The Cochaperone BAG2 Sweeps Paired Helical Filament-Insoluble Tau from the Microtubule

Tau inclusions are a prominent feature of many neurodegenerative diseases including Alzheimer`s disease. Their accumulation in neurons as ubiquitinated filaments suggests a failure in the degradation limb of the Tau pathway. The components of a Tau protein triage system consisting of CHIP/Hsp70 and other chaperones have begun to emerge. However, the site of triage and the master regulatory elements are unknown. Here, we report an elegant mechanism of Tau degradation involving the cochaperone BAG2. The BAG2/Hsp70 complex is tethered to the microtubule and this complex can capture and deliver Tau to the proteasome for ubiquitin-independent degradation. This complex preferentially degrades Sarkosyl insoluble Tau and phosphorylated Tau. BAG2 levels in cells are under the physiological control of the microRNA miR-128a, which can tune paired helical filament Tau levels in neurons. Thus, we propose that ubiquitinated Tau inclusions arise due to shunting of Tau degradation toward a less efficient ubiquitin-dependent pathway.

Predictors of critical care admission in emergency department patients triaged as low to moderate urgency

Aim. This paper is a report of a study to identify predictors of critical care admission in emergency department patients triaged as low to moderate urgency that may be apparent early in the emergency department episode of care.

Background. Observations of clinical practice show that a number of emergency department patients triaged as low to moderate urgency require critical care admission, raising questions about the relationship between illness severity and physiological status early in the emergency department episode of care.

Methods. A retrospective case control design was used. All participants were aged over 18 years, triaged to Australasian Triage Scale categories 3, 4 or 5, and attended emergency department between 1 July 2004 and 30 June 2005. Cases were admitted to intensive care unit or coronary care unit and controls were admitted to general medical or surgical units. Cases (n = 193) and controls (n = 193) were matched by age, gender, emergency department discharge diagnosis and triage category.

Results. Critical care admission associated with: (i) a presenting complaint of nausea, vomiting and diarrhoea (OR = 3·40, 95%CI:1·22–9·47, P = 0·019), (ii) heart rate abnormalities at triage (OR = 2·10, 95%CI:1·19–3·71, P = 0·011), (iii) temperature abnormalities at triage (OR = 2·87 95%CI:1·05–7·89, P = 0·041), (iv) respiratory rate at first nursing assessment (OR = 1·66, 95%CI:1·05–2·06, P = 0·31) or (v) heart rate abnormalities at first nursing assessment (OR = 1·57, 95%CI = 1·04−2·39, P = 0·033).

Conclusion. Derangements in temperature, respiratory rate and heart appear to increase risk of critical care admission. Further work using a prospective approach is needed to establish which physiological parameters have the highest predictive validity, the level(s) of physiological abnormality with highest clinical utility, and the optimal timing for collection of physiological data.

Implementation of evidence into practice : Development of a tool to improve emergency nursing care of acute stroke

Background
Stroke is an increasing global health issue that places considerable burden on society and health care services. An important part of acute stroke management and decreasing stroke-related mortality is preventing complications within the first 24–48 hours. The current climate of prolonged time spent in the Emergency Department (ED) means that many aspects of stroke management are now the responsibility of emergency nurses.

Aims
The aims of this paper are to: i) examine the evidence related to nursing care of acute stroke, ii) identify evidence-based elements of stroke care with most applicability to emergency nursing and iii) use evidence-based stroke care recommendations to develop a guideline for the emergency nursing management of acute stroke.

Results
Emergency nursing care of acute stroke should focus on optimal triage decisions, physiological surveillance, fluid management, risk management, and early referral to specialists.

Conclusions
The role of emergency nurses in stroke care will increase and it is important that emergency nurses deliver evidence-based stroke care in order to optimise patient outcomes. Guidelines and decision support tools for use in emergency nursing must be practical and have high levels of clinical utility for maximum uptake in a busy clinical environment.

Responding to the ageing profile of emergency department patients

Background
Older people with acute superimposed on chronic health problems are becoming a core aspect of emergency department (ED) caseload. This project explored the ED experience from the perspective of older patients and their carers.

Method
A convenience sample of thirty participants was recruited across three participating EDs: tw o metropolitan and one regional. The project utilised two approaches to data collection: 1) an observation approach where a project officer observed participants from the time of ED presentation until discharge, or for up to six hours; and 2) a subsequent interview was conducted with the participant and their carer within a week of the ED presentation. Data from both sources were integrated, and independently thematically analysed by two members of the team.

Results
Thirty participants aged over 65 were recruited. Their average age was 77.1 (sd=6.7) years, 59% w ere female, and 74% were triage category 1- 3 (indicating moderate/high acuity). Participants spent on average 7 hours 47 minutes in the ED, with 50% discharged home, 43% admitted to general wards or MAPU, and 7% discharged to residential care/hospice. Key themes in the factors influencing the patient experience and examples of quality care were identified, along with opportunities to improve the capacity for EDs to be “older person friendly”, and “person-centred.” Challenges include improving the effectiveness of communication between staff and patients/carers (including issues around people from culturally and linguistically diverse backgrounds), availability of allied health professionals to assist with discharge planning, and a tendency for older people not to seek ED care until the health problem was severe. Patient exemplars highlight key themes.

Discussion and implications
Results of the project highlight positive aspects of emergency department care for older people and inform targets for improvement strategies. These can be used to drive ongoing improvements in care for older people presenting to EDs.

An evidence-based practice approach to improving nursing care of acute stroke in an Australian emergency department

Aims. The aim of this study was to improve the emergency nursing care of acute stroke by enhancing the use of evidence regarding prevention of early complications.
Background. Preventing complications in the first 24–48 hours decreases stroke-related mortality. Many patients spend considerable part of the first 24 hours following stroke in the Emergency Department therefore emergency nurses play a key role in patient outcomes following stroke.
Design. A pre-test/post-test design was used and the study intervention was a guideline for Emergency Department nursing management of acute stroke.
Methods. The following outcomes were measured before and after guideline implementation: triage category, waiting time, Emergency Department length of stay, time to specialist assessment, assessment and monitoring of vital signs, temperature and blood glucose and venous-thromboembolism and pressure injury risk assessment and interventions.
Results. There was significant improvement in triage decisions (21Æ4% increase in triage category 2, p = 0Æ009; 15Æ6% decrease in triage category 4, p = 0Æ048). Frequency of assessments of respiratory rate (p = 0Æ009), heart rate (p = 0Æ022), blood pressure (p = 0Æ032) and oxygen saturation (p = 0Æ001) increased. In terms of risk management, documentation of pressure area
interventions increased by 28Æ8% (p = 0Æ006), documentation of nil orally status increased by 13Æ8% (ns), swallow assessment prior to oral intake increased by 41Æ3% (p = 0Æ003), speech pathology assessment in Emergency Department increased by 6Æ1% (ns) and there was 93Æ5 minute decrease in time to speech pathology assessment for admitted patients (ns).
Relevance to clinical practice. An evidence-based guideline can improve emergency nursing care of acute stroke and optimise patient outcomes following stroke. As the continuum of stroke care begins in the Emergency Department, detailed recommendations for evidence-based emergency nursing care should be included in all multidisciplinary guidelines for the management of acute stroke.

An interventional study to improve paramedic diagnosis of stroke

Objective: The aim of the Faster Access to Stroke Therapy (FAST) study was to determine the effect of educational intervention andthe use of a prehospital stroke tool on the paramedic diagnosis of stroke.

Methods: Paramedics in emergency medical service units servicing a university teaching hospital were divided into two groups: FAST study paramedics (n = 18) and non-FAST study paramedics (n = 43). The FAST study paramedics received stroke education and instruction in the use of a prehospital stroke assessment tool [Melbourne Ambulance Stroke Screen (MASS)] to assist in stroke diagnosis. Based on final hospital diagnosis, the sensitivities of paramedic stroke diagnosis in the two groups were compared for a 12-month period before andafter the intervention.

Results: The sensitivity for the FAST study paramedics in identifying stroke improved from 78% (95% confidence interval [CI]: 63% to 88%) to 94% (95% CI: 86% to 98%) (p = 0.006) after receiving the stroke education session and with use of the MASS tool. There was no change in stroke diagnosis for the non-study paramedics 78% (95% CI: 71% to 84%) to 80% (95% CI: 72% to 87%) (p = 0.695). Prenotification of impending arrival to the emergency department was associated with higher-priority triage in the emergency department, and subsequent shorter times for door to medical review (15 min vs. 31 min, p < 0.001) and door to computed tomography (CT) scanning (94 min vs. 144 min, p < 0.001).

Conclusions: Targeted stroke education and the use of a simple clinical tool can significantly improve the diagnostic sensitivity of stroke by paramedics in the prehospital setting. Accurate diagnosis combined with prenotification of the pending arrival of stroke patients will allow for the focused and timely application of resources for the management of acute stroke.

Effect of clinician designation on emergency department fast track performance

Objective To examine the effect of clinician designation on emergency department (ED) fast track performance.
Design and Setting A retrospective audit of patients managed in the fast track area of an ED in metropolitan Melbourne, Australia.
Participants Patients triaged to ED fast track from 1 January 2008 to 31 December 2008 (n=8714).
Main Outcome Measures Waiting times in relation to Australasian triage scale (ATS) recommendations and ED length of stay (LOS) for non-admitted patients were examined for each clinician group.
Results Compliance with ATS waiting time recommendations was highest (82.5%) for emergency nurse practitioners/candidates and lowest (48.2%) for junior medical officers. Median ED LOS was less than 3 h for non-admitted patients, and 85.8% of non-admitted fast track patients (n=6278) left the ED within 4 h. Patients managed by emergency nurse practitioners/ candidates had the shortest ED LOS (median 1.7 h) and patients managed by junior medical officers and locum medical officers the longest ED LOS (median 2.7 h) (x²=498.539, df=6, p<0.001).
Conclusions Clinician designation does impact on waiting times and, to a lesser extent, ED LOS for patients managed in ED fast track systems. Future research should focus on obtaining a better understanding of the relationship between clinician expertise, time-based performance measures and quality of care indicators.

Emergency department presentations of patients from CALDB receiving chemotherapy in day oncology settings

Objective
The objectives of this research were to compare the emergency department (ED) presentations for cancer patients from culturally and linguistically diverse backgrounds (CALDB) treated with chemotherapy through day oncology units with other cancer patients.

Design
A retrospective audit was conducted. Data collected included demographic factors and ED presentation characteristics. Descriptive statistics and direct logistic regression was used to summarise and compare the ED presentation rates and ED presentation characteristics of patients from CALDB and other patients.

Setting
Primary and secondary care.

Patients
All adult day oncology patients who were treated with chemotherapy and presented to an ED between 1 January and 31 December, 2007. Across the two health sites, 770 day oncology patients attended an ED on at least one occasion. Of these 37.7% were born in a non-English speaking country.

Results
Patients from CALDB were more likely to present (p < 0.001, OR = 1.55, C.I. = 1.29–1.88) and re-present to an ED (p < 0.001, OR = 2.08, C.I. = 1.37–3.16), however there was no association between CALDB and admission to hospital following the ED presentation, triage category or being seen within the clinically recommended time. Patients from CALDB tended to present for potentially preventable conditions such as nausea/vomiting/dehydration and fever.

Conclusions
Our findings suggest that targeted interventions that incorporate education and information to assist with self-care for patients from CALDB may reduce potentially preventable presentations and representations to an ED and the subsequent economic, social and personal costs associated with these ED presentations.

Role of emergency departments in screening for obese and overweight children

Introduction
Childhood obesity is a major and increasing public health issue. The role of Emergency Departments (EDs) in screening for overweight and obese children has not been studied extensively. The main aim of this study was to estimate the prevalence of overweight children in Emergency Department (ED) populations. A secondary objective was to compare the characteristics of overweight and obese children with healthy weight children.

Methods
This prospective exploratory study was conducted in the two district urban EDs in Melbourne, Australia. A total of 87 ED patients aged 2 to 15 years were included in the study. The main outcome measures were body mass index, weight and height percentiles.

Results
The median absolute BMI was 16.8 (IQR = 15.4 to 18.8). The total number of children found to be overweight (BMI > 85th percentile) or obese (BMI > 95th percentile) was 21.8% (n = 19). Of these, 5.7% (n = 5) of children in this study were classified as obese. Comparison of overweight/obese children and healthy weight children showed no differences in triage but a higher incidence of respiratory illness (15.8% compared to 2.9%).

Conclusions
This pilot study showed that 1 in 5 children who presented to EDs were either overweight or obese suggesting a possible role for EDs in the detection and referral of overweight and obese children to intervention programs. Our findings suggest that a sufficiently powered randomised controlled trial is warranted to examine the effectiveness and efficacy of EDs screening for obese and overweight children.

Frequency and nature of reported incidents during emergency department care

Background The aim of this study was to examine reported incidents affecting Emergency Department (ED) episodes of care.
Methods A retrospective audit of ED patients was carried out in an urban district hospital in Melbourne, Australia from 1 January 2008 to 31 December 2008. The main outcome measure was presence or absence of reported patient-related incident(s) during ED care.
Results There were 984 patient-related incidents (n¼984) during 2008.The most common incidents were related to patient behaviour (66.4%), patient management (10.1%) and medications (6.5%). Patients whose ED care involved reported incident(s) were older, had higher triage categories, longer length of ED stay and were more likely to need hospital admission or leave at their own risk. Eighteen per cent of reported incidents occurred in patients aged 65 years and over. Incidents affecting older patients were more likely to be related to breach of skin integrity, patient management, diagnosis and patient identification, and less likely to involve patient behaviour.
Conclusions Reported incident(s) occurred in 0.47% of ED episodes of care. Differences in personal and clinical characteristics of patients whose ED care involved reported incident(s) highlights the need for better understanding of incidents occurring in the ED in order to improve systems for high-risk patients.

Early predictors of hospital admission in emergency department patients with chronic obstructive pulmonary disease

Background: Streamlining emergency department (ED) care of patients with chronic obstructive pulmonary disease (COPD) may be an important strategy in managing the increasing burden of this disease.

Study objectives: The aim of this study was to identify factors predictive of hospital admission in ED patients with COPD, specifically factors that can be used early in the ED episode of care.

Methods: Using retrospective regression analysis, case data from 321 randomly selected medical records from five Australian EDs were analysed. Patient characteristics, triage and ED system features, physiological status, and ED treatment during the first four hours of ED care were compared between discharged and admitted patients.

Results: Factors available on ED arrival associated with increased likelihood of admission were: age (OR = 1.04, p = 0.008) respiratory symptoms affecting activities of daily living (OR = 1.8, p = 0.043) and signs of respiratory dysfunction (OR = 2.5, p = 0.005). Factors available from the first four hours of ED care associated with increased likelihood of admission were: age (OR = 1.04, p = 0.021), oxygen use at four hours (OR = 3.5, p = 0.002) and IV antibiotic administration (OR = 2.6, p = 0.026). There were conflicting findings regarding the association between ambulance transport and admission.

Descriptive analysis of emergency department oxygen use in acute exacerbation of chronic obstructive pulmonary disease

Background: Inconsistencies in oxygen therapy recommendations in acute exacerbation of chronic obstructive pulmonary disease (COPD) may result in variability in emergency department (ED) oxygen management of patients with COPD. The aim of this study was to describe oxygen management in the first 4 h of ED care for patients with exacerbation of COPD.
Methods: A retrospective medical record audit was conducted at four public and one private ED in Melbourne, Australia. Participants were 273 adult ED patients with COPD presenting with a primary complaint of shortness of breath from July 2006 to July 2007. Outcome measures were physiological data, including oxygen saturation (SpO2), oxygen delivery devices and flow rates on ED arrival, 1 and 4 h.
Results: Oxygen was used in 82.0% of patients. Patients who required oxygen had higher incidence of ambulance transport (P < 0.001), triage category 2 (P = 0.006), home oxygen use (P < 0.001), and increased work of breathing on ED arrival (P < 0.001), and higher median respiratory rate (P < 0.001) and heart rate (P = 0.001). SpO2 > 90% occurred in the majority of patients (87.5%; 96.4%; 95.6%); however, a considerable number of patients with SpO2 < 90% were not given oxygen (61.8%; 30%; 45.5%).
Conclusions: A number of patients with documented hypoxaemia were not given oxygen and there may be variables other than oxygen saturation that may influence oxygen use. Future research should focus on increasing the evidence-based supporting
oxygen use and better understanding of clinicians’ oxygen decision-making in patients with COPD.

The uptake of an early warning system in an Australian emergency department : a pilot study

Objectives: To evaluate the uptake of an emergency department early warning system (ED EWS) for recognition of, and response to, clinical deterioration.

Design, setting and participants: A descriptive exploratory study conducted in an urban district hospital in Melbourne, Australia. Systematic sampling was used to identify every 10th patient for whom the ED EWS was activated from May 2009 to May 2011.

Main outcome measures: Patient characteristics, ED system data and ED EWS activation characteristics.

Results: ED EWS activation occurred in 1.5% of ED patients; 204 patients were included in this pilot study. The median age was 65.1 years (interquartile range [IQR], 47.8-77.5 years), 89.2% of patients were classified as triage category 2 or 3, and 82.4% of patients were seen by medical staff before ED EWS activation. Hypotension (27.7%) and tachycardia (23.7%) were the most common reasons for ED EWS activation. Median duration of clinical instability was 39 minutes (IQR, 5- 129 minutes). Nurses made 93.1% of ED EWS activations. Median time between documenting physiological abnormalities and ED EWS activation was 5 minutes (IQR, 0- 20). Most patients (57.8%) required hospital admission: 4.4% of patients required intensive care unit admission.

Conclusions: The ED EWS resulted in at least two formal reports of clinical deterioration in ED patients per day, indicating reasonable uptake by clinicians. A greater understanding of clinical deterioration in ED patients is warranted to inform an evidence-based approach to recognition of, and response to, clinical deterioration in ED patients.

Clinical and economic burden of emergency department presentations for neutropenia following outpatient chemotherapy for cancer in Victoria, Australia

Objective. To examine the clinical characteristics and financial charges associated with treating adult cancer patients receiving chemotherapy in outpatient clinics who presented to the emergency department (ED) with neutropenia.
Design and Setting. A retrospective audit was conducted across two health services involving ED episodes and subsequent hospital admissions of patients who received chemotherapy through day oncology from January 1 to December 31, 2007 and presented to the ED with neutropenia. ED data were collected from the Victorian Emergency Minimum Dataset and charges were collected from Health Information Services. Descriptive and bivariate statistics were used to describe the patient and clinical characteristics and financial outcomes, and to explore associations between these factors.
Results. In total, 200 neutropenic episodes in 159 outpatients were seen in the ED over the survey period. The mean patient age was 56.6 years (standard deviation, 13.2 years) and 47.2% were male. Overall, 70.0% of ED episodes were triaged as Australasian Triage Scale 2 (emergency). The median ED wait time was 10 minutes and the median ED length of stay was 6.8 hours. The median charge for each ED episode was $764.08 Australian dollars. The total combined ED and inpatient charge per episode was in the range of $144.27-$174,732.68, with a median charge of $5,640.87.
Conclusions. This study provides important insights into the clinical and economic burden of neutropenia from both the ED and inpatient perspectives. Alternative treatment models, such as outpatient treatment, early discharge programs or prophylactic interventions to reduce the clinical and economic burden of neutropenia on our health system, must be explored.