A comparative analysis of risk stratification tools for emergency department patients with chest pain

Background: Appropriate disposition of emergency department (ED) patients with chest pain is dependent on clinical evaluation of risk. A number of chest pain risk stratification tools have been proposed. The aim of this study was to compare the predictive performance for major adverse cardiac events (MACE) using risk assessment tools from the National Heart Foundation of Australia (HFA), the Goldman risk score and the Thrombolysis in Myocardial Infarction risk score (TIMI RS). Methods: This prospective observational study evaluated ED patients aged ≥30 years with non-traumatic chest pain for which no definitive non-ischemic cause was found. Data collected included demographic and clinical information, investigation findings and occurrence of MACE by 30 days. The outcome of interest was the comparative predictive performance of the risk tools for MACE at 30 days, as analyzed by receiver operator curves (ROC). Results: Two hundred eighty-one patients were studied; the rate of MACE was 14.1%. Area under the curve (AUC) of the HFA, TIMI RS and Goldman tools for the endpoint of MACE was 0.54, 0.71 and 0.67, respectively, with the difference between the tools in predictive ability for MACE being highly significant [chi2 (3) = 67.21, N = 276, p < 0.0001]. Conclusion: The TIMI RS and Goldman tools performed better than the HFA in this undifferentiated ED chest pain population, but selection of cutoffs balancing sensitivity and specificity was problematic. There is an urgent need for validated risk stratification tools specific for the ED chest pain population.

Intraurban rail access : policy implications of five revealed perspectives from a Q-sorting exercise in three Australian cities

This project advances the current understanding of intraurban rail passengers and their travel experiences to help rail industry leaders tailor policy approaches to fit specific, relevant segments of their target population. Using a Q-sorting technique and cluster analysis, preliminary research identified five perspectives occurring in a small sample of rail passengers who varied in their frequency and location of rail travel as well as certain sociodemographic characteristics. Revealed perspectives (named to capture the gist of their content) included "Rail travel is about the destination, not the journey"; "Despite challenges, public transport is still the best option"; "Rail travel is fine"; "Rail travel? So far, so good"; and "Bad taste for rail travel." This paper discusses each of the perspectives in detail and considers them in relation to tailored policy implications. An overarching finding from this study is that improving railway travel access requires attention to physical, psychological, financial, and social facets of accessibility. For example, designing waiting areas to be more socially functional and comfortable has the potential to increase ridership by addressing social forms of access, decreasing perceived wait times, and making time at the station feel like time well spent. Even at this preliminary stage, the Q-sorting technique promises to provide a valuable, holistic, albeit fine-grained, analysis of passenger attitudes and experiences that will assist industry efforts in increasing ridership.

The Implications of Activity Based Funding for Emergency Departments : A Comprehensive Literature Review

Executive Summary Emergency Departments (EDs) locally, nationally and internationally are becoming increasingly busy. Within this context, it can be challenging to deliver a health service that is safe, of high quality and cost-effective. Whilst various models are described within the literature that aim to measure ED ‘work’ or ‘activity’, they are often not linked to a measure of costs to provide such activity. It is important for hospital and ED managers to understand and apply this link so that optimal staffing and financial resourcing can be justifiably sought. This research is timely given that Australia has moved towards a national Activity Based Funding (ABF) model for ED activity. ABF is believed to increase transparency of care and fairness (i.e. equal work receives equal pay). ABF involves a person-, performance- or activity-based payment system, and thus a move away from historical “block payment” models that do not incentivise efficiency and quality. The aim of the Statewide Workforce and Activity-Based Funding Modelling Project in Queensland Emergency Departments (SWAMPED) is to identify and describe best practice Emergency Department (ED) workforce models within the current context of ED funding that operates under an ABF model. The study is comprised of five distinct phases. This monograph (Phase 1) comprises a systematic review of the literature that was completed in June 2013. The remaining phases include a detailed survey of Queensland hospital EDs’ resource levels, activity and operational models of care, development of new resource models, development of a user-friendly modelling interface for ED mangers, and production of a final report that identifies policy implications. The anticipated deliverable outcome of this research is the development of an ABF based Emergency Workforce Modelling Tool that will enable ED managers to profile both their workforce and operational models of care. Additionally, the tool will assist with the ability to more accurately inform adequate staffing numbers required in the future, inform planning of expected expenditures and be used for standardisation and benchmarking across similar EDs. Summary of the Findings Within the remit of this review of the literature, the main findings include: 1. EDs are becoming busier and more congested Rising demand, barriers to ED throughput and transitions of care all contribute to ED congestion. In addition requests by organisational managers and the community require continued broadening of the scope of services required of the ED and further increases in demand. As the population live longer with more lifestyle diseases their propensity to require ED care continues to grow. 2. Various models of care within EDs exist Models often vary to account for site specific characteritics to suit staffing profile, ED geographical location (e.g. metropolitan or rural site), and patient demographic profile (e.g. paediatrics, older persons, ethnicity). Existing and new models implemented within EDs often depend on the target outcome requiring change. Generally this is focussed on addressing issues at the input, throughput or output areas of the ED. Even with models targeting similar demographic or illness, the structure and process elements underpinning the model can vary, which can impact on outcomes and variance to the patient and carer experience between and within EDs. Major models of care to manage throughput inefficiencies include: A. Workforce Models of Care focus on the appropriate level of staffing for a given workload to provide prompt, timely and clinically effective patient care within an emergency care setting. The studies reviewed suggest that the early involvement of senior medical decision maker and/or specialised nursing roles such as Emergency Nurse Practitioners and Clinical Initiatives Nurse, primary contact or extended scope Allied Health Practitioners can facilitate patient flow and improve key indicators such as length of stay and reducing the number of those who did not wait to be seen amongst others. B. Operational Models of Care within EDs focus on mechanisms for streaming (e.g. fast-tracking) or otherwise grouping patient care based on acuity and complexity to assist with minimising any throughput inefficiencies. While studies support the positive impact of these models in general, it appears that they are most effective when they are adequately resourced. 3. Various methods of measuring ED activity exist Measuring ED activity requires careful consideration of models of care and staffing profile. Measuring activity requires the ability to account for factors including: patient census, acuity, LOS, intensity of intervention, department skill-mix plus an adjustment for non-patient care time. 4. Gaps in the literature Continued ED growth calls for new and innovative care delivery models that are safe, clinically effective and cost effective. New roles and stand-alone service delivery models are often evaluated in isolation without considering the global and economic impact on staffing profiles. Whilst various models of accounting for and measuring health care activity exist, costing studies and cost effectiveness studies are lacking for EDs making accurate and reliable assessments of care models difficult. There is a necessity to further understand, refine and account for measures of ED complexity that define a workload upon which resources and appropriate staffing determinations can be made into the future. There is also a need for continued monitoring and comprehensive evaluation of newly implemented workforce modelling tools. This research acknowledges those gaps and aims to: • Undertake a comprehensive and integrated whole of department workforce profiling exercise relative to resources in the context of ABF. • Inform workforce requirements based on traditional quantitative markers (e.g. volume and acuity) combined with qualitative elements of ED models of care; • Develop a comprehensive and validated workforce calculation tool that can be used to better inform or at least guide workforce requirements in a more transparent manner.

Burglar target selection : a cross-national comparison

Objectives This study builds on research undertaken by Bernasco and Nieuwbeerta and explores the generalizability of a theoretically derived offender target selection model in three cross-national study regions. Methods Taking a discrete spatial choice approach, we estimate the impact of both environment- and offender-level factors on residential burglary placement in the Netherlands, the United Kingdom, and Australia. Combining cleared burglary data from all study regions in a single statistical model, we make statistical comparisons between environments. Results In all three study regions, the likelihood an offender selects an area for burglary is positively influenced by proximity to their home, the proportion of easily accessible targets, and the total number of targets available. Furthermore, in two of the three study regions, juvenile offenders under the legal driving age are significantly more influenced by target proximity than adult offenders. Post hoc tests indicate the magnitudes of these impacts vary significantly between study regions. Conclusions While burglary target selection strategies are consistent with opportunity-based explanations of offending, the impact of environmental context is significant. As such, the approach undertaken in combining observations from multiple study regions may aid criminology scholars in assessing the generalizability of observed findings across multiple environments.

Retrospective observational study of patients who present to Australian rural emergency departments with undifferentiated chest pain

Aim To identify the demographic and clinical characteristics of patients who present to Australian rural emergency departments with chest pain. Design Retrospective, observational study Setting Rural emergency departments (ED) in Queensland, Australia Participants 337 consecutive adult patients with undifferentiated chest pain that presented between 1st September 2013 and 30th November 2013. Main outcome measures Service indicators, discharge diagnoses and disposition Results Presentations for undifferentiated chest pain represented 3.5% of all patient presentations during the sampling period. The mean age of patients was 48 years and 54% were male. Overall, 92% of patients left the ED within the 4-hour NEAT target. The majority of presentations were related to cardiac concerns (39%), followed by non-cardiac chest pain (17%), musculoskeletal (15%) and respiratory (10%) conditions. More than half of these patients were discharged at the completion of the ED service (52.8%), 40.6% were admitted, 3.3% left at own risk, 2.4% did not wait and less than 1% of patients required transfer to another hospital directly from the ED. Conclusions This study has provided information on the characteristics and processes of care for patients presenting to Australian rural EDs with undifferentiated chest pain that will inform service planning and further research to evaluate the effectiveness of care for these patients.

CRC27012 A National Diagnostic Database for Emergency Plant Pests

Development of a national diagnostic database for Emergency Plant Pests which will be web-accessible.

Change to costs and lengths of stay in the emergency department and the Brisbane protocol: An observational study

- Objective To compare health service cost and length of stay between a traditional and an accelerated diagnostic approach to assess acute coronary syndromes (ACS) among patients who presented to the emergency department (ED) of a large tertiary hospital in Australia. - Design, setting and participants This historically controlled study analysed data collected from two independent patient cohorts presenting to the ED with potential ACS. The first cohort of 938 patients was recruited in 2008–2010, and these patients were assessed using the traditional diagnostic approach detailed in the national guideline. The second cohort of 921 patients was recruited in 2011–2013 and was assessed with the accelerated diagnostic approach named the Brisbane protocol. The Brisbane protocol applied early serial troponin testing for patients at 0 and 2 h after presentation to ED, in comparison with 0 and 6 h testing in traditional assessment process. The Brisbane protocol also defined a low-risk group of patients in whom no objective testing was performed. A decision tree model was used to compare the expected cost and length of stay in hospital between two approaches. Probabilistic sensitivity analysis was used to account for model uncertainty. - Results Compared with the traditional diagnostic approach, the Brisbane protocol was associated with reduced expected cost of $1229 (95% CI −$1266 to $5122) and reduced expected length of stay of 26 h (95% CI −14 to 136 h). The Brisbane protocol allowed physicians to discharge a higher proportion of low-risk and intermediate-risk patients from ED within 4 h (72% vs 51%). Results from sensitivity analysis suggested the Brisbane protocol had a high chance of being cost-saving and time-saving. - Conclusions This study provides some evidence of cost savings from a decision to adopt the Brisbane protocol. Benefits would arise for the hospital and for patients and their families.

Maallikon suorittama defibrillaatio sydänpysähdyspotilaan hoitoketjussa

Sudden cardiac arrest (CA) is one of the leading causes of death in Europe. It has been estimated that about 40 % of CA victims have ventricular fibrillation (VF) at the time of the first heart rhythm analysis. The treatment for VF is immediate cardiopulmonary resuscitation (CPR) and rapid defibrillation. The automated external defibrillator (AED) and the concept of public access defibrillation (PAD) may be a key to shortening defibrillation delays. Recent studies have shown that PAD programs are associated with high survival rates from VF when devices have been placed in certain risk sites and used by trained laypersons. Today many public places are equipped with AEDs. The purpose of this study was to find new ways of utilizing layperson defibrillation and promote the concept of public access defibrillation (PAD). The study explored the use of AEDs by non-medical first responders in Finland and cabin crew on board a commercial aircraft. A simulated study was performed to explore the role of dispatcher assistance in layperson CPR and defibrillation. A 15-year follow-up study of 59 one-year survivors after successful out-of-hospital resuscitation was performed to evaluate the long-term quality of life of the CA patients. Although there are many AEDs in use by non-medical first responders in Finland, the results of the study showed that there are large variations between individual first response units. This is considered to be caused by the lack of national standards and regulations that would define a full integration of first-responder programmes into the Emergency Medical Services system. The goal of rapid defibrillation in five minutes after the onset of CA is difficult to achieve in Finland due to sparse population and long distances. Local PAD programs may shorten the defibrillation delays. Dispatcher assistance in defibrillation by a layperson not trained to use an AED seems feasible and does not compromise the performance of CPR. In a simulated study, the quality of mouth-to-mouth ventilation performed by laypersons was found to be better after CPR training compared with performance with dispatcher assistance before training. Training was not found to have an influence on the quality of compressions or defibrillation compared with dispatcher assistance of untrained laypersons. The target groups for CPR and defibrillation training need further evaluation. The placements of the AEDs in public areas should be known by the emergency response center and the location should be marked with an international sign. The finding that once a good neurological outcome after CA is achieved, it can be maintained for more than 10 years, encourages further efforts to improve the survival of CA patients.

National report of the frame survey 2010 on the Uganda side of Lake Victoria

This is a report on the results of the Frame Survey conducted in the Uganda side of Lake Victoria during August 2010 by the LVFO Institutions, namely: the Department of Fisheries Resources (DFR) Uganda and the National Fisheries Resources Research Institute (NaFIRRI) in close collaboration with the District Fisheries offices of Busia, Bugiri, Mayuge, Jinja, Mukono, Kampala, Wakiso, Mpigi, Masaka, Kalangala and Rakai. The authors are grateful to the LVEMP II, for providing funds for the survey and the LVFO secretariat coordination. Fisheries Frame surveys have been carried out on Lake Victoria biannually since 2000 to determine the number of fishers, fish landing sites, and facilities at the landing sites, as well as the composition of fishing crafts, their mode of propulsion, fishing gears and the fish species they target. This information is used to guide development and management of the lake’s fisheries. Following the reorganisation of landing sites into Beach Management Units (BMUs), the number of landing sites decreased from 597 in 2000 to 435 in 2008. The survey in 2010 showed an increase to 503 landing sites, an indication that new landing sites are coming up. The fish landing sites continue to have inadequate facilities such as fish shades, cold rooms to service the fisheries industry and very few (5%) have access to electricity and 32% had access to all weather roads. There has been some progressive improvement in the landing site coverage of basic hygiene and sanitation facilities, especially public toilet facilities from 17% in 2000 to 39% in 2010; and portable water from 4% to 17% respectively. However more effort is required to cover all landing sites. Most landing sites (83%) have access to mobile phone networks which eases communication. 46% of landing sites had access to a Health clinic and 64% had a Primary school within a radius of 2 km.

National report of the frame survey 2012 on the Uganda side of Lake Victoria

This is a report on the results of the Frame Survey conducted in the Uganda side of Lake Victoria during August 2012 by the LVFO Institutions, namely: the Department of Fisheries Resources (DFR) Uganda and the National Fisheries Resources Research Institute (NaFIRRI) in close collaboration with the District Fisheries offices of Busia, Bugiri, Namayingo, Mayuge, Jinja, Buvuma, Buikwe, Mukono, Kampala, Wakiso, Mpigi, Kalungu, Masaka, Kalangala and Rakai. In the 2012 Frame survey some indicators of fishing effort including e.g. number of fishers, fishing crafts and long line hooks increased; whereas others like the number of gillnets less than 5 inches decreased by 10.4% from that recorded in 2010. The other indicators of fishing effort, which showed decrease in 2012 included illegal beach seines and undersized gillnets (<5 inch mesh size). However, a large proportion (66%) of long line hooks recorded in the 2012 survey were in the smallest size range (hook size >10), which target small Nile perch. The number of other illegal gears, i.e. cast nets and monofilament gillnets showed modest increases (25%) between 2010 and 2012 while beach seines decrease by 15%. Recent crackdown on illegal fishing activities as part of measures for recovery of the Nile perch stocks which are faced with depletion appear to have had an impact but much more needs to be done to eradicate illegal fishing. The fisheries in the Ugandan waters have remained predominantly near shore with 61% of all fishing crafts using paddles out of which 17% were tiny three plank, flat bottomed boats locally known as parachutes. The 2012 survey shows an increase in the number of fishing crafts using sails by 65% from 682 in 2010 to 1125 in 2012. This is an encouraging trend as more fishers are able to access distant fishing grounds using free wind power. The Mukene fishery in the Ugandan waters of Lake Victoria remained underdeveloped comprising only 15.2% of all fishing crafts, of which 31% were motorised which is a great improvement from the situation recorded in 2010. The Catamarans increased to 18 with a majority in Buikwe district where there is a private investor fishing specifically for Mukene. The Catamarans in Kalangala were reported not to be working because of the high operating cost compared to ordinary Mukene fishing boats.

Beam-target double-spin asymmetry A{LT} in charged pion production from deep inelastic scattering on a transversely polarized {3}He target at 1.4

We report the first measurement of the double-spin asymmetry A{LT} for charged pion electroproduction in semi-inclusive deep-inelastic electron scattering on a transversely polarized {3}He target. The kinematics focused on the valence quark region, 0.16access to quark spin-orbit correlations. Our results indicate a positive azimuthal asymmetry for π{-} production on {3}He and the neutron, while our π{+} asymmetries are consistent with zero.

Persistent luminescence of SrAl2O4:Ce(III), Dy, Eu nanotubes, nanowires and core-shells for people with disabilities: nano-emergency

Este estudo transversal está focado na propriedade de luminescência persistente do aluminato de estrôncio co-dopado com cério (III), disprósio (III) e európio (II), SrAl2O4:Ce3+, Dy3+, Eu2+, em sistemas de sinalização de áreas de risco e emergências para pessoas com deficiências. Na área da ciência e engenharia dos materiais, foram desenvolvidos novos materiais com características nanométricas, nanotubos, nanoarames e nanobastões luminescentes de SrAl2O4:Ce3+, Dy3+, Eu2+ para aplicações na área da reabilitação e acessibilidade de pessoas com deficiências. Os nanotubos foram obtidos a partir de micro- e nano-partículas precursoras sintetizadas por reacção do estado-sólido e tratamento térmico de recozedura (1273-1473 K). Os nanoarames e nanobastões foram preparados por moagem, sonificação e recozedura (373 K). Novas nanocápsulas de aluminatos luminescentes dopados com cério (III) e encapsulados com TiO2 foram criadas de modo a obter-se materiais multifuncionais, designadamente com acção fotocatalítica antimicrobiana, antibacteriana e resistência à água. Tais aluminatos podem ser amplamente aplicados como superfícies higiénicas, auto-limpantes, em biomateriais, no domínio de medicamentos antibióticos, na formulação de vacinas, e com ênfase à aplicação em cerâmicas fotoluminescentes. As metodologias de obtenção de tais nanoestruturas de aluminato de estrôncio dopado com cério (III) e do seu encapsulamento, desenvolvidas no âmbito desta tese, são aplicáveis a diversos aluminatos dopados com outros iões lantanídeos (Ln consiste em La, Ce, Pr, Nd, Pm, Sm, Eu, Gd, Tb, Dy, Ho, Er, Yb, Tm ou Lu) com a fórmula M(1-x-y)N2O4:Cex, Lny, onde M é Be, Mg, Ca, Sr ou Ba. Na área da oftalmologia, foi desenvolvido um equipamento médico para o diagnóstico de biofuncionalidade das células retinais fotoreceptoras, e como suporte à telemedicina oftalmológica. Este equipamento foi utilizado para realizar testes de visão cromática FM100HUE em fundo branco/preto para a personalização de materiais luminescentes. Os resultados demonstraram uma biofuncionalidade celular à visibilidade fotópica das cores em fundo preto superior no grupo de tratamento, composto por pessoas com retinopatia diabética (n=38), em comparação ao grupo de referência (n=38). Estes resultados sugerem a recomendação de materiais com fotoluminescência persistente (λem=485-555 nm), incluindo SrAl2O4:Ce3+, Dy3+, Eu2+, para o referido grupo de tratamento, em sinalização de emergência e em ambientes de baixa iluminação. Na área da arquitectura, foi proposta uma nova aplicação dos referidos nanomateriais luminescentes à base de SrAl2O4:Ce3+, Dy3+, Eu2+ em cerâmica de revestimento, tendo em vista a sua boa visibilidade e uso por pessoas com deficiências. Novos pavimentos, cerâmicos, fotoluminescentes, foram desenhados com propriedades multisensoriais (contraste táctil, sonoro e visual) e antimicrobianas, para pessoas portadoras de deficiências utilizarem, no escuro, com a prioridade de salvar vidas em emergências. Tais pisos, com relevos, podem ser combinados de modo a compor um sistema exclusivo de sinalização fotoluminescente multisensorial que possibilita a rápida evacuação mediante o uso de auxílios de mobilidade (e.g. bengala, cadeira de rodas, andadores, muletas). A solução integrada de tais inovações que potencializa a propriedade de luminescência persistente de SrAl2O4:Ce3+, Dy3+, Eu2+ de modo acessível para as pessoas com deficiências, pode contribuir para salvar vidas, no escuro, em emergências.

Engorgement des centres d'urgences: une raison légitime de refuser l'accès aux patients non urgents [Emergency department overcrowding: a legitimate reason to refuse access to urgent care for non-urgent patients?].

Non-urgent cases represent 30-40% of all ED consults; they contribute to overcrowding of emergency departments (ED), which could be reduced if they were denied emergency care. However, no triage instrument has demonstrated a high enough degree of accuracy to safely rule out serious medical conditions: patients suffering from life-threatening emergencies have been inappropriately denied care. Insurance companies have instituted financial penalties to discourage the use of ED as a source of non-urgent care, but this practice mainly restricts access for the underprivileged. More recent data suggest that in fact most patients consult for appropriate urgent reasons, or have no alternate access to urgent care. The safe reduction of overcrowding requires a reform of the healthcare system based on patients' needs rather than access barriers.