Emergency Department Presentation Research Articles

ST SEGMENT DEPRESSION: MUCH ADO ABOUT NOTHING

Abstract Introduction ST depression in ECG trace is classically used to assess the cardiac ischaemia. Several other causes of ST depression, like hypokalaemia, digoxin therapy, left ventricular hypertrophy, left bundle branch block can be easily excluded. Sometimes the ST segment depression during tachycardia is observed in young healthy people where ischemic background is rare. Case Report We present the case of an asymptomatic and without cardiovascular risk factors 29–years–old man who performed, during occasional sport visit, an ECG showing sinus tachycardia with diffuse ST segment depression. The ECG obtained at the presentation in Emergency Department of our hospital confirmed sinus tachycardia at 140 beats per minute and diffuse ST segment depression. This finding persisted during the following six hours and slowly regressed with normalization of the heart rate. The same ECG alteration was founded during an exercise test when the heart rate rised up to 90 bpm. A coronary angiography showed anatomically normal and angiographically free of stenosis coronaries; the functional study, using Fractional Flow Reserve (FFR), Coronary Flow Reserve (CFR) and Index of Microcirculatory Resistance (IMR), currently gold standard for the functional study of microcirculation, was normal. No alterations were founded at the cardiac magnetic resonance. Due to a previous resting ECG suspected of ventricular preexcitation, an electrophysiological study was performed and showed neither accessory pathways nor inducibility arrhythmias. The asymptomatic and hemodynamically stable patient was discharged and an ambulatorial follow–up was planned. Conclusion This case emphasizes the ever–present difficulty of attributing unequivocal etiological meanings to electrocardiographic alterations.

Addressing Barriers to Timely Orthopaedic Follow-up for Foot and Ankle Fractures After Emergency Department Visits.

Foot and ankle fractures present common challenges in emergency departments, warranting careful follow-up protocols for optimal patient outcomes. This study investigates the predictors of orthopaedic follow-up for these injuries after an emergency department (ED) visit. A retrospective observational study of 1450 patients seen in the ED with foot or ankle fractures from July 2015 to February 2023 was conducted. All included patients were discharged with instructions to follow-up with an orthopaedic provider. Demographic data, fracture details, and follow-up patterns were extracted from medical records. Social vulnerability was assessed using the Centers for Disease Control (CDC) Social Vulnerability Index. Univariate and multivariate analyses were performed to identify predictors of follow-up. A subgroup analysis comparing patients who followed up >7 days from ED presentation (ie, delayed follow-up) to those who followed up within 7 days of presentation was then performed. Statistical significance was assessed at P < .05. Overall, 974/1450 (67.2%) patients followed up with orthopaedics at an average time of 4.16 days. After risk adjustment, Medicaid coverage (odds ratio [OR] = 0.56, P = .018), increased overall social vulnerability (OR = 0.83, P = .032), and increased vulnerability across the dimensions of socioeconomic status (P = .002), household characteristics (P = .034), racial and ethnic minority status (P = .007), and household type and transportation (P = .032) were all associated with lower odds of follow-up. Phalangeal fractures were also associated with decreased odds of follow-up (OR = 0.039, P < .001), whereas ankle fractures were more likely to follow-up (OR = 1.52, P = .002). In the subgroup analysis, patients of older age (P = .008), non-white race (P = .024), motor vehicle accident (MVA) (P = .027) or non-private insurance (P = .027), those experiencing phalangeal fractures (P = .015), and those seen by an orthopaedic provider in the ED (P = .006) were more likely to present with delayed follow-up. Patients with increased social vulnerability and Medicaid insurance are less likely to seek follow-up care after presentation to the ED with foot and ankle fractures.

Patterns and correlates of health service contact prior to serious offences by people with severe mental illness.

Contact with health services prior to offences committed by people with mental illness is an opportunity for intervention and prevention. This study examines the pattern and correlates of health service contact by people with severe mental illness before a serious offence. Linkage of a cohort of 477 Forensic Patients found not guilty due to mental illness between 1990 and 2016, and statewide databases of contact with emergency departments, hospital admission and outpatient mental health services in the state of New South Wales, Australia. A total of 84% of the sample had contact with any health service and 76% had contact with an outpatient mental health service prior to the index offence. About two-thirds of the sample had contact with a mental health service in the year before the offence. Factors independently associated with the absence of contact at any point prior to the index offence were non-English-speaking background, being engaged in employment or study, and an absence of childhood abuse or neglect. Although nearly every Forensic Patient had a psychotic illness at the time of the index offence, psychosis was not diagnosed at the time of 61/106 (57.5%) emergency department presentations, in 54/174 (31.0%) hospital admissions and 149/222 (67.1%) attendances at outpatient mental health services prior to the offence. Most Forensic Patients had contact with health services prior to their offences but many were not identified as having a psychotic illness. Although the symptoms of psychosis may have emerged in the period between contact and the offence, the findings suggest that emerging or underlying psychosis were missed or attributed to other conditions.

Predictive value of procalcitonin for early atrial fibrillation recurrence post-cardioversion at the emergency department

Abstract Funding Acknowledgements None. Background Cardioversion of acute atrial fibrillation (AF) in the emergency department (ED) has been shown to be a safe and effective treatment strategy that allows direct discharge from the ED thereby reducing avoidable hospitalizations. However, early AF recurrence may present a limitation, thereby necessitating the identification of predictors of AF recurrence post-ED cardioversion. Methods 117 patients with acute AF (first detected or recurrent paroxysmal) of &amp;lt;48 hours duration, managed by pharmacological (PC) or electrical cardioversion (EC) at the ED were prospectively enrolled upon ED presentation. Clinical, echocardiography, routine laboratory and NT-proBNP and procalcitonin assessments were performed upon presentation. We investigated the utility of inflammatory biomarker procalcitonin as predictor of acute success of cardioversion and early AF recurrence up to 30 days post-cardioversion. Results Study group consisted of 50% males, of mean(±SD) age 67±12years, 41% with first episode and 59% with paroxysmal AF, left ventricular ejection fraction (LVEF) 54±7% and left atrial diameter (LAD) 39±5mm. Median (IQR) creatinine, NTproBNP, hsTroponinT and procalcitonin were: 0.9(0.8-1.1)mg/dl, 517(137-1454)pg/ml, 11.8(6.7-19)pg/ml and 0.03(0.02-0.05)pg/ml, respectively. Of the total group, 59% had paroxysmal and 41% first-episode AF, whereas 70% received EC and 30% PC. Acute cardioversion success was achieved in 81%, while sinus rhythm was maintained in 84% at 8 days and in 86% in 30 days post-cardioversion. In univariate regression analysis, lower procalcitonin levels were associated with higher acute cardioversion success [HR, 95%CI: 0.208(0.050-0.863), p=0.031] as well as lower risk of AF recurrence at 8 days [HR, 95%CI: 0.142(0.028-0.730), p=0.019] and 30 days post-cardioversion [HR, 95%CI: 0.190(0.044-0.818), p=0.026]. Predictive value of procalcitonin was maintained after adjustment for LAD in multivariate regression (all p&amp;lt;0.05). Conclusions In acute AF managed by cardioversion in the ED, procalcitonin, a marker of inflammatory stimulation, may predict acute non-response as well as early AF recurrence up to 30 days post-cardioversion.

Prognostic utility of point-of-care measured bioadrenomedullin in patients presenting with acute heart failure at the emergency department

Abstract Funding Acknowledgements None. Background Acute heart failure (AHF) is a severe condition that is frequently encountered in the emergency department (ED). We aimed to investigate the role of bioadrenomedullin (bio-ADM)- a molecule previously shown to be associated with clinical congestion- as an early prognostic marker for short-term outcomes in patients presenting with AHF in the ED. Methods Seventy-six AHF patients were prospectively enrolled upon ED presentation. Clinical, echocardiography, standard laboratory and cardiac biomarker assessments were performed. Bio-ADM was measured from whole blood sample using a commercially available point-of-care immunoassay. We examined prognostic utility of bio-ADM for predicting 30-day mortality. Results Study group consisted of 61% males, of mean(±SD) age 71±13years, systolic blood pressure (SBP) 140±41mmHg, categorized according to AHF clinical phenotypes as 15(20%) pulmonary edema, 53(70%) decompensated chronic HF and 8(10%) cardiogenic shock. Median (IQR) creatinine, NTproBNP, hsTroponinT and bio-ADM were: 1.15(0.90-1.83)mg/dl, 5094(2836-12816)pg/ml, 38(24-91)pg/ml and 52.3(45-113)pg/ml, respectively. Levels of bio-ADM were higher in patients with cardiogenic shock compared to acute pulmonary edema and decompensated chronic HF [median (IQR): 266.8(101.9-500)pg/ml, 49.8(45-67.5)pg/ml and 47.4(45-97.5)pg/ml, respectively], (p=0.019). Log(bio-ADM) was significantly correlated with SBP (Spearman rho= -0.387, p=0.003), logCreatinine (rho=0.430, p&amp;lt;0.001), log(NTproBNP) (rho=0.430, p=0.003) and log(hsTroponinT) (rho= 0.386, p=0.003). During 30-days follow-up, 15 patients died. In ROC analysis, a bio-ADM cutoff of 64.8pg/ml predicted 30-day mortality with 75% sensitivity and 65% specificity (AUC 0.763, p=0.017). In a multivariable Cox proportional hazards model that included log(bio-ADM), log(NTproBNP) and logCreatinine and adjusted for AHF phenotype, only log(bio-ADM) seemed to be independently prognostic of 30-day mortality (HR,95%CI: 5.80, 0.97-34.66, p=0.054). Conclusions In a broad AHF population, point-of-care bio-ADM measured upon presentation at the ED is associated with worse clinical and biochemical AHF profiles and may provide independent prognostic information for 30-day mortality.30-day mortality by bio-ADM ≥ vs &amp;lt;64.8

Tracking the 3-year trajectory of referrals to an early psychosis intervention service.

To review the baseline and clinical characteristics of patients referred to a New Zealand Early Psychosis Intervention (EPI) service across a 4-year timeframe. We compared two cohorts, and identified variables associated with being accepted or declined, and reasons for decline, by an EPI service between 2013 and 2017. There were 576 people with suspected psychosis referred to the EPI service for assessment: 300 (52%) were accepted, 221 (38%) declined and 55 (10%) were not processed. Reasons for being declined by EPI services were a long duration of psychosis (DUP, 48%) and no evidence of psychosis (47%). There were no significant differences between the accepted and declined group in Emergency Department presentations for self-harm or suicide attempts and acute admissions to a psychiatric inpatient unit over the 3-year follow-up period. To optimise the identification of true positive cases, EPI services require clear entry criteria. Replicating this study in other EPI services with different entry criteria may provide evidence to develop a more uniform screening process. Improved outcomes may be enhanced by measuring effectiveness and liaising with other EPI services.

Emergency department presentation and management of patients with acute decompensated heart failure at the Baghdad Teaching Hospital

Acute decompensated heart failure (ADHF) is a leading cause of hospital admission and many factors are known to precipitate decompensation. We aimed to assess the decompensating factors of heart failure and the management of patients admitted to the emergency department (ED). A total of 107 patients were examined, all diagnosed with ADHF in the ED of the Baghdad Teaching Hospital, from June 2017 to December 2017, and presenting with decom¬pensation (pulmonary oedema, peripheral oedema, and fatigue). The mean patient age was 62.5 ± 9.8 years (range: 43–85 years); the majority of them were in their 7th decade (37.4%), and men were slightly more than women. Hy¬pertension was the most commonly associated comorbidity (68.2%), followed by diabetes mellitus (57.9%), coronary artery disease (51.4%), dyslipidaemia (37.4%), arrhythmia (28%), and chronic obstructive pulmonary disease / asthma (23.4%). The most common presentation was pulmonary oedema (88.8%) followed by peripheral oedema (61.7%), and fatigue (26.2%). Uncontrolled hypertension was the most common precipitating condition for decompen¬sation (58.9%), followed by infection (39.3%), acute coronary syndrome (31.8%), arrhythmia (27.1%), non-compliance (11.2%), and anaemia (2.8%). The majority of the admitted patients were managed with intravenously-administered (i.v.) diuretics (92.5%) that may have been combined with oxygen therapy (63.6%), antibiotics (58.9%), β-blockers (50.5%), nitroglycerin (40.2%), i.v. fluids (38.3%), and/or digoxin (19.6%).

A clinical decision instrument for head CT in intoxicated patients presenting to the emergency department: the DITCH study

Performing head CT in intoxicated patients presenting to the emergency department (ED) is common, yet low yield. In our previous study, acute findings were found only in patients with at least one of: neurological Deficits, Intubation, Trauma, Convulsions or Headache. We hypothesise that the absence of these DITCH clinical features rules out the need for immediate CT. We collected data for intoxicated patients attending EDs in our district from March 2021 to May 2022 inclusive. We recorded clinical presentation features, agents, disposition and head CT results. There were 1,308 intoxicated patients out of a total of 219,273 ED presentations. Median age was 38 years. Common ingestions were ethanol, stimulants, GABA-ergics and opioids. 407 patients (31%) had head CT, with 31 patients (7.6%) having 36 acute findings: 19 intracranial haemorrhages, 8 fractures, 2 cerebral oedema and 7 haematomas. All patients with acute CT findings had one of the DITCH features, and all had trauma. The sensitivity and NPV of the hypothesis were 100%. In patients that were not scanned, there were no re-presentations.Our internal validation study is further evidence that acute findings on head CT in intoxicated patients presenting to the ED are only found in those who had one of the DITCH features.

Unrecognized Focal Nonmotor Seizures in Adolescents Presenting to Emergency Departments.

Many adolescents with undiagnosed focal epilepsy seek evaluation in emergency departments (EDs). Accurate history-taking is essential to prompt diagnosis and treatment. In this study, we investigated ED recognition of motor vs nonmotor seizures and its effect on management and treatment of focal epilepsy in adolescents. This was a retrospective analysis of enrollment data from the Human Epilepsy Project (HEP), an international multi-institutional study that collected data from 34 sites between 2012 and 2017. Participants were 12 years or older, neurotypical, and within 4 months of treatment initiation for focal epilepsy. We used HEP enrollment medical records to review participants' initial diagnosis and management. A total of 83 adolescents were enrolled between 12 and 18 years. Fifty-eight (70%) presented to an ED before diagnosis of epilepsy. Although most ED presentations were for motor seizures (n = 52; 90%), many patients had a history of nonmotor seizures (20/52 or 38%). Adolescents with initial nonmotor seizures were less likely to present to EDs (26/44 or 59% vs 32/39 or 82%, p = 0.02), and nonmotor seizures were less likely to be correctly identified (2/6 or 33% vs 42/52 or 81%, p = 0.008). A history of initial nonmotor seizures was not recognized in any adolescent who presented for a first-lifetime motor seizure. As a result, initiation of treatment and admission from the ED was not more likely for these adolescents who met the definition of epilepsy compared with those with no seizure history. This lack of nonmotor seizure history recognition in the ED was greater than that observed in the adult group (0% vs 23%, p = 0.03) and occurred in both pediatric and nonpediatric ED settings. Our study supports growing evidence that nonmotor seizures are often undiagnosed, with many individuals coming to attention only after conversion to motor seizures. We found this treatment gap is exacerbated in the adolescent population. Our study highlights a critical need for physicians to inquire about the symptoms of nonmotor seizures, even when the presenting seizure is motor. Future interventions should focus on improving nonmotor seizure recognition for this population in EDs.

Increasing Use of Rapid Magnetic Resonance Imaging for Children with Blunt Head Injury

To increase the percentage of patients who undergo rapid magnetic resonance imaging (rMRI) rather than computed tomography (CT) for evaluation of mild traumatic brain injury (TBI) from 45% in 2020 to 80% by December 2021. This was a quality improvement initiative targeted to patients presenting to the pediatric emergency department (ED) presenting with mild traumatic brain injury (TBI), with baseline data collected from January 2020 to December 2020. From January 2021 to August 2021 we implemented a series of improvement interventions and tracked the percentage of patients undergoing neuroimaging who received rMRI as their initial study. Balancing measures included proportion of all patients with mild TBI who underwent neuroimaging of any kind, proportion of patients requiring sedation, emergency department (ED) length of stay (LOS), and percentage with clinically important TBI. The utilization of rMRI increased from a baseline of 45% to a mean of 92% in the intervention period. Overall neuroimaging rates did not change significantly after the intervention (19.8 vs 23.2%, p=0.24). There was no difference in need for anxiolysis (12 vs 7%, p=0.30) though ED LOS was marginally increased (1.4 vs 1.7 hours, p=<0.01). In this quality improvement initiative, transition to rMRI as the primary imaging modality for the evaluation of minor TBI was achieved at a level 1 pediatric trauma center with no significant increase in overall use of neuroimaging.

CAN REFERRAL TO COMMUNITY-BASED EXERCISE PHYSIOLOGIST SERVICES REDUCE EMERGENCY DEPARTMENT BURDEN? A CHART AUDIT

INTRODUCTION &amp; AIMS Despite the rapid growth of exercise physiology in Australia, its potential within the healthcare system remains underutilised. Healthcare system strain, characterised by increased emergency department (ED) waiting times and length-of-stay is exacerbated by preventable, non-urgent ED attendances. In 2022, musculoskeletal conditions constituted the majority of &amp;gt;800,000 non-urgent ED presentations. Community care and underutilised allied health services, such as exercise physiology, may offer better management options. This study aimed to examine characteristics of patients presenting to ED for musculoskeletal conditions, treatment advice provided on physical activity, and referral practices to community-based exercise physiology services. METHODS A retrospective chart audit (n=267) examined patient characteristics, referral patterns and treatment advice due to non-urgent musculoskeletal conditions at Eastern Health EDs. RESULTS Most (n=223, 84%) patients presented with conditions that had persisted for a mean (SD) duration of 9.3 (32.4) days. Conditions affecting the leg (n=92, 34%), lower back (n=59, 22%) and arm (n=44, 16%) were most common. Sharp pain was the most common descriptor of pain (n=33, 12%). Almost half (45%, n=119) had comorbid cardiovascular disease (n=59, 22%), metabolic conditions (n=31, 12%) or mental health issues (n=29, 11%). Treatment advice on physical activity was provided for 17% to patients with 12% advised to avoid physical activity (n=31, 12%) and 5% to stay active (n=12). Advice to return to (n=2, 1%) or take time off (n=47, 18%) work was provided for 19% (n=49) patients. No patients were referred to exercise physiology services. CONCLUSION Patients presenting to EDs for musculoskeletal conditions appeared suitable for referral to community-based exercise physiology services, yet no referrals were identified. Moreover, few patients received advice on whether to stay active or avoid physical activity. Strategies to increase external ED referral to exercise physiology are warranted to alleviate burden within this setting.

Factors that influence presentation to an emergency department during systemic anti-cancer therapy: An exploratory qualitative study

PurposeTo explore factors that influence presentation to an emergency department during ambulatory systemic anti-cancer therapy. DesignAn exploratory qualitative study using semi-structured interviews. MethodsA purposive sample of adult patients with any cancer who had commenced systemic anti-cancer therapy in the ambulatory setting up to six months prior participated in semi-structured interviews between November 2016 – December 2017. Interviews were transcribed verbatim, and data analysed thematically using a template analysis approach. ResultsTwenty patients and four caregivers took part. Five themes were generated from the interview data: 1) the unknown and unpredictable; 2) a change of lifestyle; 3) social determinants and access; 4) trust in care providers; and 5) the unavailability of care. ConclusionAs the number of systemic anti-cancer agents and patients eligible for them continues to grow, identifying, implementing and evaluating initiatives to mitigate emergency department presentations present an important area for health services research. Addressing timely access to trusted care and enhancing patient capacity for self-management present important areas for nurse-led system innovation. Findings from this study offer important insights into where and how nurses can mitigate emergency department presentations for individuals receiving systemic anti-cancer therapy by enabling accessible, coordinated and person-centred cancer care.

Drawing blood from a peripheral intravenous cannula and its effect on cannula dwell time, phlebitis, and bloodstream infection: A randomised controlled study

BackgroundRoutine blood sampling can be conducted using venepuncture, inserting a new peripheral intravenous cannula (PIVC), or utilising an existing one. The practice of blood sampling from a cannula requires handling and movement of the cannula bung. It is discouraged due to safety concerns linked to increased risk of phlebitis, infection, or reduced dwell time. AimTo assess cannula dwell time, the prevalence of phlebitis, and bloodstream infection when using a peripheral intravenous cannula compared with venepuncture for blood sampling. DesignA randomised controlled study. Reporting followed CONSORT recommendations. MethodAdult patients admitted to the emergency department whose health condition required a blood sample to be drawn and insertion of a PIVC were screened for eligibility between May and July 2022. Participants were randomised to either have blood sampled by venepuncture as the control or drawn through the peripheral intravenous cannula as the intervention. Follow-up occurred on day three post emergency department presentation. ResultsOne hundred and five participants were randomised of whom 50 had blood sampled by venepuncture and 55 through the peripheral intravenous cannula. No difference was observed in cannula dwell time, prevalence of phlebitis or signs of bloodstream infection. ConclusionThis study showed peripheral intravenous cannula outcomes were no different when the peripheral intravenous cannula was used to sample blood compared with participants whose blood was sampled by venepuncture.

Occupational injuries caused by fire and smoke in Victoria, Australia, 2003–2021: a descriptive study

ObjectivesHospital attendance related to fire, flame or smoke exposure is commonly associated with work. The aim of this study was to examine time trends and risk factors for work-related fire/flame/smoke...

A two-year retrospective cohort study investigating the occurrence and short-term outcomes of dog-bite injures in regional Western Australia

BackgroundDog bite injuries are a preventable yet common cause of animal related hospitalisation. Dog bites in metropolitan areas have been well characterised however there is limited information regarding dog bites in regional areas. This study sought to describe the demographics, clinical presentation and short-term outcomes of patients presenting with dog bite related injuries to Broome Regional Hospital (BRH). MethodsA retrospective cohort study examined all dog bite related injuries presenting to BRH Emergency Department (ED) between July 1st 2021 – June 30th 2023, with the terms “dog” AND “bitten OR bite” in ED triage note. Chart review was performed to extract demographics, clinical presentation and short-term outcomes of dog bite related injuries. ResultsAfter exclusions, 207 patients were identified during the 2-year study period; approximately four dog-bites per week. Median age was 32 (IQR: 32, range 1–97 years old) with 46 % of patients being female. Residents of the Kimberley represented 78 % of presentations for dog bites. Dogs that belonged to or were known to patients were involved in 74 % of cases. The lower limb below the knee (42 %) was most commonly bitten, followed by the distal upper limb (30.5 %) and then face (13 %). Most patients presented on the same-day (67 %), were treated with antibiotics (79 %) and 83 % were discharged on the day of presentation. There were 43 (23 %) patients who required repair in the ED or operating theatre. Thirty-three patients were admitted to BRH. Seven patients required transfer for subspecialty tertiary level care. ConclusionDog-bite trauma is common and consumes significant health resources associated with ED presentations, hospital admissions, theatre usage and transfer in severe cases. A multifaceted approach encompassing education, engineering, and enforcement is required to prevent dog bites.

The Healthy Ageing/Vulnerable Environment (HAVEN) Index: Measuring neighbourhood age‐friendliness

AbstractThis study describes the development and testing of the Healthy Ageing/Vulnerable Environment (HAVEN) Index, a prototype composite spatial index for South Australia that reflects an area’s age‐friendliness. The index incorporates over 40 indicator variables across six variable themes: income and employment; education; health and housing; social connectedness; geographic access; and physical environment. Based on the deficit accumulation approach, the modelling uses area‐level rather than individual‐level data and is compiled through quantitative geospatial methods. Analysis using the HAVEN Index of state‐wide mortality data and hospital emergency department (ED) presentations for Central Adelaide found that vulnerable areas were associated with a higher risk of mortality and ED presentation. Comparisons between the HAVEN Index and a widely used national area‐level measure of socio‐economic differences found that the HAVEN Index compares favourably and provides additional information about local areas, which can inform needs‐based approaches to support the reduction of spatial inequalities and the development of age‐friendly neighbourhoods.

Evaluation of a community-based brief intervention service for youth in crisis with suicidal ideation or self-harm.

To evaluate the implementation of a mixed virtual and in-person brief intervention for young people, aged 12-25 years, presenting to a large urban mental health service in crisis with suicidal ideation and/or self-harm. A pragmatic, real-world evaluation was conducted on the Youth Brief Intervention Service between June 2021 (inception) and October 2022. Service users were offered four sessions over an approximate one-month period. Sessions focused on distress tolerance, safety plans and support systems. Implementation outcomes related to service uptake, retention, fidelity of the model and service user experience. Effectiveness outcomes were measured pre-post and included mental health-related hospital service utilization (primary outcome), functioning, mental health status, self-harm, suicidal ideation and quality of life. Of the 136 young people referred to the Youth Brief Intervention Service, 99 were accepted with 17 disengaging before the first session. Eighty percent of people who commenced, completed the package of care. Young persons' and parent/carers experience of service was high (97% and 88%, respectively). Mental health-related emergency department presentations and inpatient days decreased from 3 months pre-intake to 3 months post-intake (42 vs. 7 presentations, X2 = 25.3, p < .001; 11 vs. 0 inpatient days, X2 = 9.1, p = .01). There were significant improvements in mental health status, days engaging in self-harm, general health and functioning and quality of life. The Youth Brief Intervention Service is feasible, acceptable, subjectively beneficial and coincided with less mental health-related emergency department presentations and inpatient days, and improved mental health status and behaviour.

Post-discharge Mental Healthcare and Emergency General Surgery Readmission for Patients with Serious Mental Illness.

To determine the association between post-discharge mental healthcare and odds of readmission after emergency general surgery (EGS) hospitalization for patients with serious mental illness (SMI). A mental health visit (MHV) after medical hospitalization is associated with decreased readmissions for patients with SMI. The impact of a MHV after surgical hospitalization is unknown. Using Medicare claims, we performed a retrospective cohort study of hospitalized EGS patients with SMI aged >65.5 (2016-2018). EGS included colorectal, general abdominal, hepatopancreatobiliary, hernia, intestinal obstruction, resuscitation, and upper gastrointestinal conditions. SMI was defined as schizophrenia spectrum, mood, or anxiety disorders. The exposure was MHV within 30 days of discharge. The primary outcome was 30-day readmission. Secondary outcomes included emergency department presentation and psychiatric admission. Inverse probability weighting was used to evaluated outcomes. Of 88,092 analyzed patients, 11,755 (13.3%) had a MHV within 30 days of discharge. 23,696 (26.9%) of patients were managed operatively, 64,395 (73.1%) non-operatively. After adjustment for potential confounders, patients with a post-discharge MHV had lower odds of acute care readmission than patients without a MHV in both operative (OR 0.60; 95% CI: [0.40-0.90]) and non-operative (OR 0.67; 95% CI [0.53-0.84]) cohorts. There was no association between post-discharge MHV and ED presentation or psychiatric admission in the operative or non-operative groups. Post-discharge MHV after EGS hospitalization was associated with decreased odds of readmission for patients with SMI managed operatively and nonoperatively. In older EGS patients with SMI, coordination of MHVs may be a mechanism to reduce readmission disparities.

Use of the Canadian CT head rule for patients on anticoagulant/anti-platelet therapy presenting with mild traumatic brain injury: prospective observational study.

Background and importanceMild traumatic brain injury (mTBI) is a frequent presentation in Emergency Department (ED). There are standardised guidelines, the Canadian CT Head Rule (CCHR), for CT scan in mTBI that rule out patients on either anticoagulant or anti-platelet therapy. All patients with these therapies undergo a CT scan irrespectively of other consideration.ObjectiveTo determine whether standard guidelines could be applied to patients on anticoagulants or anti-platelet drugs.Design, settings, and participants1,015 patients with mTBI and Glasgow Coma Score (GCS) of 15 were prospectively recruited, 509 either on anticoagulant or anti-platelet therapy and 506 on neither. All patients on neither therapy underwent CT scan following guidelines. All patients with mTBI on either therapy underwent CT scan irrespective of the guidelines.Outcome measure and analysisPrimary endpoint was the incidence of post-traumatic intracranial bleeding in patients either on anticoagulants or anti-platelet drugs and in patients who were not on these therapies. Bayesian statistical analysis with calculation of Confidence Intervals (CI) was then performed.Main resultsSixty scans were positive for bleeding: 59 patients fulfilled the criteria and 1 did not. Amongst patients with haemorrhage, 24 were on either therapy and only one did not meet the guidelines but in this patient the CT scan was performed before 2 h from the mTBI. Patients on either therapy did not have higher bleeding rates than patients on neither. There were higher bleeding rates in patients on anti-platelet therapy who met the guidelines vs. patients who did not. These rates overlapped with patients on neither therapy, meeting CCHR.ConclusionThe CCHR might be used for mTBI patients on either therapy. Anticoagulants and anti-platelet drugs should not be considered a risk factor for patients with mTBI and a GCS of 15. Multicentric studies are needed to confirm this result.

A retrospective audit of adult and paediatric anaphylaxis management from two Australian metropolitan mixed emergency departments

BackgroundAnaphylaxis is a potentially life-threatening allergic reaction, with presentations to emergency departments (EDs) increasing across Australia. Understanding the features of those presenting with anaphylaxis and aspects related to its optimal clinical management across the admission, treatment and discharge settings is needed to minimise its impact. We aimed to evaluate the nature and management of presentations related to anaphylaxis across two Australian EDs.MethodsRetrospective audit of paediatric and adult patients presenting to a community or tertiary level ED with anaphylaxis from 1 May 2018 to 30 April 2019. Data extracted from medical records included demographic characteristics, causative agents, clinical features, treatments administered across community, ambulance or ED settings, as well as post-discharge care arrangements including provision of Adrenaline Auto-Injector (AAI) and Allergy/Anaphylaxis Action Plan (AAP).ResultsA total of 369 (107 paediatric and 262 adult) ED presentations were identified. A total of 94 (36%) adult and 46 (43%) paediatric patients received pre-hospital adrenaline, with a further 91 (35%) adult and 29 (27%) paediatric patients receiving a dose of adrenaline in the ED. The most commonly administered treatment in ED were corticosteroids, given to 157 (60%) adult and 55 (51%) paediatric patients. Among those requiring an AAI for discharge, 123/210 (59%) adult and 57/91 (63%) of paediatric patients left hospital with an AAI. In contrast, among those requiring an allergy/anaphylaxis action plan (AAP) on discharge, 61/206 (30%) adult and 30/90 (33%) of paediatric patients left hospital with one. Factors associated with an increased likelihood of receiving AAI on discharge in paediatric and adult patients included receipt of any adrenaline, receipt of two or more doses of adrenaline, and longer duration of hospital stay. Adults presenting within business hours were more likely to be discharged with AAI, but no such difference was observed for paediatric patients. Similar findings were evident for provision of AAP on discharge.ConclusionThese findings demonstrate the need to improve assessment and treatment in the ED. In particular, the observed large variability in provision of AAI and AAP on discharge presents opportunities to explore strategies to improve awareness and provision of these critical components of post-discharge care.