Predictive performance of the common red flags in emergency department headache patients: a HEAD and HEAD-Colombia study.

OBJECTIVES: Only a small proportion of patients presenting to an ED with headache have a serious cause. The SNNOOP10 criteria, which incorporates red and orange flags for serious causes, has been proposed but not well studied. This project aims to compare the proportion of patients with 10 commonly accepted red flag criteria (singly and in combination) between patients with and without a diagnosis of serious secondary headache in a large, multinational cohort of ED patients presenting with headache. METHODS: Secondary analysis of data obtained in the HEAD and HEAD-Colombia studies. The outcome of interest was serious secondary headache. The predictive performance of 10 red flag criteria from the SNNOOP10 criteria list was estimated individually and in combination. RESULTS: 5293 patients were included, of whom 6.1% (95% CI 5.5% to 6.8%) had a defined serious cause identified. New neurological deficit, history of neoplasm, older age (>50 years) and recent head trauma (2-7 days prior) were independent predictors of a serious secondary headache diagnosis. After adjusting for other predictors, sudden onset, onset during exertion, pregnancy and immune suppression were not associated with a serious headache diagnosis. The combined sensitivity of the red flag criteria overall was 96.5% (95% CI 93.2% to 98.3%) but specificity was low, 5.1% (95% CI 4.3% to 6.0%). Positive predictive value was 9.3% (95% CI 8.2% to 10.5%) with negative predictive value of 93.5% (95% CI 87.6% to 96.8%). CONCLUSION: The sensitivity and specificity of the red flag criteria in this study were lower than previously reported. Regarding clinical practice, this suggests that red flag criteria may be useful to identify patients at higher risk of a serious secondary headache cause, but their low specificity could result in increased rates of CT scanning. TRIAL REGISTRATION NUMBER: ANZCTR376695.

Computed tomography brain scan utilization in patients with headache presenting to emergency departments: a multinational study.

BACKGROUND AND IMPORTANCE: Recommended indications for emergency computed tomography (CT) brain scans are not only complex and evolving, but it is also unknown whether they are being followed in emergency departments (EDs). OBJECTIVE: To determine the CT utilization and diagnostic yield in the ED in patients with headaches across broad geographical regions. DESIGN: Secondary analysis of data from a multinational cross-sectional study of ED headache presentations over one month in 2019. SETTING AND PARTICIPANTS: Hospitals from 10 participating countries were divided into five geographical regions [Australia and New Zealand (ANZ); Colombia; Europe: Belgium, France, UK, and Romania; Hong Kong and Singapore (HKS); and Turkey). Adult patients with nontraumatic headache as the primary presenting complaint were included. Patients were identified from ED management systems. OUTCOME MEASURES AND ANALYSIS: The outcome measures were CT utilization and diagnostic yield. CT utilization was calculated using a multilevel binary logistic regression model to account for clustering of patients within hospitals and regions. Imaging data (CT requests and reports) were sourced from radiology management systems. MAIN RESULTS: The study included 5281 participants. Median (interquartile range) age was 40 (29-55) years, 66% were women. Overall mean CT utilization was 38.5% [95% confidence interval (CI), 30.4-47.4%]. Regional utilization was highest in Europe (46.0%) and lowest in Turkey (28.9%), with HKS (38.0%), ANZ (40.0%), and Colombia (40.8%) in between. Its distribution across hospitals was approximately symmetrical. There was greater variation in CT utilization between hospitals within a region than between regions (hospital variance 0.422, region variance 0.100). Overall mean CT diagnostic yield was 9.9% (95% CI, 8.7-11.3%). Its distribution across hospitals was positively skewed. Regional yield was lower in Europe (5.4%) than in other regions: Colombia (9.1%), HKS (9.7%), Turkey (10.6%), and ANZ (11.2%). There was a weak negative correlation between utilization and diagnostic yield ( r  = -0.248). CONCLUSION: In this international study, there was a high variation (28.9-46.6%) in CT utilization and diagnostic yield (5.4-11.2%) across broad geographic regions. Europe had the highest utilization and the lowest yield. The study findings provide a foundation to address variation in neuroimaging in ED headache presentations.

Effect of intravenous fluid volume on biomarkers of endothelial glycocalyx shedding and inflammation during initial resuscitation of sepsis.

PURPOSE: To investigate the effect of IV fluid resuscitation on endothelial glycocalyx (EG) shedding and activation of the vascular endothelium and inflammation. MATERIALS AND METHODS: A planned biomarker sub-study of the REFRESH trial in which emergency department (ED) patients) with suspected sepsis and hypotension were randomised to a restricted fluid/early vasopressor regimen or IV fluid resuscitation with later vasopressors if required (usual care). Blood samples were collected at randomisation (T0) and at 3 h (T3), 6 h (T6)- and 24 h (T24) for measurement of a range of biomarkers if EG shedding, endothelial cell activation and inflammation. RESULTS: Blood samples were obtained in 95 of 99 enrolled patients (46 usual care, 49 restricted fluid). Differences in the change in biomarker over time between the groups were observed for Hyaluronan (2.2-fold from T3 to T24, p = 0.03), SYN-4 (1.5-fold from T3 to T24, P = 0.01) and IL-6 (2.5-fold from T0 to T3, p = 0.03). No difference over time was observed between groups for the other biomarkers. CONCLUSIONS: A consistent signal across a range of biomarkers of EG shedding or of endothelial activation or inflammation was not demonstrated. This could be explained by pre-existing EG shedding or overlap between the fluid volumes administered in the two groups in this clinical trial. Trial registration Australia New Zealand Clinical Trials Registry ACTRN126160000006448 Registered 12 January 2016.

Is headache during pregnancy a higher risk for serious secondary headache cause? A HEAD study report.

OBJECTIVES: Pregnancy is defined as a 'red flag' in headache assessment. We aimed to describe the prevalence and causes of serious secondary headache in pregnant ED patients. METHODS: Unplanned secondary analysis of HEAD Study/HEAD Colombia data. RESULTS: 3.2% (117/3643) of ED headache patients aged 18-50 years were pregnant, of whom six (5.1%) had a serious secondary cause identified. The proportion of patients with serious headache causes was not significantly different between pregnant female, non-pregnant female and male patient subgroups (P = 0.89). CONCLUSION: Inclusion of pregnancy as a 'red flag' in ED headache assessment is not supported by these data.

Potential role of general practice in reducing emergency department demand: A qualitative study.

OBJECTIVE: To inform local, state and national strategies intended to reduce demand for ED care, the present study aimed to identify key factors influencing the current provision of acute care within primary healthcare (PHC) and explore the policy and system changes potentially required. METHODS: Semi-structured interviews with key stakeholders were audio-recorded, transcribed verbatim and analysed through content and thematic approaches incorporating the Walt and Gilson health policy framework. RESULTS: Eleven interviews were conducted. Five key considerations were highlighted, namely the barriers and enablers for general practitioners (GPs) in providing acute care, barriers to patient use of PHC instead of ED, suggestions for new PHC models and improvements for current ED models. Additionally, economic issues relating to clinic funding and GP remuneration, complexities of state or federal funding and management of urgent care centres (UCC) were identified. Potential policy changes included GP clinics incorporating emergency appointments, GP triage, further patient streaming and changes to the ED medical workforce model, as well as linking hospitals with PHC clinics. Suggested system changes included improving rapid access to non-GP specialists, offering qualifications for urgent care within PHC, developing integrated information technology systems and educating patients regarding appropriate healthcare system pathways. CONCLUSION: The present study suggested that while PHC has the potential to attenuate the demands for ED services, a whole-of-system approach focusing on realignment of priorities and integrated changes are needed.

Safety culture in emergency medicine: An exploratory qualitative study.

BACKGROUND: Safety culture in Emergency Departments (EDs) requires special attention due to unique operational feature of the ED environment. Which may influence a culture of patients' safety in the ED. OBJECTIVE: To identify the factors that influence patient safety culture in EDs. METHODS: A qualitative study using semi-structured interviews with 12 ED staff was carried out in two Australian EDs. The data was thematically analysed to identify and describe the factors perceived by staff as influencing patient safety culture. RESULTS: The findings revealed four super-ordinate themes and 19 categories. The themes were the following: (1) Environmental and Organisational; (2) Healthcare Professional (3) Managerial factors; and (4) Patients factors. CONCLUSIONS: Safety culture in the ED is influenced by complex set of factors. The results of this study may help ED workers with improving patient safety culture and healthcare quality in the ED.

Thunderclap headache syndrome presenting to the emergency department: an international multicentre observational cohort study.

BACKGROUND: Most headache presentations to emergency departments (ED) have benign causes; however, approximately 10% will have serious pathology. International guidelines recommend that patients describing the onset of headache as 'thunderclap' undergo neuroimaging and further investigation. The association of this feature with serious headache cause is unclear. The objective of this study was to determine if patients presenting with thunderclap headache are significantly more likely to have serious underlying pathology than patients with more gradual onset and to determine compliance with guidelines for investigation. METHODS: This was a planned secondary analysis of an international, multicentre, observational study of adult ED patients presenting with a main complaint of headache. Data regarding demographics, investigation strategies and final ED diagnoses were collected. Thunderclap headache was defined as severe headache of immediate or almost immediate onset and peak intensity. Proportion of patients with serious pathology in thunderclap and non-thunderclap groups were compared by χ² test. RESULTS: 644 of 4536 patients presented with thunderclap headache (14.2%). CT brain imaging and lumbar puncture were performed in 62.7% and 10.6% of cases, respectively. Among patients with thunderclap headache, serious pathology was identified in 10.9% (95%CI 8.7% to 13.5%) of cases-significantly higher than the proportion found in patients with a different headache onset (6.6% (95% CI 5.9% to 7.4%), p<0.001.). The incidence of subarachnoid haemorrhage (SAH) was 3.6% (95% CI 2.4% to 5.3%) in those with thunderclap headache vs 0.3% (95% CI 0.2% to 0.5%) in those without (p<0.001). All cases of SAH were diagnosed on CT imaging. Non-serious intracranial pathology was diagnosed in 87.7% of patients with thunderclap headache. CONCLUSIONS: Thunderclap headache presenting to the ED appears be associated with higher risk for serious intracranial pathology, including SAH, although most patients with this type of headache had a benign cause. Neuroimaging rates did not align with international guidelines, suggesting potential need for further work on standardisation.

Migraine in the Emergency Department: A Prospective Multinational Study of Patient Characteristics, Management, and Outcomes.

BACKGROUND AND AIM: Migraine headache is commonly diagnosed in emergency departments (ED). There is relatively little real-world information about the epidemiology, investigation, management, adherence to therapeutic guidelines and disposition of patients treated in ED with a final diagnosis of migraine. The primary aim of the current study is to get a snapshot of assessment and management patterns of acute migraine presentations to the different settings of EDs with a view to raise awareness. METHODS: This is a planned sub-study of a prospective study conducted in 67 health services in 10 countries including Australia, New Zealand, Southeast Asia, Europe, and the UK investigating the epidemiology and outcome of adult patients presenting to ED with nontraumatic headache. Outcomes of interest for this study are demographics, clinical features (including severity), patterns of investigation, treatment, disposition, and outcome of patients diagnosed as having migraine as their final ED diagnosis. RESULTS: The cohort comprises 1,101 patients with a mean age of 39 years (SD ± 13.5; 73.7% [811]) were female. Most patients had had migraine diagnosed previously (77.7%). Neuroimaging was performed in 25.9% with a very low diagnostic yield or significant findings (0.07%). Treatment of mild migraine was in accordance with current guidelines, but few patients with moderate or severe symptoms received recommended treatment. Paracetamol (46.3%) and nonsteroidal anti-inflammatory drugs (42.7%) were the most commonly prescribed agents. Metoclopramide (22.8%), ondansetron (19.2%), chlorpromazine (12.8%), and prochlorperazine (12.8%) were also used. CONCLUSIONS: This study suggests that therapeutic practices are not congruent with current guidelines, especially for patients with severe symptoms. Efforts to improve and sustain compliance with existing management best practices are required.

Clinical presentation and assessment of older patients presenting with headache to emergency departments: A multicentre observational study.

OBJECTIVE: To describe the characteristics, assessment and management of older emergency department (ED) patients with non-traumatic headache. METHODS: Planned sub-study of a prospective, multicentre, international, observational study, which included adult patients presenting to ED with non-traumatic headache. Patients aged ≥75 years were compared to those aged <75 years. Outcomes of interest were epidemiology, investigations, serious headache diagnosis and outcome. RESULTS: A total of 298 patients (7%) in the parent study were aged ≥75 years. Older patients were less likely to report severe headache pain or subjective fever (both P < 0.001). On examination, older patients were more likely to be confused, have lower Glasgow Coma Scores and to have new neurological deficits (all P < 0.001). Serious secondary headache disorder (composite of headache due to subarachnoid haemorrhage (SAH), intracranial haemorrhage, meningitis, encephalitis, cerebral abscess, neoplasm, hydrocephalus, vascular dissection, stroke, hypertensive crisis, temporal arteritis, idiopathic intracranial hypertension or ventriculoperitoneal shunt complications) was diagnosed in 18% of older patients compared to 6% of younger patients (P < 0.001). Computed tomography brain imaging was performed in 66% of patients ≥75 years compared to 35% of younger patients (P < 0.001). Older patients were less likely to be discharged (43% vs 63%, P < 0.001). CONCLUSIONS: Older patients with headache had different clinical features to the younger cohort and were more likely to have a serious secondary cause of headache than younger adults. There should be a low threshold for investigation in older patients attending ED with non-traumatic headache.

Acceptability of emergency department triage nurse's advice for patients to attend general practice: A cross-sectional survey.

OBJECTIVES: Demand for ED care is increasing at a rate higher than population growth. Strategies to attenuate ED demands include diverting low-acuity general practice-type ED attendees to alternate primary healthcare settings. The present study assessed the ED attendees' receptiveness to accept triage nurse's face-to-face advice to explore alternate options for medical care and what factors influence the level of acceptance. METHODS: The ED attendees of four major public hospital EDs in Brisbane were surveyed between August and October 2018, using a questionnaire informed by Health Belief Model's cues to action. RESULTS: Of the 514 valid responses, 81% of respondents were very likely/likely to accept the triage nurse's advice to see a general practitioner. Self-perceived urgency of presenting condition/s (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.78-0.97), not having confidence in general practitioner (OR 0.37, 95% CI 0.21-0.66) and having a medical record at the hospital (OR 0.60, 95% CI 0.36-0.99) were negatively associated with the likelihood of accepting the advice. For every point increase in perceived seriousness, the odds of accepting the advice decreased by 16% (95% CI 6-25%). CONCLUSION: Most of the participants believed that EDs were for emergent care and they attended the ED because they perceived their presenting condition/s to be serious and/or urgent. The acceptability of face-to-face advice by triage nurse to seek help in general practice was influenced by perceived threats of the illness, and the underlying beliefs about availability, accessibility, suitability and affordability of the service.

Epidemiology, investigation, management, and outcome of headache in emergency departments (HEAD study)-A multinational observational study.

OBJECTIVE: To describe the epidemiology of nontraumatic headache in adults presenting to emergency departments (EDs). BACKGROUND: Headache is a common reason for presentation to EDs. Little is known about the epidemiology, investigation, and treatment of nontraumatic headache in patients attending EDs internationally. METHODS: An international, multicenter, observational, cross-sectional study was conducted over one calendar month in 2019. Participants were adults (≥18 years) with nontraumatic headache as the main presenting complaint. Exclusion criteria were recent head trauma, missing records, interhospital transfers, re-presentation with same headache as a recent visit, and headache as an associated symptom. Data collected included demographics, clinical assessment, investigation, treatment, and outcome. RESULTS: We enrolled 4536 patients (67 hospitals, 10 countries). "Thunderclap" onset was noted in 14.2% of cases (644/4536). Headache was rated as severe in 27.2% (1235/4536). New neurological examination findings were uncommon (3.2%; 147/4536). Head computed tomography (CT) was performed in 36.6% of patients (1661/4536), of which 9.9% showed clinically important pathology (165/1661). There was substantial variation in CT scan utilization between countries (15.9%-75.0%). More than 30 different diagnoses were made. Presumed nonmigraine benign headache accounted for 45.4% of cases (2058/4536) with another 24.3% classified as migraine (1101/4536). A small subgroup of patients have a serious secondary cause for their headache (7.1%; 323/4536) with subarachnoid hemorrhage (SAH), stroke, neoplasm, non-SAH intracranial hemorrhage/hematoma, and meningitis accounting for about 1% each. Most patients were treated with simple analgesics (paracetamol, aspirin, or nonsteroidal anti-inflammatory agents). Most patients were discharged home (83.8%; 3792/4526). In-hospital mortality was 0.3% (11/4526). CONCLUSION: Diagnosis and management of headache in the ED is challenging. A small group of patients have a serious secondary cause for their symptoms. There is wide variation in the use of neuroimaging and treatments. Further work is needed to understand the variation in practice and to better inform international guidelines regarding emergent neuroimaging and treatment.

The Headache in Emergency Departments study: Opioid prescribing in patients presenting with headache. A multicenter, cross-sectional, observational study.

OBJECTIVE: To describe the patterns of opioid use in patients presenting to the emergency department (ED) with nontraumatic headache by severity and geography. BACKGROUND: International guidelines recognize opioids are ineffective in treating primary headache disorders. Globally, many countries are experiencing an opioid crisis. The ED can be a point of initial exposure leading to tolerance for patients. More geographically diverse data are required to inform practice. METHODS: This was a planned, multicenter, cross-sectional, observational substudy of the international Headache in Emergency Departments (HEAD) study. Participants were prospectively identified throughout March 2019 from 67 hospitals in Europe, Asia, Australia, and New Zealand. Adult patients with nontraumatic headache were included as identified by the local site investigator. RESULTS: Overall, 4536 patients were enrolled in the HEAD study. Opioids were administered in 1072/4536 (23.6%) patients in the ED, and 386/3792 (10.2%) of discharged patients. High opioid use occurred prehospital in Australia (190/1777, 10.7%) and New Zealand (55/593, 9.3%). Opioid use in the ED was highest in these countries (Australia: 586/1777, 33.0%; New Zealand: 221/593, 37.3%). Opioid prescription on discharge was highest in Singapore (125/442, 28.3%) and Hong Kong (12/49, 24.5%). Independent predictors of ED opioid administration included the following: severe headache (OR 4.2, 95% CI 3.1-5.5), pre-ED opioid use (OR 1.42, 95% CI 1.11-1.82), and long-term opioid use (OR 1.80, 95% CI 1.26-2.58). ED opioid administration independently predicted opioid prescription at discharge (OR 8.4, 95% CI 6.3-11.0). CONCLUSION: Opioid prescription for nontraumatic headache in the ED and on discharge varies internationally. Severe headache, prehospital opioid use, and long-term opioid use predicted ED opioid administration. ED opioid administration was a strong predictor of opioid prescription at discharge. These findings support education around policy and guidelines to ensure adherence to evidence-based interventions for headache.

Strategies and interventions for improving safety culture in Australian Emergency Departments: A modified Delphi study.

BACKGROUND: Patient safety and safety culture are critical for quality healthcare delivery in general and in Emergency Departments (EDs) in particular. The aim of this study is to identify strategies that may contribute to the improvement and maintenance of patient safety culture and which are considered most feasible in the ED environment. METHODS: A two-step modified Delphi method with 11 experts' panel was performed to establish consensus. A list of potential expert participants with a background in patient safety culture in EDs was compiled through the professional networks of the supervisory team. Snowball sampling was used to identify additional possible participants. The expert panel included key leaders in the emergency medicine community in Queensland, Australia: patient safety experts and researchers, patient safety directors, and healthcare providers in an Australian ED The study ran from September 2018 to December 2018. The tool used in Round 1 in this study was developed through triangulating the outcomes of a review of literature, results from a survey of ED staff and findings from semi-structured interviews with key stakeholders in ED. The results from Round 1 informed the development of the Round 2 tool. The responses from the Delphi Round 1 tool were analysed as both qualitative data and quantitative data. The responses from the Delphi Round 2 tool were treated as quantitative data and analysed with the SPSS software. Consensus was calculated based on more than 80% agreement in collapsed categories 1 and 2 (or 4 and 5) of the five-point Likert scale. RESULTS: Only six strategies out of 17 (35%) achieved consensus for both importance and feasibility. These strategies may therefore be considered the most important and feasible key strategies for improving safety culture in EDs. Seven strategies (41.1%) achieved consensus for importance, but not for feasibility and four strategies (23.55%) did not achieve consensus for either importance or feasibility. CONCLUSIONS: This study offers practical solutions for safety culture improvement in the ED context. Six key strategies were seen as both important and feasible and these grouped into three main themes; leadership through agenda setting, operational management approaches to reinforce the agenda and commitment, and systems and structures to reinforce the agenda and monitor progress.

Factors predictive for computed tomography use and abnormality in paediatric head injuries in Australia and New Zealand.

OBJECTIVES: To investigate patient-level factors predictive for computed tomography of the brain (CTB) use and abnormality in head injured children in Australia and New Zealand. METHODS: Retrospective data from tertiary, urban/suburban and regional/rural EDs including factors predictive for CTB use and abnormality. RESULTS: Of 3072 children at 31 EDs, 212 (6.9%) had a CTB scan, of which 66 (31%) were abnormal. Increasing age, serious mechanisms of injury and decreasing Glasgow Coma Score were predictive for ordering CTB. Decreasing age was predictive for CTB abnormalities. Other factors were not. CONCLUSION: Patient-level drivers of CTB use in children in Australia and New Zealand are consistent with international data.

Mental health presentations to a paediatric emergency department.

OBJECTIVE: To explore trends in presentation and key performance indicators with respect to children seeking mental health services at The Prince Charles Hospital Children's Emergency Department (TPCH-CED), Brisbane. METHODS: A retrospective audit was performed utilising data obtained from the local Emergency Department Information System for all mental health presentations between 1 January 2013 and 1 January 2018 to TPCH-CED. RESULTS: A total of 1078 children presented to TPCH-CED requiring mental health review between 2013 and 2018. Mental health presentations almost doubled over the 5 years (185 attendances in 2013; 342 in 2017); however, as a proportion of overall presentations, there was no significant increase. The percentage of mental health presentations meeting the National Emergency Access Target criteria dropped from 63% in 2013 to 39% in 2017 (P < 0.0001). Those requiring a mental health inpatient stay were more likely to have very extended length of stay within the CED. Suicidal ideation was the most common presenting complaint (72% of mental health presentations). Violence and aggression were noted in a consistent proportion of mental health presentations (4.4-12%). CONCLUSIONS: Despite failing to demonstrate an interval increase in the proportion of children presenting to TPCH-CED requiring mental health services, it is clear that children with mental health needs, like their adult counterparts, disproportionately experience delays to appropriate care when compared with children presenting with other emergency conditions. Ongoing research is warranted to assess standards of care and the impact of mental health presentations on CEDs.

The Australasian Resuscitation In Sepsis Evaluation: Fluids or vasopressors in emergency department sepsis (ARISE FLUIDS), a multi-centre observational study describing current practice in Australia and New Zealand.

OBJECTIVES: To describe haemodynamic resuscitation practices in ED patients with suspected sepsis and hypotension. METHODS: This was a prospective, multicentre, observational study conducted in 70 hospitals in Australia and New Zealand between September 2018 and January 2019. Consecutive adults presenting to the ED during a 30-day period at each site, with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation, were eligible. Data included baseline demographics, clinical and laboratory variables and intravenous fluid volume administered, vasopressor administration at baseline and 6- and 24-h post-enrolment, time to antimicrobial administration, intensive care admission, organ support and in-hospital mortality. RESULTS: A total of 4477 patients were screened and 591 were included with a mean (standard deviation) age of 62 (19) years, Acute Physiology and Chronic Health Evaluation II score 15.2 (6.6) and a median (interquartile range) systolic blood pressure of 94 mmHg (87-100). Median time to first intravenous antimicrobials was 77 min (42-148). A vasopressor infusion was commenced within 24 h in 177 (30.2%) patients, with noradrenaline the most frequently used (n = 138, 78%). A median of 2000 mL (1500-3000) of intravenous fluids was administered prior to commencing vasopressors. The total volume of fluid administered from pre-enrolment to 24 h was 4200 mL (3000-5661), with a range from 1000 to 12 200 mL. Two hundred and eighteen patients (37.1%) were admitted to an intensive care unit. Overall in-hospital mortality was 6.2% (95% confidence interval 4.4-8.5%). CONCLUSION: Current resuscitation practice in patients with sepsis and hypotension varies widely and occupies the spectrum between a restricted volume/earlier vasopressor and liberal fluid/later vasopressor strategy.

Conservative versus Interventional Treatment for Spontaneous Pneumothorax.

BACKGROUND: Whether conservative management is an acceptable alternative to interventional management for uncomplicated, moderate-to-large primary spontaneous pneumothorax is unknown. METHODS: In this open-label, multicenter, noninferiority trial, we recruited patients 14 to 50 years of age with a first-known, unilateral, moderate-to-large primary spontaneous pneumothorax. Patients were randomly assigned to immediate interventional management of the pneumothorax (intervention group) or a conservative observational approach (conservative-management group) and were followed for 12 months. The primary outcome was lung reexpansion within 8 weeks. RESULTS: A total of 316 patients underwent randomization (154 patients to the intervention group and 162 to the conservative-management group). In the conservative-management group, 25 patients (15.4%) underwent interventions to manage the pneumothorax, for reasons prespecified in the protocol, and 137 (84.6%) did not undergo interventions. In a complete-case analysis in which data were not available for 23 patients in the intervention group and 37 in the conservative-management group, reexpansion within 8 weeks occurred in 129 of 131 patients (98.5%) with interventional management and in 118 of 125 (94.4%) with conservative management (risk difference, -4.1 percentage points; 95% confidence interval [CI], -8.6 to 0.5; P = 0.02 for noninferiority); the lower boundary of the 95% confidence interval was within the prespecified noninferiority margin of -9 percentage points. In a sensitivity analysis in which all missing data after 56 days were imputed as treatment failure (with reexpansion in 129 of 138 patients [93.5%] in the intervention group and in 118 of 143 [82.5%] in the conservative-management group), the risk difference of -11.0 percentage points (95% CI, -18.4 to -3.5) was outside the prespecified noninferiority margin. Conservative management resulted in a lower risk of serious adverse events or pneumothorax recurrence than interventional management. CONCLUSIONS: Although the primary outcome was not statistically robust to conservative assumptions about missing data, the trial provides modest evidence that conservative management of primary spontaneous pneumothorax was noninferior to interventional management, with a lower risk of serious adverse events. (Funded by the Emergency Medicine Foundation and others; PSP Australian New Zealand Clinical Trials Registry number, ACTRN12611000184976.).

Implementation study reporting diagnostic accuracy, outcomes and costs in a multicentre randomised controlled trial of non-expert lung ultrasound to detect pulmonary oedema.

BACKGROUND: Lung ultrasound experts claim that 'B line' artefacts herald pulmonary oedema, but links between early recognition and improved outcome are unconfirmed, particularly for non-expert clinicians. OBJECTIVE: Assess individual and system impacts of early, non-expert lung ultrasound (LUS) in breathless older patients. METHODS: Prospective single-blinded randomised controlled trial of point of care LUS by non-expert clinicians, augmenting ED assessment of patients over 60 years, presenting with dyspnoea. After brief training, clinicians at three hospitals used computer-generated block randomisation envelopes to allocate a convenience sample of consenting presenters to conventional or LUS-augmented management. ED provisional diagnosis was compared to a post-discharge chart audit diagnosis, blinded to ultrasound findings. Secondary outcomes were the length of stay in ED and hospital, costs and discharge destinations. RESULTS: From three sites, 224 controls were compared with 218 interventions. LUS improved diagnostic accuracy, with a small effect size in favour of LUS (risk difference: 6.5%, 95% CI 0.9-12) and a number needed to scan of 16 (95% CI 8-107). With LUS, ED and hospital stay increased non-significantly, while discharge destination trends improved. No harm ensued. CONCLUSIONS: Non-expert LUS augmenting dyspnoea workup may improve diagnostic accuracy, but did not significantly alter costs or outcomes in the ED or the hospital. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry (ACTRN12613001023741).

General practitioner-type patients in emergency departments in metro North Brisbane, Queensland: A multisite study.

OBJECTIVE: To estimate the proportion of ED patients in urban Queensland who are potentially suitable for general practitioner (GP) care. METHODS: A retrospective analysis was conducted using ED Information System data from Metro North Hospital and Health Service in Brisbane, Australia for three consecutive financial years (2014-2015 to 2016-2017). The hospitals included two Principal Referral and two Public Acute hospitals. GP-type patients were calculated using the Australian Institute of Health and Welfare (AIHW), Australasian College for Emergency Medicine (ACEM) and the validated Sprivulis methods. RESULTS: Of the 822 841 ED presentations, 219 567 (27%) were potentially GP-type patients by AIHW, 49 307 (6%) by ACEM and 61 836 (8%) by Sprivulis methods. The higher proportion of GP-type presentations were during 08.00 to 17.00 hours by AIHW and ACEM methods. Of the lower-acuity triage categories of 4 (286 154 presentations) and 5 (5658 presentations), AIHW estimated that 62% and 80% of the patients were GP-type patients, as compared to 9% and 22% by ACEM, and 9% and 0.3% by Sprivulis method. The mean costs of adult GP-type patients is $345 by the AIHW and $406 by the ACEM method, lower than non-GP type patients ($706 and $622, respectively). CONCLUSIONS: There is considerable variation in what is considered GP-type ED presentations based on the three methods employed and this variation may have fuelled the debate surrounding what is 'avoidable' ED utilisation. Regardless, the study findings provide an interesting addition to defining and addressing appropriate utilisation of ED services.