Incident monitoring in emergency departments: an Australian model.

The specialty-based study of incidents, adverse events, and errors in medicine has largely occurred in anesthesia and to a lesser extent in intensive care and psychiatry. Few studies have specifically addressed the problem in emergency medicine (EM). Because of the significant risks, the resulting adverse outcome, and the high degree of preventability of errors occurring in the emergency department (ED), it is essential that an incident monitoring system be part of the ED's risk management program. The combination of time pressure, uncertainty, complexity, and workload means the ED is a high-risk environment. The delivery of high-quality emergency care is dependent on having an effective patient processing system in place and, because EM is a "systems-dependent" specialty, the environment lends itself to improvements to the system (re-engineering) to improve the safety of the environment given that the majority of errors in the ED are probably the result of failures of the system. This paper describes an existing incident monitoring system that has recently been adopted by six EDs in Australia. It was developed as a result of a similar successful program in anesthesia, and funded by the Federal Department of Health of Australia. Incorporating incident monitoring and analysis to identify causative factors of incidents and the subsequent implementation of corrective strategies as part of the ED risk management program may result in improvement in the quality of care through a reduction in the frequency of incidents.

A primary stenting strategy as an alternative to fibrinolytic therapy in acute myocardial infarction. An analysis of results in hospital and at 6 weeks and 6 months.

OBJECTIVE: To report the feasibility and results to 6 months of a primary stenting strategy in patients with acute myocardial infarction (AMI). DESIGN: Prospective, single-centre, observational study. SETTING: A tertiary referral teaching hospital (Royal North Shore Hospital, Sydney), July 1997 to November 1998. SUBJECTS: 102 (of 194) consecutive patients presenting to the emergency department with AMI who were eligible for fibrinolytic therapy, and for a primary stenting strategy. The first 50 patients were under 70 years of age, and had not had previous coronary artery bypass grafting (CABG). The following 52 patients included patients up to 80 years and with previous CABG. OUTCOME MEASURES: Major adverse cardiac and cerebrovascular events: death, reinfarction, cerebrovascular accident (CVA) and repeat target lesion revascularisation, in hospital, and at 6 weeks and 6 months. Minor in-hospital adverse events: bleeding requiring blood transfusion, vascular complications and new-onset heart failure. Time delays to treatment, and duration of hospital stay. RESULTS: Normal flow was established in the infarct-related artery in 97/102 patients (95%). Stenting, percutaneous transluminal coronary angioplasty (PTCA), CABG or medical therapy was performed in 74, 11, 9 and 8 patients, respectively. Minor in-hospital events, time delays and hospital stay were similar to those reported previously. At 6 weeks, major adverse cardiac and cerebrovascular events had occurred in 5% of patients (four repeat target lesion revascularisation and one reinfarction). By 6 months, repeat target lesion revascularisation had been performed in an additional 10% of patients. No deaths had occurred. CONCLUSIONS: A primary stenting strategy can be performed safely, without significant delays and with excellent short and intermediate term outcomes.

Biochemical markers of acute myocardial infarction: strategies for improving their clinical usefulness.

We investigated the early diagnostic utility, including incremental value, of the serum cardiac markers creatine kinase (CK), CK-MB (mass and activity measurements), cardiac troponin T, and myoglobin in the diagnosis of acute myocardial infarction (AMI) in patients presenting to a major teaching hospital with chest pain and non-diagnostic electrocardiographs (ECG). The reference diagnosis of acute myocardial infarction was made by a single, independent cardiologist using World Health Organization criteria. CK and CK-MB mass were the only significant predictors of AMI at presentation to the Emergency Department. Logistic regression analysis revealed that CK did not significantly predict (P = 0.23) myocardial infarction once CK-MB mass was in the model. Using test results on follow up, in addition to presentation CK-MB mass, change in CK-MB mass was the only other significant independent predictor of AMI. Likelihood ratios for various levels of the significant markers in the logistic regression are given. In conclusion, CK-MB mass measurement was the only useful serum cardiac marker for the diagnosis of AMI in patients presenting with chest pain with non-diagnostic ECGs.

An aid to blind nasal intubation.

Blind nasal intubation remains an important technique in the management of the difficult airway. Many aids to this technique have been described, but unfortunately, these often require additional expense, training, and equipment. Methods that involve listening at the end of the endotracheal tube and observing moisture condensation in the tube are relatively insensitive and may expose the operator to the patient's bodily fluids. Our aim was to devise an aid to blind nasal intubation that was effective, inexpensive, simple to learn, and easy to assemble. It is essential that breath sounds can be monitored through the endotracheal tube, as it is felt that this helps to minimize retropharyngeal perforation caused by the tube abutting the posterior pharyngeal wall. We describe the use of an endotracheal tube stethoscope in conjunction with either 'inline' or 'sidestream' capnometry and present a case of successful nasotracheal intubation using this device. The total cost of this aid is less than $10 Australian.

Prevalence of domestic violence among patients attending a hospital emergency department.

A cross-sectional study was conducted to determine the prevalence of domestic violence victims among patients using emergency services at Sydney's Royal North Shore Hospital, in an affluent urban area of New South Wales. This study used a self-administered questionnaire (used in a similar study at the Royal Brisbane Hospital) to investigate the history of domestic violence among patients attending the emergency department during 64 randomly selected nursing shifts in October-November 1994. Adult domestic violence was reported by 19.3 per cent of females and 8.5 per cent of males, confirming the results of the Brisbane study. Evidence for underreporting was found: 4 per cent of females and 6.3 per cent of males who did not report being victims revealed experiences of abuse on nine measures of types of violence, including six taken from the Conflict Tactics Scale. Results supported evidence from other studies suggesting that experience of abuse as a child is a risk factor for being in abusive relationships as an adult. In the past, comparison of results has been limited because of variation in definitions of domestic violence; this has been overcome by intentional replication of the Brisbane study. The study was enhanced by inclusion of patients from non-English-speaking backgrounds and a cohort of parents of children attending. Similar prevalence estimates were found in these groups. Results have implications for the detection and treatment of victims of domestic violence across all strata of society and have potential to raise awareness and affect attitudes towards this significant community problem.

Major trauma outcomes in the elderly.

OBJECTIVES: To study mortality and functional outcome in elderly patients suffering major trauma and to assess whether age affects prognosis. DESIGN AND SETTING: Retrospective identification of patients from the Royal North Shore Hospital, a level three trauma service and teaching hospital of the University of Sydney. The patients were followed up for an average of three years after admission. PATIENTS: One hundred and eighteen patients aged over 60 years, with injury severity scores over 15, admitted consecutively between May 1988 and July 1990. To determine the effects of age on outcome, patients were divided into two groups: those aged 61-70 years (67 patients) and over 70 years (51 patients). MAIN OUTCOME MEASURES: Death in hospital, late death after discharge, change in preinjury v. current accommodation and current functional ability, measured with the Barthel activities of daily living index. RESULTS: Thirty-six of the 118 patients died in hospital. Eighty-one of the remaining 82 patients were followed up. Twenty-five of these patients died during the study period: three in the 61-70 years age group, and 22 in the over 70 years age group (P < 0.0001). Among the long term survivors, 43 of 53 continued to live independently, and 41 of 54 scored maximum points in activities of daily living assessment. Only seven people required nursing home care. CONCLUSIONS: Age is an important factor in survival after major trauma, but those that do survive generally return to full activity and independence. Aggressive treatment for elderly trauma victims is warranted.

Acute spinal epidural hematoma.

A 17-year-old female presented to the Emergency Department with a history of recent onset of severe upper thoracic back pain, urinary retention, weakness and paraesthesia in the lower limbs. Magnetic Resonance Imaging (MRI) Scan demonstrated a spinal epidural hematoma at the C7-T2 level. This report highlights a rare, but eminently treatable condition; the use of MRI Scan as a specific diagnostic tool; and the need for urgent surgical decompression to ensure good recovery of function.