Buruli ulcer - A neglected tropical disease in the Barwon region of Victoria, Australia: An emerging public health threat with local and national ramifications.

Mycobacterium ulcerans (MU) is known to be endemic in heavily touristed coastal regions of Victoria and is the cause of Buruli ulcer (BU) disease. The incidence, severity and geographic spread of MU infection/BU disease is increasing, including metropolitan Victorian suburbs. While the specifics of disease transmission and effective prevention strategies remain uncertain, severe complications can be mitigated by health systems that provide vigilant population surveillance to underpin early recognition, early specialist involvement and definitive treatment for the individual. Current theories regarding disease transmission and 'best practice' (or best guess) prevention and mitigation measures are presented herein. Opportunities to improve the health system response to this emerging public health threat are identified. It is incumbent upon all healthcare providers, including ED clinicians, to contribute by familiarising themselves with the established and emerging areas of endemicity of MU infection and the array of BU clinical presentations.

Testing Rover Science Protocols to Identify Possible Biosignatures on Mars: Achieving Sampling Goals Under a Highly Constrained Time Line.

At a Mars analog site in Utah, we tested two science operation methods for data acquisition and decision-making protocols: a scenario where the tactical day is preplanned, but major adjustments may still be made before plan delivery; and a scenario in which the sol path must largely be planned before a given tactical planning day and very few adjustments to the plan may be made. The goal was to provide field-tested insight into operations planning for rover missions where science operations must facilitate the efficient choice of sampling locations at a site relevant to searching for habitability and biosignatures. Results of the test indicate that preplanning sol paths did not result in a sol cost savings nor did it improve science return or optimal biologically relevant sample collection. In addition because facies variations in an environment can be subtle and evident only at scales below orbital resolution, acquiring systematic observations is crucial. We also noted that while spectral data provided insight into the chemical components as a whole at this site, they did not provide a guide to targets for which the traverse should be altered. Finally, strategic science planning must include a special effort to account for terrain.

Distant supervision of trainee emergency physicians undertaking a remote placement: A preliminary evaluation.

OBJECTIVE: Clinical supervision is an essential part of post-graduate medical training. The current study investigated emergency medicine trainees' experiences and preferences regarding distant supervision via information and communication technology (ICT). METHODS: Four emergency medicine trainees completed a 6-month placement, one at a time, at a rural urgent care centre. Trainees were remotely supervised by emergency physicians located at another ED using ICT. Trainees recorded the frequency and content of their distant supervision experiences. Trainees also completed semi-structured interviews before and after the placement to describe their experiences and preferences regarding distant supervision. Quantitative data were analysed descriptively using counts and proportions. Qualitative data were analysed using the principles of thematic analysis. RESULTS: Trainees provided care to 1458 patients and communicated with a supervisor for 126 (8.6%) patients. Phone or audio-visual ICT was used for 111 (88.1%) and 12 (9.5%) patients, respectively. Trainees described the placement as a unique learning experience that demanded independent practice, enhanced their communication and leadership skills and increased their confidence. The trainees also described disadvantages to the placement such as reduced quality and quantity of communication with supervisors, ICT failure and the supervisor's inability to provide hands-on assistance. Trainees provided their perspectives on the essential requirements of a successful remote placement that involved distant supervision. CONCLUSIONS: According to trainees, distant supervision had positive and negative effects on their supervision experiences, professional development and on patient management. Trainees used ICT infrequently. The trainee's perspectives on the ideal components of a remote placement programme are presented.

Restrictive interventions in Victorian emergency departments: A study of current clinical practice.

OBJECTIVE: To determine current clinical practices for managing behavioural emergencies within Victorian public hospital EDs. METHODS: A multi-centre retrospective study involving all patients who attended ED in 2016 at the Alfred, Ballarat, Dandenong, Geelong and Royal Melbourne Hospitals. The primary outcome was the rate of patient presentations with at least one restrictive intervention. Secondary outcomes included the rate of security calls for unarmed threats (Code Grey), legal status under the Mental Health Act at both the time of ED arrival and the restrictive intervention, and intervention details. For each site, data on 100 patients who had a restrictive intervention were randomly extracted for indication and methods of restraint. RESULTS: In 2016, 327 454 patients presented to the five EDs; the Code Grey rate was 1.49% (95% CI 1.45-1.54). Within the Code Grey population, 942 had at least one restrictive intervention (24.3%, 95% CI 23.0-25.7). Details were extracted on 494 patients. The majority (62.8%, 95% CI 58.4-67.1) were restrained under a Duty of Care. Physical restraint was used for 165 (33.4%, 95% CI 29.3-37.8) patients, 296 were mechanically restrained (59.9%, 95% CI 55.4-64.3), median mechanical restraint time 180 min (IQR 75-360), and 388 chemically restrained (78.5%, 95% CI 74.6-82.0). CONCLUSIONS: Restrictive interventions in the ED largely occurred under a Duty of Care. Care of patients managed under legislation that covers assessment and treatment of mental illness has a strong clinical governance framework and focus on minimising restrictive interventions. However, this is not applied to the majority of patients who experience restraint in Victorian EDs.

Management of mental health patients in Victorian emergency departments: A 10 year follow-up study.

OBJECTIVES: Despite efforts to restructure mental health (MH) services across Victoria, the social and economic burden of MH illness continues to grow. This study compares MH presentations to EDs with a study undertaken 10 years earlier. METHODS: The article is a retrospective observational study of MH presentations to four Victorian EDs between May and October 2013. Subjects were included if the presentation was MH related as determined by an International Classification of Diseases (version 10) discharge diagnosis, they were referred to an emergency crisis assessment team or had a documented presenting psychiatric complaint. Variables were extracted from electronic medical records and compared with 2004 data from a previous published study. RESULTS: There were 5659 MH presentations over the 5 months compared with 2788 in 2004. The median ED length of stay decreased from 4:18 h in 2004 to 3:20 h in 2013 (P < 0.001), with a significant reduction in length of stay >4 h from 52.5% to 35.4% (P < 0.001). There was a 22-fold increase in short stay units as discharge destination from 0.9% to 20.2% (P < 0.001). Patients presenting with concurrent methamphetamine exposure doubled from 2.2% of presentations to 4.3% (P < 0.001). CONCLUSION: Despite increasing MH-related presentations, changes in ED practice have allowed improvements in delivery of care through a shortened ED length of stay and the virtual elimination of very long stays over 24 h. However, there continues to be significant variability in management and performance across hospital sites. Identifying which interventions lead to standout site performance, and subsequent application more broadly, may improve future ED delivery of care.

Australasian disasters of national significance: an epidemiological analysis, 1900-2012.

BACKGROUND: A regional epidemiological analysis of Australasian disasters in the 20th century to present was undertaken to examine trends in disaster epidemiology; to characterise the impacts on civil society through disaster policy, practice and legislation; and to consider future potential limitations in national disaster resilience. METHODS: A surveillance definition of disaster was developed conforming to the Centre for Research on the Epidemiology of Disasters (CRED) criteria (≥10 deaths, ≥100 affected, or declaration of state emergency or appeal for international assistance). The authors then applied economic and legislative inclusion criteria to identify additional disasters of national significance. RESULTS: The surveillance definition yielded 165 disasters in the period, from which 65 emerged as disasters of national significance. There were 38 natural disasters, 22 technological disasters, three offshore terrorist attacks and two domestic mass shootings. Geographic analysis revealed that states with major population centres experienced the vast majority of disasters of national significance. Timeline analysis revealed an increasing incidence of disasters since the 1980s, which peaked in the period 2005-2009. Recent seasonal bushfires and floods have incurred the highest death toll and economic losses in Australasian history. Reactive hazard-specific legislation emerged after all terrorist acts and after most disasters of national significance. CONCLUSION: Timeline analysis reveals an increasing incidence in natural disasters over the past 15 years, with the most lethal and costly disasters occurring in the past 3 years. Vulnerability to disaster in Australasia appears to be increasing. Reactive legislation is a recurrent feature of Australasian disaster response that suggests legislative shortsightedness and a need for comprehensive all-hazards model legislation in the future.

Performance measurement in British Helicopter Emergency Medical Services and Australian Air Medical Services.

BACKGROUND: Performance outcome measures are an essential component of health service improvement. Whereas hospital critical care services have established performance measures, prehospital care services have less well-established outcome measures and this has been identified as a key issue for development. Individual studies examining long-term survival and functional outcome measures have previously been used to evaluate prehospital care delivery. There is no set of standardised patient outcome measures for Helicopter Emergency Medical Services (HEMS) in the UK or Air Medical Services (AMS) in Australia. The aim of this study is to document the patient outcome measures currently in use within British HEMS and Australian AMS. METHODS: This is an observational study analysing point prevalence of practice as of November 2009. A structured questionnaire was designed to assess the method of routine patient follow-up, and the timing and nature of applied patient outcome measures. RESULTS: Full responses were received from 17/21 (81%) British services and 6/7 (86%) Australian services. The overall response rate was 82%. CONCLUSIONS: HEMS in Britain and Australian aeromedical retrieval services do not have uniform patient outcome measures. Services tend not to follow-up patients beyond 24 h post transfer. Patient outcome data are rarely presented to an external organisation and there is no formal data comparison between surveyed services. Services are not satisfied that the data currently being collected reflects the quality of their service.

Introduction of a prehospital critical incident monitoring system--final results.

BACKGROUND: Incident monitoring has been shown to improve patient care and has been adopted widely in the hospital care setting. There are limited data on incident monitoring in the prehospital setting. HYPOTHESIS: A high-yield, systems-oriented, incident monitoring process can be implemented successfully in a prehospital setting. METHODS: This prospective, descriptive study outlines the implementation of an incident monitoring process in a regional prehospital setting. Both trauma care and non-trauma care were monitored by a system of anonymous reporting and chart review with debriefing for trauma cases that met major trauma criteria. A committee reviewed all identified cases and coded and logged all incidents and provider recommendations. RESULTS: There were 454 incidents identified from 230 cases (mean=2.0; 95% CI 1.8-2.1 per case). Anonymous reporting resulted in the identification of 113 incidents from 69 cases (1.6l per case 95% CI=1.4-1.9 per case) Major trauma cases generated 266 incidents from 134 cases (mean=2.0; 95% CI=1.8-2.2 per case), and there were 74 incidents from 26 combined cases (mean=2.9; 95% CI=2.2-3.5 per case). One incident was uncategorized. There were 315 (69.4%) incidents categorized as management problems and 123 (27.1%) were system problems. Prolonged scene time was the most common incident in both management and system categories; 56 (17.8%) and 18 (14.6%) respectively. Mitigating circumstances were found in 111 (24.4%) incidents. The most common incident-related patient outcome was none/near miss (127 (28%)). Incident monitoring most commonly led to generalized feedback (105 (23.1%)) or specific trend analysis (140 (30.8%)). Reports to higher or external bodies occurred in 18 incidents (4.0%). CONCLUSIONS: The project has been implemented successfully in a regional prehospital settling. The methodology, utilizing a number of incident detection techniques, results in a high yield of incidents over a broad range of error types. The large proportion of "near miss" type incidents allows for incident assessment without demonstrable patient harm. Many incidents were mitigated and the majority represented management-type issues.

Emergency department surge capacity: recommendations of the Australasian Surge Strategy Working Group.

For more than a decade, emergency medicine (EM) organizations have produced guidelines, training, and leadership for disaster management. However, to date there have been limited guidelines for emergency physicians (EPs) needing to provide a rapid response to a surge in demand. The aim of this project was to identify strategies that may guide surge management in the emergency department (ED). A working group of individuals experienced in disaster medicine from the Australasian College for Emergency Medicine Disaster Medicine Subcommittee (the Australasian Surge Strategy Working Group) was established to undertake this work. The Working Group used a modified Delphi technique to examine response actions in surge situations and identified underlying assumptions from disaster epidemiology and clinical practice. The group then characterized surge strategies from their corpus of experience; examined them through available relevant published literature; and collated these within domains of space, staff, supplies, and system operations. These recommendations detail 22 potential actions available to an EP working in the context of surge, along with detailed guidance on surge recognition, triage, patient flow through the ED, and clinical goals and practices. The article also identifies areas that merit future research, including the measurement of surge capacity, constraints to strategy implementation, validation of surge strategies, and measurement of strategy impacts on throughput, cost, and quality of care.

Introduction of a prehospital critical incident monitoring system--pilot project results.

BACKGROUND: Hospital medical incident monitoring improves preventable morbidity and mortality rates. Error management systems have been adopted widely in this setting. Data relating to incident monitoring in the prehospital setting is limited. PROBLEM: Implementation of an incident monitoring process in a prehospital setting. METHODS: This is a prospective, descriptive study of the pilot phase of the implementation of an incident monitoring process in a regional prehospital setting, with a focus on trauma care. Paramedics and emergency department staff submitted anonymous incident reports, and a chart review was performed on patients who met major trauma criteria. Selected trauma cases were analyzed by a structured interview/debriefing process to elucidate undocumented incidents. A project committee coded and logged all incidents and developed recommendations. RESULTS: Of 4,429 ambulance responses, 41 cases were analyzed. Twenty-four (58.5%; 95% CI = 49.7-67.4%) were reported anonymously, and the rest were major trauma patients. A total of 77 incidents were identified (mean per case = 1.8; CI = 1.03-2.57). Anonymous cases revealed 26 incidents (mean = 1.1; CI = 0.98-1.22); eight trauma debriefings revealed 38 incidents (mean = 4.8; CI = 0.91-8.69) and nine trauma chart reviews revealed 13 incidents (mean = 1.6; CI = 1.04-2.16). A total of 56 of 77 (72.7%; CI = 65.5-80.0%) incidents related to system inadequacies, and 15 (57.7%; CI = 46.7-68.6%) anonymously reported incidents related to resource problems. A total of 35 of 77 (45.5%; CI = 40.4-50.5%) incidents had minimal or no impact on the patients' outcomes. Thirty-four of 77 (44.2%; CI = 39.3-49.1%) incidents were considered mitigated by circumstance. Incident monitoring led to generalized feedback in most cases (65 of 77; 84.4%; CI = 77.6-91.3%); in three cases (3.9%; CI = 3.7-4.1%), specific education occurred; two cases were reported to an external body (2.6%; CI = 2.5-2.7%); three cases resulted in remedial action (3.9%; CI = 3.7-4.1%); four for trend/further observation and analysis responses (5.2%; CI = 4.9-5.5%). CONCLUSIONS: The pilot project demonstrates successful implementation of an incident monitoring system within a regional, prehospital environment. The combination of incident detecting techniques has a high yield with potential to capture different error types. The large proportion of incidents in the "near miss" category allows analysis of incidents without patient harm. The majority of incidents were system related and many were mitigated by circumstance. The model used is appropriate for ongoing incident monitoring in this setting.

Video of a disaster drill is effective in educating registrars on the hospital disaster plan.

OBJECTIVE: To test whether an instructional video of edited footage from a disaster drill is effective in educating registrars on the hospital disaster plan. METHODS: This was a prospective pre- and post-intervention study. Forty hospital registrars were shown a 15 min video based on footage obtained at a simulated mass casualty incident. The video provided information on the ED disaster response plan and principles of hospital disaster management. A survey was developed to assess disaster plan knowledge before and after viewing the video. The survey had a predetermined 'pass mark' of 14/20 (70%). RESULTS: Thirty-nine registrars completed the surveys. Three of 39 (7.7% 95% confidence interval [CI] 7.0-8.3%) registrars achieved the pass mark in the pre-video survey and 35/39 (89.7% 95% CI 81.2-98.3%) registrars achieved the pass mark in the post-video survey (chi(2)-test P < 0.001) with an absolute increase in the pass rate of 82% (95% CI 75.8-88.2%). CONCLUSION: This finding justifies compulsory viewing of the video in the registrar orientation package locally and might encourage more widespread use of educational video in hospital disaster preparedness.

What a disaster?! Assessing utility of simulated disaster exercise and educational process for improving hospital preparedness.

INTRODUCTION: Recent events have brought disaster medicine into the public focus. Both the government and communities expect hospitals to be prepared to cope with all types of emergencies. Disaster simulations are the traditional method of testing hospital disaster plans, but a recent, comprehensive, literature review failed to find any substantial scientific data proving the benefit of these resource- and time-consuming exercises. OBJECTIVES: The objective of this study was to test the hypothesis that an audiovisual presentation of the hospital disaster plans followed by a simulated disaster exercise and debriefing improved staff knowledge, confidence, and hospital preparedness for disasters. METHODS: A survey of 50 members of the medical, nursing, and administrative staff were chosen from a pool of approximately 170 people likely to be in a position of responsibility in the event of a disaster. The pre-intervention survey tested factual knowledge as well as perceptions about individual and departmental preparedness. Post-intervention, the same 50 staff members were asked to repeat the survey, which included additional questions establishing their involvement in the exercise. RESULTS: There were 50 pre-intervention tests and 42 post-intervention tests. The intervention resulted in a significant improvement in test pass rate: pre-intervention pass rate 9/50 (18%, 95% confidence interval ((CI) = 16.1-19.9%) versus post-intervention pass rate 21/42 (50%, 95% CI = 42.4-57.6%; chi-square test, p = 0.002). Emergency department (ED) staff had a stronger baseline knowledge than non-ED staff: ED pre-test mean value for scores = 12.1 versus non-ED scores of 6.2 (difference 5.9, 95% CI = 3.3-8.4); t-test, p <0.001. Those that attended > or = 1 component had a greater increase in mean scores: increase in mean attendees was 5.6, versus the scores of non-attendees of 2.7 (difference 2.9, 95% CI = 1.0-4.9); t-test, p = 0.004. There was no significant increase in the general perception of preparedness. However, the majority of those surveyed described the exercise of benefit to themselves (53.7%, 95% CI = 45.5-61.8%) and their department (63.2%, 95% CI = 53.5-72.8%). CONCLUSIONS: The disaster exercise and educational process had the greatest benefit for individuals and departments involved directly. The intervention also prompted enterprise-wide review, and an upgrade of disaster plans at departmental levels. Pre-intervention knowledge scores were poor. Post-intervention knowledge base remained suboptimal, despite a statistically significant improvement. This study supports the widely held belief that disaster simulation is a worthwhile exercise, but more must be done. More time and resources must be dedicated to the increasingly important field of hospital disaster preparedness.