Most common principal diagnoses assigned to Australian emergency department presentations involving alcohol use: a multi-centre study.

OBJECTIVES: Alcohol is the most widely consumed psychoactive substance in Australia and the consequences of alcohol consumption have enormous personal and social impacts. This study aimed to describe the principal diagnoses of emergency department (ED) presentations involving alcohol use in the previous 12 hours at eight hospitals in Victoria and the Australian Capital Territory, Australia. METHODS: Twelve months' data (1 July 2018 - 30 June 2019) were collected from eight EDs, including demographics, ICD-10 codes, hospital location and self-reported drinking in the preceding 12 hours. The ten most common ICD-10 discharge codes were analysed based on age, sex and hospital geographic area. RESULTS: ICD codes pertaining to mental and behavioural disorders due to alcohol use accounted for the highest proportion in most EDs. Suicide ideation/attempt was in the five highest ICD codes for all but one hospital. It was the second most common alcohol-related presentation for both males and females. CONCLUSIONS: Alcohol plays a major role in a range of presentations, especially in relation to mental health and suicide. IMPLICATIONS FOR PUBLIC HEALTH: The collection of alcohol involvement in ED presentations represents a major step forward in informing the community about the burden of alcohol on their health resources.

Sydney 'lockout' liquor licensing law restrictions have been associated with a sustained reduction in emergency department presentations from assaults over 5 years.

OBJECTIVES: The present study assessed the impact of changes to the New South Wales Liquor Act in 2014 on assault-related presentations to the ED of St Vincent's Hospital. This hospital is the primary receiving hospital for the area affected by these laws. METHODS: Patients presenting to the ED with an assault-related diagnosis were identified from the ED and trauma registry databases from 2009 to 2019 and retrospectively reviewed. The number of presentations in the 5 years prior to the introduction of the laws in 2014 was compared to the number occurring in the 5 years following this. Admission to the intensive care unit (ICU) and in-hospital death were used as markers for severe injury. RESULTS: From 2009 to 2019 there were 2983 assault-related presentations to the ED, with 153 requiring ICU admission and 12 deaths. The mean number of presentations annually fell from 342 to 255 after the introduction of the laws (P = 0.01). The reduction in presentations was sustained for the entire 5-year period after the introduction of the laws. Although the mean number of patients requiring ICU admission per year fell from 17 to 14, and the mean number of deaths annually fell from 1.6 to 0.8, neither of these were statistically significant. CONCLUSIONS: There has been a significant reduction in assault-related presentations to St Vincent's Hospital following the changes to the liquor licensing laws that has been sustained for 5 years with no significant decrease in the those with severe assault injuries.

'Dalarinji': A flexible clinic, belonging to and for the Aboriginal people, in an Australian emergency department.

OBJECTIVE: Equity and access to high-quality healthcare for Aboriginal and Torres Strait Islander (Aboriginal) people has remained refractory for complex and multifactorial reasons, and there are sound ethical arguments for addressing this urgently. In EDs all patients who 'leave at own risk' (LAOR) or 'do not wait to be seen' (DNW) are at increased risk of readmission, morbidity or death. This also incurs additional resource costs to the health system. Aboriginal patients have high rates of DNW and LAOR. The Flexiclinic model of care was co-designed to better support the needs of Aboriginal patients in the ED and to reduce the rates of DNW and LAOR. METHODS: 'Dalarinji', or Flexiclinic, is a flexible model of care within the ED collaboratively devised with the Aboriginal Health Unit to address the major factors that influence this vulnerable cohort leaving the St Vincent's Hospital ED (SVHED) prior to being assessed or before completion of treatment. RESULTS: In the 3 months since its introduction, the Flexiclinic approach has significantly improved the quality and equity of access to medical care at SVHED for Aboriginal patients with the average summed rate of DNW and LAOR falling to 5.2% of presentations, representing a fivefold decrease in the probability of Aboriginal patients receiving incomplete care. CONCLUSION: The Flexiclinic approach has significantly improved medical care at SVHED for Aboriginal patients. It has been well received by both staff and patients and has had no adverse effects on delivery of services to other patient groups.

Supporting black lives 'mattering' with flexible health care.

Black lives 'mattering' should mean intrinsically supporting feasible healthcare options for Aboriginal and Torres Strait Islander people. This requires reimagining outmoded, 'neo-colonial' type models of care with implicit prejudice in hospital emergency departments (EDs). Equitably serving the needs of vulnerable cohorts like First Nations people that currently suffer most from lack of access to suitable healthcare is incumbent on government and society. To 'close the gap' for Aboriginal people, flexible treatment options should be designed with and for indigenous communities; developing models of care that will improve Aboriginal patient's attendance and completion of treatment in emergency departments. Flexiclinic, jointly developed by the Aboriginal Liaison Service and St Vincent's Hospital ED has developed such an innovative model. Since its recent inception, it has already shown enormous benefits, both in promoting equitable access and improving the health and welfare of Aboriginal patients who are receiving ongoing and quality care.

Restraint in paediatrics: A delicate balance.

Patient restraint in health care is currently under intense review. There are two disparate groups that should be considered. First, infants and young children are commonly restrained while undergoing simple medical procedures such as venepuncture or immunisation, and this practice may be better framed as 'hugging' not 'holding'. Second, there is a distinct but significant group of children and adolescents with serious psychiatric or organic illness with behavioural disturbances necessitating restraint, who are the primary focus of this paper. Nevertheless, the balance between restraining any young person in health care and causing preventable harm is delicate: any form of child restraint, whether physical, chemical or seclusion, merits ethical reflection and should be undertaken judiciously. All clinicians should prioritise the dignity and privacy of the young person while weighing the vulnerability of this cohort of patients.

Role and impact of brain computed tomography in the management of drug overdoses and guideline recommendations.

OBJECTIVE: Patients presenting with overdoses commonly receive computed tomography brain (CTB) scans in their assessment. There is no current guideline or validated decision support tool for neuroimaging in overdose patients. We investigated the proportion of overdose patients who received a CTB scan and its impact on management. METHODS: A single site retrospective study was conducted to analyse drugs and alcohol overdose-related presentations over a 2 year period. Outcome measures were the proportion of patients who received a CTB scan and the proportion of those who had an associated change in management. A decision support tool to guide the indications for CTB in overdose patients was developed based on this. RESULTS: A total of 7521 drugs and alcohol-related presentations were screened, where 4086 were overdoses. This involved 3200 patients. CTB scans were conducted in 519 (12.7%) of presentations. The majority of patients with CTB did not have head injury (n = 325, 62.5%). Of 519 CTB scans, 25 (4.8%) were abnormal of which 20 (3.9%) were associated with a change in management. A decision support tool was devised and tested and provided a relatively high yield where a CTB could be justified. CONCLUSIONS: A high proportion of overdose patients received CTB scans. There was only a low yield in terms of management alteration. We propose that clinicians adopt a guided approach using a decision support tool to minimise unnecessary CTB scans.

Driving change: A partnership study protocol using shared emergency department data to reduce alcohol-related harm.

BACKGROUND: Sharing anonymised ED data with community agencies to reduce alcohol-related injury and assaults has been found effective in the UK. This protocol document outlines the design of an Australian multi-site trial using shared, anonymised ED data to reduce alcohol-related harm. DESIGN AND METHOD: Nine hospitals will participate in a 36 month stepped-wedge cluster randomised trial. After a 9 month baseline period, EDs will be randomised in five groups, clustered on geographic proximity, to commence the intervention at 3 monthly intervals. 'Last-drinks' data regarding alcohol use in the preceding 12 h, typical alcohol consumption amount, and location of alcohol purchase and consumption, are to be prospectively collected by ED triage nurses and clinicians at all nine EDs as a part of standard clinical process. Brief information flyers will be delivered to all ED patients who self-report risky alcohol consumption. Public Health Interventions to be conducted are: (i) information sharing with venues (via letter), and (ii) with police and other community agencies, and (iii) the option for public release of 'Top 5' venue lists. OUTCOMES: Primary outcomes will be: (i) the number and proportion of ED attendances among patients reporting recent alcohol use; and (ii) the number and proportion of ED attendances during high-alcohol hours (Friday and Saturday nights, 20.00-06.00 hours) assigned an injury diagnosis. Process measures will assess logistical and feasibility concerns, and clinical impacts of implementing this systems-change model in an Australian context. An economic cost-benefit analysis will evaluate the economic impact, or return on investment.