Prospective observational study of emergent endotracheal intubation practice in the intensive care unit and emergency department of an Australian regional tertiary hospital

Objective: The present study aimed to describe the characteristics and outcomes of intubation occurring in the ICU and ED of an Australian tertiary teaching hospital. Methods: This was a prospective observational study of intubation practice across the Geelong Hospital over a 6 month period from 1 August 2012 to 31 January 2013. Data were entered by the intubating team through an online data collection form. Results: There were 119 patients intubated and 134 attempts at intubation in the ED and ICU over a 6 month period. The first-pass success rate was 104/119 (87.4%), and all but a single patient was intubated by the second attempt. Propofol, fentanyl, midazolam and suxamethonium were the most common drugs used in rapid sequence induction. AEs were reported in 44/134 (32.8%) of intubation attempts, with transient hypoxia and hypotension being the most common. A significant adverse outcome, namely aspiration pneumonitis, occurred in one patient. There were no peri-intubation deaths. Conclusion: The majority of airways are managed by ICU and ED consultants and trainees, with success rates and AE rates comparable with other published studies. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Epidemiology of early Rapid Response Team activation after emergency department admission

BACKGROUND: Rapid Response Team (RRT) calls can often occur within 24h of hospital admission to a general ward. We seek to determine whether it is possible to identify these patients before there is a significant clinical deterioration. METHODS: Retrospective case-controlled study comparing patient characteristics, vital signs, and hospital outcomes in patients triggering RRT activation within 24h of ED admission (cases) with matched ED admissions not receiving a RRT call (controls). RESULTS: Over 12 months, there were 154 early RRT calls. Compared with controls, cases had a higher heart rate (HR) at triage (92 vs. 84beats/min; p=0.008); after 3h in the ED (91 vs. 80beats/min; p=0.0007); and at ED discharge (91 vs. 81beats/min; p=0.0005). Respiratory rate (RR) was also higher at triage (21.2 vs. 19.2breaths/min; p=0.001). On multiple variable analysis, RR at triage and HR before ward transfer predicted early RRT activation: OR 1.07 [95% CI 1.02-1.12] for each 1breath/min increase in RR; and 1.02 [95% CI 1.002-1.030] for each beat/minute increase in HR, respectively. Study patients required transfer to the intensive care in approximately 20% of cases and also had a greater mortality: (21% vs. 6%; OR 4.65 [95% CI 1.86-11.65]; p=0.0003) compared with controls. CONCLUSIONS: Patients that trigger RRT calls within 24h of admission have a fourfold increase in risk of in-hospital mortality. Such patients may be identified by greater tachycardia and tachypnoea in the ED.

Fuel stores of juvenile waders on autumn migration in high arctic Canada

Little is known about the fuel stores that arctic-breeding waders put on before departure from the breeding grounds. During a ship-based expedition to arctic Canada, we caught waders at seven, mainly coastal sites, with-in 68°-76°N and 139°-67°W, from 28 July to 31 August 1999. More than two hundred waders of twelve species were trapped, mainly White-rumped Calidris fuscicollis, Semipalmated C. pusilla, Baird's C. bairdii and Buff-breasted Sandpipers Tryngites subruficollis. The vast majority of the birds were juveniles. Body masses and visual fat stores were low, close to the lowest values found anywhere during the non-breeding season for the different species. The relatively fattest birds were Buff-breasted Sandpipers, but they were still far from their maximum body mass on spring migration. We conclude that juvenile arctic waders depart from their natal areas with only small fuel stores, which is in concordance with a time-minimising migration strategy.

Composition of fuel stores and digestive limitations to fuel deposition rate in the long-distance migratory thrush nightingale, Luscinia luscinia

During their autumn migratory phase, thrush nightingales (Luscinia luscinia) previously starved for 2 d were allowed to refuel under three different ambient temperature conditions (-7 degrees, 7 degrees, and 22 degrees C). During the refueling period, as well as during the preceding control and starvation periods, food intake, body mass, and feces production were monitored. In addition, daily energy expenditure was measured during the refueling period. The compilation of the energy balance during the refueling period revealed an energy density of the deposited tissue of 33.6 kJ g-1. Assuming that the deposited tissue consists of fat and protein exclusively, with energy densities of 39.6 and 5.5 kJ g-1 wet mass, respectively, we estimated the deposited tissue to consist of 82% fat and 18% wet protein (6% dry protein and 12% water). Nitrogen balances during control, starvation, and refueling phases and during a period of prolonged and complete starvation indicated that 5% of the nutrient stores consisted of dry protein. Our results support recent findings that nutrient stores for migration often contain protein in addition to fat and consequently are 15%-25% less energy rich than pure fat stores. These proteins might be stored as muscle or other functional tissue and may be required to support the extra mass of the stores and/or reflect an incapacity of the metabolic machinery to catabolize far exclusively. Fuel deposition rate was positively related with ambient temperature, whereas food intake rate was unaffected by temperature. These results indicate that the rate of fuel deposition is limited by a ceiling in food intake rate; when this ceiling is reached, fuel deposition rate is negatively affected by daily energy expenditure rate. To a certain extent, the ceiling in food intake rate varies depending on feeding conditions over the previous days. These variations in food intake capacity probably reflect the building and breakdown of gut tissues and/or gut enzyme systems and might be insensible and not evolutionary adaptive. Significant energetic costs, however, are probably associated with the maintenance of gut tissues. It is therefore feasible that changes in digestive capacity are regulated and are directed at energy economization.

Model to predict inpatient mortality from information gathered at presentation to an emergency department: The Triage Information Mortality Model (TIMM)

OBJECTIVES: To derive and validate a mortality prediction model from information available at ED triage. METHODS: Multivariable logistic regression of variables from administrative datasets to predict inpatient mortality of patients admitted through an ED. Accuracy of the model was assessed using the receiver operating characteristic area under the curve (ROC-AUC) and calibration using the Hosmer-Lemeshow goodness of fit test. The model was derived, internally validated and externally validated. Derivation and internal validation were in a tertiary referral hospital and external validation was in an urban community hospital. RESULTS: The ROC-AUC for the derivation set was 0.859 (95% CI 0.856-0.865), for the internal validation set was 0.848 (95% CI 0.840-0.856) and for the external validation set was 0.837 (95% CI 0.823-0.851). Calibration assessed by the Hosmer-Lemeshow goodness of fit test was good. CONCLUSIONS: The model successfully predicts inpatient mortality from information available at the point of triage in the ED.

Impact of automated dispensing cabinets on medication selection and preparation error rates in an emergency department: a prospective and direct observational before-and-after study

RATIONALE, AIMS AND OBJECTIVES: The implementation of automated dispensing cabinets (ADCs) in healthcare facilities appears to be increasing, in particular within Australian hospital emergency departments (EDs). While the investment in ADCs is on the increase, no studies have specifically investigated the impacts of ADCs on medication selection and preparation error rates in EDs. Our aim was to assess the impact of ADCs on medication selection and preparation error rates in an ED of a tertiary teaching hospital. METHODS: Pre intervention and post intervention study involving direct observations of nurses completing medication selection and preparation activities before and after the implementation of ADCs in the original and new emergency departments within a 377-bed tertiary teaching hospital in Australia. Medication selection and preparation error rates were calculated and compared between these two periods. Secondary end points included the impact on medication error type and severity. RESULTS: A total of 2087 medication selection and preparations were observed among 808 patients pre and post intervention. Implementation of ADCs in the new ED resulted in a 64.7% (1.96% versus 0.69%, respectively, P = 0.017) reduction in medication selection and preparation errors. All medication error types were reduced in the post intervention study period. There was an insignificant impact on medication error severity as all errors detected were categorised as minor. CONCLUSION: The implementation of ADCs could reduce medication selection and preparation errors and improve medication safety in an ED setting.

The effect of a staged, emergency department specific rapid response system on reporting of clinical deterioration

BACKGROUND: Despite emerging evidence regarding clinical deterioration in emergency department (ED) patients, the widespread uptake of rapid response systems (RRS) in EDs has been limited. AIMS: To evaluate the effect of an ED RRS on reporting of clinical deterioration and determine if there were differences between patients who did, and did not, deteriorate during ED care. METHODS: A retrospective cross sectional design was used to conduct this single site study in Melbourne, Australia. Stratified random sampling identified 50 patients with shortness of breath, chest pain or abdominal pain per each year studied (2009-2012) giving a total of 600 patients. The intervention was an ED RRS implemented in stages. RESULTS: The frequency of clinical deterioration was 14.8% (318 episodes/89 patients). Unreported deterioration decreased each year (86.7%; 68.8%; 55.3%; 54.0%, p=0.141). Patients who deteriorated during ED care had a longer median ED length of stay (2.8h; p<0.001), were 31.9% more likely to need hospital admission (p<0.001) and 4.9% more likely to die in hospital (p=0.044). CONCLUSIONS: A staged ED specific RRS decreased the frequency of unreported clinical deterioration. Controlled multi-site studies of ED specific RRSs are needed to examine the effect of formal ED RRSs on patient outcomes.

Physiological status during emergency department care : relationship with inhospital death after clinical deterioration

OBJECTIVE: To examine the relationship between patient physiological status in the emergency department (ED) and inhospital mortality after rapid response team (RRT) or cardiac arrest team (CAT) activations within 72 hours of emergency admission to medical or surgical wards. DESIGN, SETTING AND PARTICIPANTS: A multisite, retrospective, cohort study of 660 randomly selected (220 patients per site) adult medical or surgical patients who were admitted from the ED during 2012 and who had had an RRT or CAT activation within 72 hours of admission, at three hospitals in Melbourne, Australia. MAIN OUTCOME MEASURE: Inhospital mortality. RESULTS: There were 825 RRT activations (for 634 patients) and 42 CAT activations (for 35 patients). The median time to the first RRT or CAT activation was 18.8 hours and was significantly shorter in patients who died in hospital (14.6 v 20.6 hours, P=0.036). Compared with survivors, patients who died were more likely to have at least one observation meeting RRT criteria during their ED stay (45.9% v 34.8%; P=0.029): tachypnoea (21.1% v 13.4%, P=0.039), hypotension (20.2% v 11.8%, P=0.018), hypoxaemia (8.3% v 3.1%, P=0.001) and altered conscious state (6.2% v 1.3%, P=0.001) were more common in patients who died. The risk-adjusted odds ratio (OR) for inhospital death was highest for patients with an altered conscious state during their ED stay (OR, 4.633; 95% CI, 1.365-15.728; P=0.014). CONCLUSIONS: In patients who needed an RRT or CAT activation within the first 72 hours of emergency admission to medical or surgical wards, there was a strong association between physiological derangement during ED care and inhospital death.

Cancer diagnosed in the emergency department of a regional health service

OBJECTIVE: Patients diagnosed with cancer in the Emergency Department (ED) have more advanced disease at diagnosis and poorer outcomes. High rates of initial presentation to ED suggest potential problems with access to care. The aim of this project was to interpret findings in regional/rural Victoria and explore implications for practice.

DESIGN: Cross-sectional study linking two independent data sets.

SETTING: Regional city of Geelong and surrounding rural areas in south-west Victoria.

PARTICIPANTS: All newly diagnosed cancer patients in 2009.

MAIN OUTCOME MEASURES: Number of cancer patients diagnosed in the ED.

RESULTS: One in five newly diagnosed cancer patients present to ED 6 months prior to cancer diagnosis. One in 10 is diagnosed as a result of their ED visit. Patients presenting to ED were older, more often men and from disadvantaged areas. Symptoms on presentation included chest complaints, bowel obstruction, abdominal pain, anaemia and generalised weakness. Cancer diagnosed in the ED is associated with advanced stage and shorter survival.

CONCLUSION: Reasons for presentation to ED would be multifactorial and include complex cases with coexisting symptoms making diagnosis difficult. The general public appear to have a low level of awareness of alternative primary care services or difficulty accessing such information. Some of the changes towards reducing the number of patients presenting to ED will include patient education.