Emergency Department In Melbourne Research Articles

Non-SARS-CoV-2 respiratory viral detection and whole genome sequencing from COVID-19 rapid antigen test devices: a laboratory evaluation study

There has been high uptake of rapid antigen test device use for point-of-care COVID-19 diagnosis. Individuals who are symptomatic but test negative on COVID-19 rapid antigen test devices might have a different respiratory viral infection. We aimed to detect and sequence non-SARS-CoV-2 respiratory viruses from rapid antigen test devices, which could assist in the characterisation and surveillance of circulating respiratory viruses in the community. We applied archival clinical nose and throat swabs collected between Jan 1, 2015, and Dec 31, 2022, that previously tested positive for a common respiratory virus (adenovirus, influenza, metapneumovirus, parainfluenza, rhinovirus, respiratory syncytial virus [RSV], or seasonal coronavirus; 132 swabs and 140 viral targets) on PCR to two commercially available COVID-19 rapid antigen test devices, the Panbio COVID-19 Ag Rapid Test Device and Roche SARS-CoV-2 Antigen Self-Test. In addition, we collected 31 COVID-19 rapid antigen test devices used to test patients who were symptomatic at The Royal Melbourne Hospital emergency department in Melbourne, Australia. We extracted total nucleic acid from the device paper test strips and assessed viral recovery using multiplex real-time PCR (rtPCR) and capture-based whole genome sequencing. Sequence and genome data were analysed through custom computational pipelines, including subtyping. Of the 140 respiratory viral targets from archival samples, 89 (64%) and 88 (63%) were positive on rtPCR for the relevant taxa following extraction from Panbio or Roche rapid antigen test devices, respectively. Recovery was variable across taxa: we detected influenza A in nine of 18 samples from Panbio and seven of 18 from Roche devices; parainfluenza in 11 of 20 samples from Panbio and 12 of 20 from Roche devices; human metapneumovirus in 11 of 16 from Panbio and 14 of 16 from Roche devices; seasonal coronavirus in eight of 19 from Panbio and two of19from Roche devices; rhinovirus in 24 of 28 from Panbio and 27 of 28 from Roche devices; influenza B in fourof 15 in both devices; and RSV in 16 of 18 in both devices. Of the 31 COVID-19 devices collected from The Royal Melbourne Hospital emergency department, 11 tested positive for a respiratory virus on rtPCR, including one device positive for influenza A virus, one positive for RSV, four positive for rhinovirus, and five positive for SARS-CoV-2. Sequences of target respiratory viruses from archival samples were detected in 55 (98·2%) of 56samples from Panbio and 48 (85·7%) of 56 from Roche rapid antigen test devices. 98 (87·5%) of 112 viral genomes were completely assembled from these data, enabling subtyping for RSV and influenza viruses. All 11samples collected from the emergency department had viral sequences detected, with near-complete genomes assembled for influenza A and RSV. Non-SARS-CoV-2 respiratory viruses can be detected and sequenced from COVID-19 rapid antigen devices. Recovery of near full-length viral sequences from these devices provides a valuable opportunity to expand genomic surveillance programmes for public health monitoring of circulating respiratory viruses. Australian Government Medical Research Future Fund and Australian National Health and Medical Research Council.

Frequency of and associations with alterations of medical emergency team calling criteria in a teaching hospital emergency department

BackgroundMedical emergency team (METs), activated by vital sign–based calling criteria respond to deteriorating patients in the hospital setting. Calling criteria may be altered where clinicians feel this is appropriate. Altered calling criteria (ACC) has not previously been evaluated in the emergency department (ED) setting. ObjectivesThe objectives of this study were to (i) describe the frequency of ACC in a teaching hospital ED and the number and type of vital signs that were modified and (ii) associations between ACC in the ED and differences in the baseline patient characteristics and adverse outcomes including subsequent MET activations, unplanned intensive care unit (ICU) admissions and death within 72 h of admission. MethodsRetrospective observational study of patients presenting to an academic, tertiary hospital ED in Melbourne, Australia between January 1st, 2019 and December 31st, 2019. The primary outcome was frequency and nature of ACC in the ED. Secondary outcomes included differences in baseline patient characteristics, frequency of MET activation, unplanned ICU admission, and mortality in the first 72 h of admission between those with and without ACC in the ED. ResultsAmongst 14 159 ED admissions, 725 (5.1%) had ACC, most frequently for increased heart or respiratory rate. ACC was associated with older age and increased comorbidity. Such patients had a higher adjusted risk of MET activation (odds ratio [OR]: 3.14, 95% confidence interval [CI]: 2.50–3.91, p = <0.001), unplanned ICU admission (OR: 1.97, 95% CI: 1.17–3.14, p = 0.016), and death (OR: 3.87, 95% CI: 2.08–6.70, p = 0.020) within 72 h. ConclusionsACC occurs commonly in the ED, most frequently for elevated heart and respiratory rates and is associated with worse patient outcomes. In some cases, ACC requires consultant involvement, more frequent vital sign monitoring, expeditious inpatient team review, or ICU referral.

Australian Infant Food Allergy Emergency Presentations Following Updated Early Food Introduction Guidelines

The Australasian Society of Clinical Immunology and Allergy food allergy prevention guidelines were updated in 2016 to recommend home introduction of allergenic foods actively in the first year of life, including to infants at high risk of allergy. An important consideration for parents and providers is whether this practice increases food allergy reactions or anaphylaxis. We aimed to determine whether the 2016 update of food allergy prevention guidelines was associated with an increase in food allergy or anaphylaxis emergency department (ED) presentations. We obtained hospital electronic medical records for infants aged 4 to 12 months who attended the Royal Children's Hospital Melbourne ED in 2015 or in 2018 with a presenting problem or an encounter diagnosis of food allergy or anaphylaxis. Emergency department presentations owing to food allergy increased from 1.0% (95% CI, 0.85-1.23) in 2015 to 1.4% (95% CI, 1.22-1.67) in 2018 (P= .006). There was no increase in the number of anaphylaxis presentations (28 in 2015 and 22 in 2018) or peanut anaphylaxis presentations (three in 2015 and three in 2018). Overall, the proportion of food allergy presentations attributed to IgE-mediated food allergy was similar (82.1% in 2015 and 84.1% in 2018), whereas peanut allergy presentations increased slightly, although not statically significantly, from 14.6% to 21.2% (P= .09). Food protein-induced enterocolitis syndrome ED presentations were five in 2015 (4.3%) and 12 in 2018(7.6%), although not statistically significant (P= .25). Changes to food allergy prevention guidelines recommending the earlier introduction of allergenic food may have led to a small increase in ED presentations for food allergy but not anaphylaxis.

Characteristics of self-harm presentations to the emergency department of the Royal Melbourne Hospital, 2012–2019: Data from the Self-Harm Monitoring System for Victoria

BackgroundRates of self-harm and suicide are increasing world-wide, particularly in young females. Emergency departments (EDs) are a common first point-of-contact for young people who self-harm. We examined age- and sex-related differences in: (1) rates of self-harm over an eight-year period; (2) changes in demographic, presentation, and treatment characteristics over this period, and; (3) rates of, and time to, self-harm re-presentation. MethodsThis was a retrospective observational study of all self-harm presentations in persons aged nine years and older to the Royal Melbourne Hospital ED over an eight-year period, 1 January 2012–31 December 2019. The Royal Melbourne Hospital is one of the largest and busiest public EDs in Melbourne, Australia and serves a primary catchment area of approximately 1.5 million people. ResultsThere were 551,692 presentations to the Royal Melbourne Hospital ED over this period (57.6 % by females). Of these, 7736 (1.4 %) were self-harm related. These self-harm presentations involved 5428 individuals (54.8 % female), giving an overall repetition event-rate of 11.2 %. Self-harm related presentations increased by 5 % per year (Incidence Rate Ratio [IRR 1.05, 95 % CI 1.02–1.08); a 44 % increase over the eight-year period (IRR 1.44, 95 % CI 1.15–1.80). This increase was more pronounced for young people aged< 25 years. The most common method was self-poisoning, primarily by anxiolytics or analgesics. The proportion of presentations involving self-poisoning alone declined modestly over time, whilst the proportion involving self-injury alone increased. For just over half of all presentations the person was seen by ED mental health staff. The median time to first re-presentation was 4.5 months (Inter-Quartile Range [IQR] 0.7–13.2 months). ConclusionsRates of hospital presenting self-harm may be increasing, particularly amongst young people, whilst most self-harm presentations occurred outside office hours; so appropriate ED staffing, training and clinical care models are needed. Around half of those with a repeat episode of self-harm repeated within three months of their index (i.e., first recorded) presentation. Efforts to establish appropriate aftercare services, including alternatives to ED services with service availability 24 h a day 7 days a week, aimed at reducing repetition rates, should be prioritised.

Negative predictive value of the FebriDx host response point-of-care test in patients presenting to a single Australian emergency department with suspected COVID-19: an observational diagnostic accuracy study

ObjectivesTo determine the negative predictive value (NPV) of the FebriDx point-of-care host response device in patients presenting with symptoms suggestive of COVID-19 infection in a mostly immunised Australian emergency department...

Presentations to emergency departments in Melbourne, Australia diagnosed as allergic contact dermatitis.

This study investigated cases diagnosed as allergic contact dermatitis (ACD) in emergency departments (EDs) and management. A multisite retrospective study of patients attending EDs in metropolitan Melbourne between July 2017 and June 2018 was performed. Using International Statistical Classification of Disease-10 (ICD-10) codes, the Victorian Agency for Health Information generated a list of cases of contact dermatitis (CD). Demographic and clinical data were analysed. Two hundred twenty-eighty patients from 14 different sites were diagnosed with ACD. Hair dyes caused the most cases, and one such case was admitted to hospital. It was apparent from the specified causes that cases of irritant CD were misdiagnosed as ACD. There were significant differences in management with dermatology input, with dermatologists more often advising oral corticosteroids (33.3% vs. 14.5%, P=0.004) topical corticosteroids (92.9% vs. 38.7%, P < 0.01), emollients (38.1% vs. 20.4%, P=0.01) and less often advising antihistamines (16.7% vs. 44.6%, P < 0.001). With dermatology input, potent or very potent steroids were more likely to be prescribed (69.3% vs. 11.1%, P < 0.001); without, a mild potency steroid was more likely to be prescribed (63.9% vs. 4%, P=0.01). Improved understanding, diagnosis and management of CD are needed in EDs.

Development and Validation of the Medical Emergency Team-Risk Prediction Model for Clinical Deterioration in Acute Hospital Patients, at Time of an Emergency Admission.

To develop and validate a prediction model to estimate the risk of Medical Emergency Team (MET) review, within 48 hours of an emergency admission, using information routinely available at the time of hospital admission. Development and validation of a multivariable risk model using prospectively collected data. Transparent Reporting of a multivariable model for Individual Prognosis Or Diagnosis recommendations were followed to develop and report the prediction model. A 560-bed teaching hospital, with a 22-bed ICU and 24-hour Emergency Department in Melbourne, Australia. A total of 45,170 emergency admissions of 30,064 adult patients (≥18 yr), with an inpatient length of stay greater than 24 hours, admitted under acute medical or surgical hospital services between 2015 and 2017. The outcome was MET review within 48 hours of emergency admission. Thirty candidate variables were selected from a routinely collected hospital dataset based on their availability to clinicians at the time of admission. The final model included nine variables: age; comorbid alcohol-related behavioral diagnosis; history of heart failure, chronic obstructive pulmonary disease (COPD), or renal disease; admitted from residential care; Charlson Comorbidity Index score 1 or 2, or 3+; at least one planned and one emergency admission in the last year; and admission diagnosis and one interaction (past history of COPD × admission diagnosis). The discrimination of the model was comparable in the training (C-statistics 0.82; 95% CI, 0.81-0.83) and the validation set (0.81; 0.80-0.83). Calibration was reasonable for training and validation sets. Using only nine predictor variables available to clinicians at the time of admission, the MET-risk model can predict the risk of MET review during the first 48 hours of an emergency admission. Model utility in improving patient outcomes requires further investigation.

Management of patients presenting with low back pain to a private hospital emergency department in Melbourne, Australia.

Recent studies suggest many patients with non-specific low back pain presenting to public hospital EDs receive low-value care. The primary aim was to describe management of patients presenting with low back pain to the ED of a private hospital in Melbourne, Australia, and received a final ED diagnosis of non-specific low back pain. We also determined predictors of hospital admission. Retrospective review of patients who presented with low back pain and received a final ED diagnosis of non-specific low back pain to Cabrini Malvern ED in 2015. Demographics, lumbar spinal imaging, pathology tests and medications were extracted from hospital records. Multivariate logistic regression was used to determine independent predictors of hospital admission. Four hundred and fifty presentations were included (60% female); 238 (52.9%) were admitted to hospital. One hundred and seventy-seven (39.3%) patients received lumbar spine imaging. Two hundred and eighty (62.2%) patients had pathology tests and 391 (86.9%) received medications, which included opioids (n = 298, 66.2%), paracetamol (n = 219, 48.7%), NSAIDs (n = 161, 35.8%), benzodiazepines (n = 118, 26.2%) and pregabalin (n = 26, 5.8%). Predictors of hospital admission included older age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.02-1.05), arrival by ambulance (OR 2.03, 95% CI 1.06-3.90) and receipt of pathology tests (OR 3.32, 95% CI 2.01-5.49) or computed tomography scans (OR 1.86, 95% CI 1.12-3.11). We observed high rates of imaging, pathology tests and hospital admissions compared with previous public hospital studies, while medication use was similar. Implementation of strategies to optimise evidence-based ED care is needed to reduce low-value care and improve patient outcomes.

Emergency nurses’ perceptions of their role in responding to escalations of care for clinical deterioration

BackgroundClinical leadership is fundamental to patient safety. The Emergency Department (ED) nurse-in-charge is a key leadership role; however, few studies have explored the management of clinical deterioration from the ED nurse-in-charge perspective. The aim of this study was to explore ED nurses-in-charge’ perceptions of their role in responding to episodes of escalation of care for clinical deterioration of ED patients. MethodsA prospective exploratory descriptive design was used to address the study aims. The study was conducted in an urban ED in Melbourne, Australia. Senior emergency nurses who fulfilled the role of being in charge of the ED were invited to participate. In-depth semi-structured interviews were conducted between December 2015 and March 2016. Interview transcripts were analysed using thematic analysis. ResultsTwo major themes, each with two subthemes were identified. The first major theme of Clinical Risk Management comprised sub-themes of Clinical Skills and Confidence. The second major theme of Resource Management comprised sub-themes of Human Resource Management and Logistical Resource Management. ConclusionsStrong collaboration, logistical and clinical risk management roles were perceived as fundamental to the nurse-in-charge's capacity to respond to escalations of care for clinical deterioration within in a complex team environment such as the ED.

Back pain "red flags": which are most predictive of serious pathology in the Emergency Department?

To determine the frequency of red flag signs and symptoms in patients presenting with back pain to the Emergency Department (ED) and association with serious pathologies and investigations performed. This retrospective observational study evaluated consecutive patients presenting with back pain to a Melbourne ED over a 14-month period. Data regarding red flags, patient characteristics, ED-initiated investigations, and diagnoses were extracted from medical records. Prevalence of each red flag and sensitivity, specificity, and likelihood ratios for diagnosing serious spinal or non-spinal pathology were calculated. Analysis was undertaken on 1000 eligible participants with back pain. 69% had red flags. Participants were categorised into diagnostic groups: musculoskeletal (80.6%), serious spinal (3.3%), and serious non-spinal (14.6%) pathologies. A number of red flags had positive likelihood ratios (LR) > 5, indicating a higher probability of serious pathology (spinal/non-spinal) including fever (LR + 68.8), tuberculosis history (LR + 13.8), known nephrolithiasis/abdominal aortic aneurysm (LR + 10.2), unexplained weight-loss (LR + 9.2), writhing in pain (LR + 6.9), urinary symptoms (LR + 5.4), and flank pain (LR + 5.2). Red flags with positive LR > 5 indicating a higher probability of serious spinal pathology were saddle anaesthesia (LR + 11.0), tuberculosis history (LR + 9.8), intravenous drug-use (LR + 6.9), acute-onset urinary retention (LR + 6.4), and anal tone loss (LR + 6.3). The majority of this study cohort had back pain of benign cause. Some red flags were associated with greater risk of serious pathology, others were not. Further evidence regarding red flags and their association with serious pathology is required, to better inform clinical guidelines.

Predictive values of haematuria and hydronephrosis in suspected renal colic: An emergency department retrospective audit.

To determine the predictive values of haematuria and hydronephrosis in suspected renal colic. We undertook a retrospective audit of adult patients who received a computed tomography (CT) of the kidneys, ureter and bladder (CTKUB) for suspected renal colic, presenting to Eastern Health Emergency Departments in Melbourne, Australia, between 1 January 2016 and 30 June 2016. CT hydronephrosis was used as a substitute for ultrasound hydronephrosis. We looked at the association of haematuria and CT proven hydronephrosis with CT proven ureteric and obstructing pelvic calculi. Of 769 adult cases who received a CTKUB for suspected renal colic, 384 were positive (49.9%) and 385 were negative (50.1%). For haematuria and renal colic, sensitivity was 87.3% (83.3-90.7), specificity 33.8% (28.9-39.0), positive predictive value (PPV) 55.7% (53.7-57.8), negative predictive value (NPV) 73.6% (67.1-79.3). For CT hydronephrosis and renal colic, sensitivity was 88.0% (84.2-91.1), specificity 85.0% (80.9-88.5), PPV 85.7% (82.4-88.5), NPV 87.4% (84.0-90.2). Of 110 cases with both negative CT hydronephrosis and negative haematuria, four had ureteric calculi, NPV 96.4% (90.8-98.6). This audit suggests that a diagnostic strategy relying on the absence of haematuria or hydronephrosis, or both, to rule out ureteric calculi may result in a small number of stones being missed.

Sex disparities in the assessment and outcomes of chest pain presentations in emergency departments

ObjectiveTo determine whether sex differences exist in the triage, management and outcomes associated with non-traumatic chest pain presentations in the emergency department (ED).MethodsAll adults (≥18 years) with non-traumatic chest pain...

Determination of the best early warning scores to predict clinical outcomes of patients in the emergency department

ObjectiveEarly warning scores (EWS) are used to predict patient outcomes. We aimed to determine which of 13 EWS, based largely on emergency department (ED) vital sign data, best predict important...

Prevalence and utility of point-of-care ultrasound in the emergency department: A prospective observational study.

An observational study on the current diagnostic and procedural utility, as well as impact of point-of-care ultrasound (POCUS) in the emergency department (ED). Point-of-care ultrasound (POCUS) has been recognised as a useful non-invasive bedside tool in providing valuable information, as well as its utility in procedural guidance for clinicians. However, its current prevalence and utility in ED remain unknown. In October 2016, a 31-day prospective observational study was performed in three Monash Health Emergency Departments in Melbourne, Australia. Data regarding patients' presenting complaints, frequency, operators' qualifications and POCUS module were collected and analysed. Factors associated with diagnostic impacts were identified. A total of 390 (2.1%) POCUS examinations were performed among 18,355 presentations in the three Monash Health EDs during the study period. POCUS was performed as a diagnostic tool in 344 (88.2%) and procedural guidance in 46 (11.8%) cases. eFAST/AAA and bedside echocardiography were the two most frequently utilised diagnostic modules. Overall, the majority of diagnostic POCUS cases were indicated for abdominal pain (35.3%), chest pain (14.0%) and trauma mainly traffic accidents (5.8%). Procedural POCUS was most commonly used for vascular access (71.7%), where dyspnoea (21.6%) was the most common presenting complaint. The majority of the cases were performed by FACEMs (Fellows of Australasian College of Emergency Medicine) (66.4%). Despite known diagnostic and procedural values, the prevalence of POCUS in ED was found to be lower than what was expected. The prevalence was shown to be proportional to the level of clinical expertise among the operators. Training and utility of POCUS among physicians and trainees should be further advocated and supported.

Epidemic Thunderstorm Asthma

Introduction:On November 21 and 22 of 2016, Victoria witnessed an unprecedented epidemic thunderstorm asthma emergency event in size acuity and impact. This scenario was never exercised nor contemplated. The event resulted in a 73% increase in calls to the Emergency Services Telecommunications Authority and 814 ambulance cases in the six hours from 6 pm on November 21, 2016. A 58% increase in people presented to public hospital emergency departments in Melbourne and Geelong on November 21 and 22, 2016 (based on the three-year average). 313 calls were made to the nurse on call from people with breathing, respiratory, and allergy problems (compared to an average of 63 calls for the previous month). Tragically, ten deaths are linked to this event.Methods:A substantial amount of work has been completed, much of which goes towards addressing the Inspector-General for Emergency Management recommendations following a review of the event, including: Release of an epidemic thunderstorm asthma campaign and education programs which were rolled out across Victoria for the community and health professionals from September through November 2017;Development of a new epidemic thunderstorm asthma forecasting system on 1 October 2017 and updated warning protocols during the 2017 grass pollen season;Implementation of a Real-time Health Emergency Monitoring System to alert the department of demands on public hospital emergency departments on the system; andIntroduction of a new State Health Emergency Response Plan in October 2017 to improve coordination and communications before and during a health emergency.Discussion:The presentation will concentrate on the lessons learned more than two years down the track from the event in November 2016.

The utility of Point-Of-Care Ultrasound (POCUS) in emergency department; an observational study

Objective An observational study on the current diagnostic and procedural utility and impact of point of care ultrasound (POCUS) in Emergency Departments. Background POCUS has been recognised as a readily available, non-invasive imaging tool; providing prompt clinical information at the bedside, as well as a useful guiding tool during procedural interventions. However, its current use and clinical impact in ED remain unknown. Methods In October 2016, a 31-day prospective observational study was performed in three Monash Health Emergency Departments in Melbourne, Australia. Data regarding patients’ presenting complaints, frequency, operators’ qualifications and POCUS module were archived and analysed. Factors associated with diagnostic impacts were identified. Results A total of 390 (2.82%) POCUS examinations were performed among 18,355 (13,822 adults) presentationsin the three Monash Health EDs during the 31-day study period. 292 (74.9%) cases were retrieved from electronic medical records (Symphony), recorded as Clinician-Performed Ultrasound (CPU);and 98 (25.1%) cases from written records which were collected by research assistants. The POCUS was performed as a diagnostic tool in 344 (88.2%) and procedural in 46 (11.8%) cases. eFAST/AAA and BELS were the two most frequently utilised diagnostic modalities. Overall, the majority of diagnostic POCUS cases were in patients presented with abdominal pain (35.3%), chest pain (14.0%) and trauma mainly motor vehicle accidents (5.8%). Procedural POCUS was most commonly used for vascular access (71.7%), where dyspnoea (21.6%) was the most common presenting complaint. Most of the cases were performed by Senior Medical Staffs (66.4%). DiagnosticPOCUS overall sensitivity and specificity were 94.1% (95% CI 85.6 - 98.4%) and 99.6% (97.5 - 100%); positive and negative predictive values were 98.5% (95% CI 90.1 – 99.8%) and 98.2% (95% CI 95.6 – 99.3%), respectively. Conclusions Despite known diagnostic and procedural pros, the prevalence of POCUS in our EDs was found to be lower than what is expected and potentially beneficial in our population. In our study, POCUS mostly served for diagnostic purposes and demonstrated satisfactory diagnostic values. However, the true diagnostic and therapeutic impacts could not be elicited given the few numbers of cases. Prevalence is shown to be proportional to the level of clinical expertise among the operators. Training and utility of POCUS among physicians ought to be further advocated and supported.

Methamphetamine use in patients presenting to emergency departments and psychiatric inpatient facilities: what are the service implications?

The aim of this study is to understand better the service implications of patients presenting to an inner city Australian Emergency Department (ED) and Acute Psychiatric Inpatient Service (AIS) with a history of recent crystal methamphetamine use. An audit was taken of all patients with recent crystal methamphetamine use presenting to St Vincent's Hospital Melbourne ED and AIS over the month of September 2017. Recorded information included patient demographics, diagnosis, aggressive episodes, restrictive interventions and other risk incidents. Methamphetamine was related to 21.7% of AIS admissions. Of these individuals, half were involved in aggression towards staff. In the ED, 65.7% of patients with amphetamine use were aggressive to staff and 50% were aggressive towards other patients. There were high rates of physical (69.2%) and mechanical restraint (61.5%) in the ED setting. Methamphetamine use in the AIS was commonly associated with enduring psychotic disorders, whilst those managed exclusively in the ED were most commonly in an acute intoxicated state. Methamphetamine use presents a significant challenge to EDs and acute mental health services. Additional resources are required to manage these patients and their impact on the health system needs to be factored into future service planning.

Dr Google in the ED: searching for online health information by adult emergency department patients.

To determine the prevalence, predictors, and characteristics of health-related internet searches by adult emergency department (ED) patients; to examine the effect of searching on the doctor-patient relationship and treatment compliance. A multi-centre, observational, cross-sectional study; a purpose-designed 51-item survey, including tools for assessing e-health literacy (eHEALS) and the effects of internet searching on the doctor-patient relationship (ISMII). Setting, participants: 400 adult patients presenting to two large tertiary referral centre emergency departments in Melbourne, February-May 2017. Descriptive statistics for searching prevalence and characteristics, doctor-patient interaction, and treatment compliance; predictors of searching; effect of searching on doctor-patient interaction. 400 of 1056 patients screened for eligibility were enrolled; their mean age was 47.1 years (SD, 21.1 years); 51.8% were men. 196 (49.0%) regularly searched the internet for health information; 139 (34.8%) had searched regarding their current problem before presenting to the ED. The mean ISMII score was 30.3 (95% CI, 29.6-31.0); searching improved the doctor-patient interaction for 150 respondents (77.3%). Younger age (per 10-year higher age band: odds ratio [OR], 0.74; 95% CI, 0.61-0.91) and greater e-health literacy (per one-point eHEALS increase: OR, 1.11; 95% CI, 1.06-1.17) predicted searching the current problem prior to presentation; e-health literacy predicted ISMII score (estimate, 0.39; 95% CI, 0.20-0.39). Most patients would never or rarely doubt their diagnosis (79%) or change their treatment plan (91%) because of conflicting online information. Online health care information was frequently sought before presenting to an ED, especially by younger and e-health literate patients. Searching had a positive impact on the doctor-patient interaction and was unlikely to reduce adherence to treatment.

Downstream consequences of diagnostic error in pediatric anaphylaxis

BackgroundPediatric anaphylaxis is commonly misdiagnosed in the Emergency Department (ED). We aimed to determine the impact of inaccurate diagnosis on the management and follow-up of pediatric anaphylaxis presenting to the ED.MethodsRetrospective chart review of ED management of children aged 0–18 years with allergic presentations to three EDs in Melbourne, Australia in 2014. Cases were included if an ED diagnosis of anaphylaxis was recorded, or the presentation met international consensus criteria for anaphylaxis.ResultsOf the 60,143 pediatric ED presentations during the study period, 1551 allergy-related presentations were identified and reviewed. 187 met consensus criteria for anaphylaxis, and another 24 were diagnosed with anaphylaxis without meeting criteria. Of the 211 presentations, 105 cases were given an ED diagnosis of anaphylaxis and 106 cases were given an alternative diagnosis in ED.Those diagnosed with anaphylaxis were more likely to receive epinephrine [85.7% vs 31.1% (OR = 13.27, 95% CI: 6.09–26.3)], to be observed for the recommended four hours [56.2% vs 29.2% (OR = 3.10, 95% CI 1.76–5.48, p < 0.001)], to have an epinephrine autoinjector available on discharge [81.9% vs 35.8% (OR = 4.12, 95% CI 2.07–8.22, p < 0.001)] and to be referred to an allergist [35.2% vs 16.0% (OR = 2.85, 95% CI 1.48–5.49, p < 0.01)]. Provision of anaphylaxis action plans and allergen avoidance advice was poorly documented for all patients.ConclusionAccurate diagnosis of anaphylaxis in ED has a significant impact on observation times, prescription of epinephrine autoinjectors and referral to an allergist. These factors are key to reducing mortality and the significant morbidity that results from childhood anaphylaxis.

Predicting functional decline in older emergency patients-the Safe Elderly Emergency Discharge (SEED) project.

to profile the trajectory of, and risk factors for, functional decline in older patients in the 30 days following Emergency Department (ED) discharge. prospective cohort study of community-dwelling patients aged ≥65 years, discharged home from a metropolitan Melbourne ED,31 July 2012 to 30 November 2013. The primary outcome was functional decline, comprising either increased dependency in personal activities of daily living (ADL) or in skills required for living independently instrumentalADL (IADL), deterioration in cognitive function, nursing home admission or death. Univariate analyses were used to select risk factors and logistic regression models constructed to predict functional decline. at 30 days, 34.4% experienced functional decline; with 16.7% becoming more dependent in personal ADL, 17.5% more dependant in IADL and 18.4% suffering deterioration in cognitive function. Factors independently associated with decline were functional impairment prior to the visit in personal ADL(Odds Ratio [OR] 3.21, 95% confidence interval [CI] 2.26-4.53) or in IADL (OR 6.69, 95% CI 4.31-10.38). The relative odds were less for patients with moderately impaired cognition relative to those with normal cognition (OR 0.38, 95% CI 0.19-0.75). There was a 68% decline in the relative odds of functional decline for those with any impairment in IADL who used an aid for mobility (OR 0.32, 95% CI 0.14-0.7). older people with pre-existing ADL impairment were at high risk of functional decline in the 30 days following ED presentation. This effect was largely mitigated for those who used a mobility aid. Early intervention with functional assessments and appropriate implementation of support services and mobility aids could reduce functional decline after discharge.