs-TnT or hs-TnI concentrations, bTnI-IgG was an independent predictor of MI. Amongst all patients with MI not ruled-out on presentation (hs-TnT >5ng/L) and not high-risk (hsTnT<14ng/L), the addition of bTnI-IgG to a model containing hs-TnT, HxMI and sex improved discrimination (AUC increase of 0.014 (95%CI: 0.004 to 0.025) from 0.788 to 0.802, p=0.009). Within a diagnostic pathway analyses of n=2126 matched patient data points, adding presentation bTnI-IgG measurement alone to an MI risk stratification model consisting of hs-TnT ≤URL, HxMI and sex yielded 14% more low risk patients identified (n=586 v 667 patients) through improved specificity (77% to 88%) whilst maintaining an overall sensitivity of >99%. bTnI-IgG also predicted 1-year mortality and new stroke in all patients (Odds Ratios 0.292 [95%CI 0.130 to 0.654] p=0.009) and 0.255 ([95%CI 0.078 to 0.834] p=0.024), respectively. Conclusions Measurement of bTnI-IgG that is free from cTnT could potentially improve ED presentation diagnostic test performance and risk stratification of MI patients using criteria that includes hs-TnT. No effects upon hs-TnI assays were observed. This data suggests current hs-TnT test design and measurements may be impacted by binding interactions between TnT and TnI. Finally, bTnI-IgG can independently predict mortality and stroke outcomes within 1 year of index presentation.

Abstract 18862: Optimal High Sensitivity Troponin “Delta” for Prediction of 30-Day Mace

Introduction: High-sensitivity troponin (hsTnT) values are used extensively in clinical practice to determine acute myocardial infarction (MI). Most hsTnT algorithms use an accelerated diagnostic protocol based on ranges of hsTnT and time-based changes within those ranges. Little is known about the performance of a protocol based on absolute change with time regardless of absolute values. Research question: Is there a level of hsTnT change (dTnT) that can be used as a single decision factor in the triage of chest pain? Goals/Aims: To assess the diagnostic value of dTnT in ruling out 30-day MI or 30-day death and to identify optimal cut-off values. Methods: Retrospective review of patients with chest pain (CP) who presented to the ED of a single tertiary medical center between September 2017 to September 2019. Patients were included if they had at least 2 hsTnT measurements. dTnT was calculated using the difference between the first and second readings. Presence or absence of MI or death at 30 days from this ED presentation was also recorded from chart review. ROC analysis was performed to determine cut-off values for predicting each event. Statistical analysis was performed using SPSS. Results: dTnT was available in 488 patients and predicted 30-day MI (4/488) with a high AUC of 0.864 (p=0.01). The Cut-off value range of 12.5 to 20.5% had a similar sensitivity of 75% but the specificity increased as the cut-off increased to 20.5%, highest specificity being 87%.dTnT was not sensitive in predicting 30-day death, the AUC was 0.524 (p=0.9). Conclusion: Without compromising on sensitivity, the specificity of this test may increase as the cut-off value is increased. The use of troponin change as a risk marker for MACE in pts with CP has optimal sensitivity and good specificity in predicting 30-day MI and its diagnostic utility should be evaluated further.

End-of-life care: A retrospective cohort study of older people who died within 48 hours of presentation to the emergency department.

To describe the characteristics of, and care provided to, older people who died within 48 h of ED presentation. A descriptive retrospective cohort study of people 65 years and older presenting to two EDs in Queensland, Australia, between April 2018 and March 2019. Data from electronic medical records were collected and analysed. Two hundred and ninety-five older people who died within 48 h of ED presentation were included. Nearly all arrived by ambulance (92%, n = 272) and 36% (n = 106) were from aged care facilities. Three-quarters (75%, n = 222) were triaged into the most urgent triage categories (i.e. Australasian Triage Scale; ATS 1/2). Fewer than half were previously independent with mobility (38%, n = 111) and activities of daily living (43%, n = 128). Sixty-one per cent (n = 181) had a pre-existing healthcare directive. Twenty-two per cent (n = 66) died in ED, most commonly due to pneumonia, intracerebral haemorrhage, cardiac arrest and/or sepsis. Over half had one or more ED visits (52%, n = 154) and/or hospital admissions (52%, n = 152) 6 months prior. Identification of patients at end-of-life (EoL) is not always straightforward; consider recent reduction in independence and recent ED visits/hospital admissions. System-based strategies that span pre-hospital, ED and in-patient care are recommended to facilitate EoL pathway implementation and care continuity.

Methods of the PivotaL triAl of the Atellica VTLi point of care emergencY dePartment high sensitivity troponin evalUationS

BackgroundThe Atellica® VTLi point-of-care (POC) High Sensitivity Cardiac Troponin-I (hs-cTnI) assay is intended for use as an aid in the diagnosis of myocardial infarction (MI). Our primary objective is to assess its diagnostic performance in patients presenting with suspected acute coronary syndrome (ACS). MethodsThis prospective observational study will enrol ∼1500 patients at ∼20 U.S. Emergency Departments. After informed consent, adults (>21 years of age) with suspected ACS, and no prior enrollment in this study, will provide a fingerstick and venous blood sample within 2 h of ED presentation, >2 to ≤4 h, and >4 to ≤9 h (max. blood draw = 60 mL). HEART and EDACS scores will be prospectively documented. Patients without the first blood draw may be enrolled if the second draw was obtained. Capillary and venous whole blood will undergo Atellica VTLi assay testing, with remaining venous sample processed to plasma and run. All results will be blinded to the clinical care team. Site operators will undergo a 3-day familiarization period. Quality control testing will be performed daily. At 30 ± 3 days, patient mortality status, major adverse cardiac events, and rehospitalizations will be determined. A clinical endpoint adjudication committee, blinded to hs-cTnI VTLi result, will define the final diagnosis. Sensitivity, specificity, and predictive values will describe the assay performance. ResultsWe expect study completion within 114 weeks of enrollment of the first patient. ConclusionsIt is anticipated that the Atellica VTLi hs-cTnI assay validation study will define a performance equivalent to lab-based hs-cTnI, with results within ∼8 min at the point of care.

Lack of patient and primary care physician follow-up in geriatric emergency department patients with head trauma from a fall

Study objectiveFalls are the leading cause of injuries in the US for older adults. Follow-up after an ED-related fall visit is essential to initiate preventive strategies in these patients who are at very high risk for recurrent falls. It is currently unclear how frequently follow-up occurs and whether preventive strategies are implemented. Our objective is to determine the rate of follow-up by older adults who sustain a fall related head injury resulting in an ED visit, the rate and type of risk assessment and adoption of preventive strategies. MethodsThis 1-year prospective observational study was conducted at two South Florida hospitals. All older ED patients with an acute head injury due to a fall were identified. Telephone surveys were conducted 14 days after ED presentation asking about PCP follow-up and adoption of fall prevention strategies. Clinical and demographic characteristics were compared between patients with and without follow up. ResultsOf 4951 patients with a head injury from a fall, 1527 met inclusion criteria. 905 reported follow-up with their PCP. Of these, 72% reported receiving a fall assessment and 56% adopted a fall prevention strategy. Participants with PCP follow-up were significantly more likely to have a history of cancer or hypertension. ConclusionOnly 60% of ED patients with fall-related head injury follow-up with their PCP. Further, 72% received a fall assessment and only 56% adopted a fall prevention strategy. These data indicate an urgent need to promote PCP fall assessment and adoption of prevention strategies in these patients.

THU353 Late Onset Of Immune Checkpoint Inhibitor-Related Diabetes After 3 Years

Abstract Disclosure: S. Avula: None. A. Ahmed: None. M. Salim: None. Z.J. Anderson: None. A. Kumar: None. A. Estrada: None. Background: Immune checkpoint inhibitor-induced diabetes mellitus (ICI-DM) is characterized by acute onset of dramatic hyperglycaemia with severe insulin deficiency following exposure to PD-1/PD-L1 inhibitors. The frequency of type 1 diabetes related to ICIs is estimated to be ∼3.5%. Endogenous insulin secretion is depleted within a few weeks of the clinical onset of diabetes. Moreover, the positive rate for islet-related autoantibodies varies from 5% to 50%. Case: 51-year-old male with a PMH of stage 4 adenocarcinoma of the lung with metastasis to brain, bone, and kidneys was sent to the ED for a POC BG above 700 mg/dl. He was diagnosed with stage 4 lung adenocarcinoma three years prior to the current presentation. He received stereotactic radiotherapy for the brain metastases, Carboplatin/pemetrexed/pembrolizumab x4 cycles, then continued maintenance therapy of pemetrexed/pembrolizumab with the last dose given 3 weeks prior. He had recent evidence of progression, so chemotherapy adjustment was planned, and he started dexamethasone 4mg on the day prior to presentation. Upon ED presentation, he reported new onset polyuria and polydipsia for 1 week accompanied by 10% weight loss over the last 3 months. His vitals were stable. Physical examination was unremarkable. Serum glucose level was found to be 726 mg/dl, Bicarbonate level 28 mEq/L (22-30), creatinine 1.99 mg/dl (baseline 1.2), venous blood PH was 7.29, Bicarbonate 24 mEq/L (24-28), anion gap 15 mEq/L (8-16), B-hydroxybutyrate 2.91 mmol/L (0.02-0.27), sodium 127 mEq/L(135-148) and HbA1c 6.3%. He received normal saline boluses and NPH insulin 15 units SQ, after which his repeat BG level was 426 mg/dl. Given prediabetic Hba1c with recent dexamethasone therapy he was thought to have steroid-induced hyperglycaemia. He was discharged on NPH 15 units daily with Novolog sliding scale. Upon clinic follow-up 1 week later, his BGs did not improve significantly despite stopping steroids. His C-peptide level was low at 0.22 ng/ml (1.10-4.40) with BG 443mg/dl, and GAD -65 antibodies were negative. He continued to have hyperglycaemia while on NPH /Novolog regimen, thus he was switched to Lantus and Novolog regimen with better glycaemic control. He continues to have significant insulin requirements 3 months later. Conclusion: Although the mean interval between the first ICI administration and T1DM development was found to be 201 ± 187 days, the development of type 1 DM may occur with longer intervals from initiating the ICI therapy. In our case, the patient developed new-onset diabetes with low C-peptide after 1,095 days from receiving the first dose of pembrolizumab. On the previous case reports, the presence of GAD-65 antibodies is typically associated with shortened intervals between receiving the ICI therapy and the development of DM. Presentation: Thursday, June 15, 2023

Paediatric diabetes-related presentations to emergency departments in Victoria, Australia from 2008 to 2018.

Despite significant treatment advances in paediatric diabetes management, ED presentations for potentially preventable (PP) complications such as diabetic ketoacidosis (DKA) remains a major issue. We aimed to examine the characteristics, rates and trends of diabetes-related ED presentations and subsequent admissions in youth aged 0-19 years from 2008 to 2018. Data were obtained from the Victorian Emergency Minimum Dataset and the National Diabetes Register. A diabetes-related ED presentation is defined using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification diagnosis codes. 'Non-preventable' presentations were the number of youths with newly diagnosed diabetes, and the remaining are classified as PP diabetes-related presentations. Poisson regression model was used to examine the trends in incidence rate and prevalence. Four thousand eight hundred and seventy-two (59%) of 8220 presentations were PP, 4683 (57%) were for DKA whereas 6200 (82%) required hospital admission. Diabetes-related ED presentations decreased from 38.4 to 27.5 per 100 youth with diabetes per year between 2008 and 2018 (β = -0.04; confidence interval [CI] -0.04 to -0.03; P < 0.001). Females, those aged 0-4 years and rural youth had higher rates of ED presentations than males, older age groups and metropolitan youth. DKA presentations decreased from 20.1 presentations per 100 youth with diabetes in 2008-2009 to 14.9 presentations per 100 youth with diabetes in 2017-2018. The rate of DKA presentations was 68% higher in rural areas compared to metropolitan areas (incidence rate ratio 1.68; CI 1.59-1.78; P < 0.001). Although the rates of diabetes-related ED presentations declined, PP diabetes-related presentations and subsequent hospitalisation remain high. Patient level research is required to understand the increased DKA presentations in rural youth.

Initial experience of a Priority Primary Care Centre in metropolitan Melbourne.

To report the initial experience of a newly built Priority Primary Care Centre (PPCC) from the ED perspective. A single-centre prospective cohort study, assessing referrals to the PPCC from 1 February to 30 June 2023. There were 1240 patients referred to the PPCC from the ED, of which 87 (7.0%) were referred back to the ED. The incidence rate of PPCC referrals was 4.2% (95% confidence interval 4.0-4.5). The PPCC enabled re-direction of a small proportion of ED presentations. Early results suggest that such patients can be adequately selected and managed at PPCCs.

Machine learning in clinical practice: Evaluation of an artificial intelligence tool after implementation.

Artificial intelligence (AI) has gradually found its way into healthcare, and its future integration into clinical practice is inevitable. In the present study, we evaluate the accuracy of a novel AI algorithm designed to predict admission based on a triage note after clinical implementation. This is the first of such studies to investigate real-time AI performance in the emergency setting. The novel AI algorithm that predicts admission using a triage note was translated into clinical practice and integrated within St Vincent's Hospital Melbourne's electronic emergency patient management system. The data were collected from 1 January 2021 to 17 August 2022 to evaluate the diagnostic accuracy of the AI system after implementation. A total of 77 125 ED presentations were included. The live AI algorithm has a sensitivity of 73.1% (95% confidence interval 72.5-73.8), specificity of 74.3% (73.9-74.7), positive predictive value of 50% (49.6-50.4) and negative predictive value of 88.7% (88.5-89) with a total accuracy of 74% (73.7-74.3). The accuracy of the system was at the lowest for admission to psychiatric units (34%) and at the highest for gastroenterology and medical admission (84% and 80%, respectively). Our study showed the diagnostic evaluation of a real-time AI clinical decision-support tool became less accurate than the original. Although real-time sensitivity and specificity of the AI tool was still acceptable as a decision-support tool in the ED, we propose that continuous training and evaluation of AI-enabled clinical support tools in healthcare are conducted to ensure consistent accuracy and performance to prevent inadvertent consequences.

A short multi-factor screening tool to assess falls-risk in older people presenting to an Australian emergency department: A feasibility study

ObjectiveThe purpose of this study was to evaluate use of a short multi-factor falls-risk screening tool for older people within the emergency department, to enable rapid identification of falls-risk and triggers for multidisciplinary referral for further falls-specific assessment. MethodsOlder people, aged ≥70 years, presenting to the emergency department with a fall-related injury or disease (n = 137) were recruited by a research nurse following randomisation. A short multi-factor screening tool was completed, comprised of 14 falls-risk-related assessment components. ResultsOnly one participant did not generate any referrals. Participants generated most referrals for medications (85.4%), social and housing (84.6%), vision (67.2%), podiatry (66.9%), or function and mobility (54.7%). Based on our results, the screening tool could be reduced to eleven components. The median time-to-screen was 11 min (IQR 9–15), with 736 triggers generated for referral and further assessment of falls-risk. ConclusionFalls are a major cause of ED presentation for older people. A short multi-factor screening tool with eleven components could be adapted to local familiar falls-risk tools and be completed in less than 10 min. Further research to trial the feasibility of completing ED referrals based on screening results is required to confirm the usefulness of such screening and referral within the ED.

Silver Trauma Review Clinic: a novel model of care to manage non-operative injuries in older patients

BackgroundIncreasing numbers of older patients are presenting to the ED following trauma. These patients require multidisciplinary care that the traditional trauma model fails to provide. A Silver Trauma Review Clinic...

Patients languishing in emergency departments: A descriptive analysis of mental health-related emergency department presentations in Australia between 2016-17 and 2020-21.

In the context of concerns regarding hospital access block, this paper provides a descriptive longitudinal analysis of mental health-related ED episodes in Australian public hospitals between 2016-17 and 2020-21. We descriptively analysed Australian Institute of Health and Welfare data for mental health-related ED presentations, outcomes and 5-year trends for Australian public hospitals. There were more than 300,000 Australian mental health-related ED presentations in 2020-21. Presentations increased by an average annual rate of 2.8% between 2016-17 and 2020-21, commonly involving first responder (police, paramedic) attendance. From 2016-17 to 2020-21, the average annual rate of mental health-related ED presentations receiving a triage category of resuscitation increased by 13.7%, emergency by 9.4% and urgent by 4.7%. 90% of MH-related ED presentations were completed within 14h, which was longer than the 90th percentile for all ED presentations (up to 8h). Current mental health policies have not stemmed the rising tide of ED presentations. Mental health-related ED presentations are increasing in number and severity, likely due to health systemic and societal factors. Psychiatry patients stay longer in EDs than other patients. Healthcare reforms should be targeted to provide the best outcome based on principles of equity of access.

Assessing the utility of night-time presentations as a proxy for alcohol-related harm among young emergency department trauma patients.

To assess the usefulness of night-time presentations to measure alcohol-related harm (ARH) in young trauma patients, aged 12-24 years, attending Western Australian EDs. A retrospective longitudinal study examined alcohol-related ED presentations in Western Australia (WA; 2002-2016) among 12- to 24-year-olds. Data from the Emergency Department Data Collection, WA State Trauma Registry Database and Hospital Morbidity Data Collection were used to identify ARH through specific codes and text searches. These were compared to ARH estimates based on presentation time. Statistical analysis involved sensitivity and specificity calculations and Cox proportional hazards modelling. We identified 2644 (17.8%) night-time presentations as a proxy measure of ARH among the 14 887 presentations of patients aged 12-24 years. This closely matched the 3064 (20.6%) identified as ARH through coding methods. The highest risk for an ARH presentation occurred during the night hours between 00.00 and 04.59 hours. During these hours, the risk was 4.4-5.1 times higher compared to presentations at midday (between 12.00 and 12.59 hours). However, when looking at individual patients, we observed that night-time presentations were not a strong predictor of ARH (sensitivity: 0.39; positive predictive value: 0.46). Implementing targeted interventions during night hours could be beneficial in addressing ARH presentations. However, relying solely on the time of presentation as a proxy for ARH is unlikely to effectively identify ARH in young individuals. Instead, the present study emphasises the importance of implementing mandatory data collection strategies in EDs to ensure accurate measurement of ARH cases.

Early sepsis in Australia and New Zealand: A point-prevalence study of haemodynamic resuscitation practices.

Optimal resuscitation of sepsis-induced hypotension is uncertain, particularly the role of restrictive fluid strategies, leading to variability in usual practice. The objective of this study is to understand resuscitation practices in patients presenting to ED with early sepsis. Design, participants and setting: Prospective, observational, multicentre, single-day, point-prevalence study enrolling adult patients present in 51 Australian and New Zealand ICUs at 10.00 hours, 8 June 2021. Site-level data on sepsis policies and patient-level demographic data, presence of sepsis and fluid and vasopressor administration in the first 24 h post-ED presentation. A total of 722 patients were enrolled. ED was the ICU admission source for 222 of 722 patients (31.2%) and 78 of 222 patients (35%) met the criteria for sepsis within 24 h of ED presentation. Median age of the sepsis cohort was 61 (48-72) years, 58% were male and respiratory infection was the commonest cause (53.8%). The sepsis cohort had a higher severity of illness than the non-sepsis cohort (144/222 patients) and chronic immunocompromise was more common. Of 78 sepsis patients, 55 (71%) received ≥1 fluid boluses with 500 and 1000 mL boluses equally common (both 49%). In the first 24 h, 2335 (1409-3125) mL (25.3 [13.2-42.9] mL/kg) was administered. Vasopressors were administered in 53 of 78 patients (68%) and for 25 patients (47%) administration was peripheral. ICU patients presenting to the ED with sepsis receive less fluids than current international recommendations and peripheral vasopressor administration is common. This finding supports the conduct of clinical trials evaluating optimal fluid dose and vasopressor timing for early sepsis-induced hypotension.

Balanced crystalloids (RInger’s lactate) versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department (BRISK-ED): a protocol for a pilot randomized controlled trial

BackgroundCurrent guidelines for diabetic ketoacidosis (DKA) recommend treatment with normal saline (NS). However, NS, with its high chloride concentrations, may worsen acidosis and contribute to a hyperchloremic metabolic acidosis. Alternatives to NS are balanced crystalloids (e.g. Ringer’s Lactate [RL]) which have chloride concentrations similar to human plasma; therefore, treatment with balanced crystalloids may lead to faster DKA resolution. A recent systematic review and meta-analysis by Catahay et al. (2022) demonstrated the need for more blinded, high-quality trials comparing NS versus RL in the treatment of DKA.MethodsWe describe a protocol for BRISK-ED (Balanced crystalloids [RInger’s lactate] versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department). Our study is a single-centre, triple-blind, pilot randomized controlled trial (RCT) of adults (≥ 18 years) with DKA presenting to an academic tertiary care ED in London, Canada.Patients with clinical suspicion for DKA will be screened and those found to not meet DKA criteria or have euglycemic DKA will be excluded. We will aim to recruit 52 patients with DKA and will randomize them 1:1 to receive intravenous RL or NS.The primary feasibility outcome will be recruitment rate, and the primary efficacy outcome will be time elapsed from ED presentation to DKA resolution. Secondary outcomes include time to insulin infusion discontinuation, intensive care unit admission, in-hospital death, and major adverse kidney events within 30 days, defined as a composite of: i) death, ii) new renal replacement therapy, or iii) final serum creatinine ≥ 200% baseline at the earliest of hospital discharge or 30 days after ED presentation. Patients, clinicians, and outcome assessors will be blinded to allocation group. We will follow an intention-to-treat analysis. Gehan-Wilcoxon, Mann–Whitney U, or chi-square tests will be used to compare groups as appropriate.DiscussionThe results of this pilot study will inform the design and feasibility of a full-scale, multicentre RCT to assess fluid choice in adult ED patients with DKA. If proven to demonstrate faster resolution of DKA, administration of balanced crystalloids may replace NS in diabetes treatment guidelines and improve patient and health systems outcomes.Trial registrationClinicalTrials.gov, Registration # NCT04926740; Registered June 15, 2021.

Adult patients with constipation presenting to the emergency department: Can care be improved?

This study aimed to establish the demographic profile of adult patients presenting with constipation and constipation-related issues to an Australian tertiary hospital ED, investigate ED management and referral pathways in this cohort and determine satisfaction of these aspects of care from a patient's perspective. This is a single-centre study conducted in an Australian tertiary hospital ED which sees 115 000 presentations annually. ED presentations of adults aged 18-80 years with symptoms of constipation were evaluated through retrospective electronic medical record audit and follow-up by survey 3-6 months after their ED presentation. The patients presenting to the ED with constipation had a median age of 48 years (IQR 33.5-63.5) and arrived self-referred by private transport. Median length of stay was 292 min. 22% of patients reported they had previously attended the ED for the same issue within the previous year. Diagnosis of chronic constipation was inconsistent, with limited supporting documentation. Constipation was largely managed with aperients. Four in five patients were satisfied with ED care; however, 3-6 months post-ED visit, 92% of patients reported ongoing bowel-related issues, reflecting the chronic course of functional constipation. This is the first study to investigate the management of constipation in adult patients in an Australian ED setting. It is important that ED clinicians recognise that functional constipation is a chronic condition and many patients have persistent symptoms. There are opportunities for quality-of-care improvements including diagnostics, treatment, and referral post-discharge to allied health, nursing and medical specialist services.

Choosing Wisely audit: Blood gas ordering in the emergency department.

Our aim was to reduce unnecessary blood gases to improve patient flow, reduce false positives and reduce unnecessary treatments. This was a retrospective, single-centre audit of 100 patients in June 2022. There were approximately 45 blood gases per 100 ED presentations. Following education and poster reminders, a re-audit was undertaken in October 2022, resulting in a reduction of 33% of blood gases ordered. We have found that many blood gases are ordered for patients who are not critically unwell, and whose disposition was not affected by their result.

(110) Evaluation of Men Under 35 Who Underwent Penile Implant Surgery

Abstract Introduction Erectile Dysfunction (ED) has become an increasingly common disorder in young adult males. There are multiple etiologies of ED ranging from vascular, neurogenic, and structural causes. Often times, ED presenting in young men is psychiatric in nature as opposed to the other causes that typically present in older patients. ED found in young, healthy men with no history of systemic disease or traumatic injury, can be challenging. Past research has shown that men ages 18-35 typically have normal lab results and are treated with PDE-5 inhibitors. However, our data suggests that patients whose symptoms do not improve following the use of PDE-5 inhibitors may have a vascular etiology of ED. Objective Our objective is to determine the prevalence of venous leaks in young adult males who present with ED, but do not respond well to PDE-5 inhibitors. Methods Patients who underwent inflatable penile prosthesis (IPP) surgery for the treatment of ED over a 36-month period under the age of 35 who had failed PDE-5 inhibitors were identified from our database retrospectively. All patients completed an IIEF-5 questionnaire and had a penile doppler ultrasound (PDUS) performed preoperatively. PDUS was used to identify and record cavernous arterial flow signals before and after stimulation. Veno-occlusive ED was described as persistent End Diastolic Velocity (EDV) over 5 cm/sec during all phases of erection. The relationships, according to Doppler diagnosis, IIEF-5 score, SHIM scale, and erection score were evaluated as well as surgical outcomes and patient comorbidities. Results 1,558 patients were evaluated in this series, of whom 32 met inclusion criteria. Patients ages ranged from 18 to 35, with a mean age of 28.4. PDUS determined that 27 (84%) suffered from veno-occlusive disease, while 3 (9%) had arterial insufficiency due to DMI and 2 (7%) had neuropraxia. Of those veno-occlusive disease patients, EDV values ranged from 7.4 to 21.2, with a mean of 13.4, with peak systolic velocity values ranging from 45 to 122cm, with a mean of 97. All patients in this cohort had successful penile prosthesis implantation without complications or need for revision. Conclusions Doppler examination does indeed suggest that patients with cavernous venous occlusive dysfunction have moderate to severe leaks. We strongly recommend a baseline PDUS following PDE-5 inhibitor failure due to the significant prevalence of veno-ccclusive disease in this rare patient population. Furthermore, if veno-occlusive disease is identified during PDUS, we encourage frank discussion of penile prosthesis placement with the patient as well as the severity of veno-occlusive disease and its resultant effect of worsening ED. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: coloplast, boston scientific

Implementation of an integrated emergency department acute atrial fibrillation pathway safely reduces cardioversions and hospitalisations: A comparative pre-post study.

Atrial fibrillation/flutter (AF/AFL) accounts for high rates of ED presentations and hospital admissions. There is increasing evidence to suggest that delaying cardioversion for acute uncomplicated AF is safe, and that many patients will spontaneously revert to sinus rhythm (SR). We conducted a before-and-after evaluation of AF/AFL management after a change in ED pathway using a conservative 'rate-and-wait' approach, incorporating next working day outpatient clinic follow-up and delayed cardioversion if required. We performed a before-and-after retrospective cohort study examining outcomes for patients who presented to the ED in Christchurch, New Zealand, with acute uncomplicated AF/AFL in the 1-year period before and after the implementation of a new conservative management pathway. A total of 360 patients were included in the study (182 'Pre-pathway' vs 178 'Post-Pathway'). Compared to the pre-pathway cohort, those managed under the new pathway had an 81.2% reduction in ED cardioversions (n = 32 vs n = 6), and 50.7% reduction in all cardioversions (n = 65 vs n = 32). There was a 31.6% reduction in admissions from ED (n = 54 vs n = 79). ED length of stay (3.9 h vs 3.8 h, net difference -0.1 h, 95% confidence interval [CI] -0.6 to 0.3), 1-year ED AF representation (32.4% vs 26.4%, net difference -6.0% [95% CI -16.0% to 3.9%]), 1-year ED ischaemic stroke presentation (2.2% in both groups) and 7-day all-cause mortality rates (hazard ratio 1.05 [95% CI 0.6 to 1.9]) were all similar. Using a conservative 'rate-and-wait' strategy with early follow-up for patients presenting to ED with AF/AFL can safely reduce unnecessary cardioversions and avoidable hospitalisations.