Death rates following emergency department chest pain assessment.

OBJECTIVES: We sought to define the rate of unexpected death from acute coronary syndrome or arrhythmia in chest pain patients directly discharged from the ED. METHODS: Retrospective audit of all chest pain patients at a tertiary ED for 7 years. Medical and post-mortem records of the deceased were reviewed with independent cardiologist adjudication to determine outcomes. Primary outcome measure was 28-day unexpected death secondary to acute coronary syndrome or arrhythmia. RESULTS: During the study period, 25 924 patients presented with chest pain, 292 (1.1%, 95% confidence interval [CI] 0.99-1.01%) died within 28 days. Of these, 16 680(64%, 95% CI 63.88-64.12%) were discharged by ED, two (0.01%, 95% CI 0-0.011%) of this group died from the primary outcome. CONCLUSION: Unexpected death is very uncommon after ED discharge of chest pain patients.

Management of Acute Coronary Syndromes in Patients in Rural Australia: The MORACS Randomized Clinical Trial.

Importance: Treatment of ST-segment elevation myocardial infarction (STEMI) in rural settings involves thrombolysis followed by transfer to a percutaneous coronary intervention-capable hospital. The first step is accurate diagnosis via electrocardiography (ECG), but one-third of all STEMI incidents go unrecognized and hence untreated. Objective: To reduce missed diagnoses of STEMI. Design, Setting, and Participants: This cluster randomized clinical trial included 29 hospital emergency departments (EDs) in rural Australia with no emergency medicine specialists, which were randomized to usual care vs automatically triggered diagnostic support from the tertiary referral hospital (management of rural acute coronary syndromes [MORACS] intervention). Patients presenting with symptoms compatible with acute coronary syndromes (ACS) were eligible for inclusion. The study was conducted from December 2018 to April 2020. Data were analyzed in August 2021. Intervention: Triage of a patient with symptoms compatible with ACS triggered an automated notification to the tertiary hospital coronary care unit. The ECG and point-of-care troponin results were reviewed remotely and a phone call was made to the treating physician in the rural hospital to assist with diagnosis and initiation of treatment. Main Outcomes and Measures: The proportion of patients with missed STEMI diagnoses. Results: A total of 6249 patients were included in the study (mean [SD] age, 63.6 [12.2] years; 48% female). Of 7474 ED presentations with suspected ACS, STEMI accounted for 77 (2.0%) in usual care hospitals and 46 (1.3%) in MORACS hospitals. Missed diagnosis of STEMI occurred in 27 of 77 presentations (35%) in usual care hospitals and 0 of 46 (0%) in MORACS hospitals (P < .001). Of eligible patients, 48 of 75 (64%) in the usual care group and 36 of 36 (100%) in the MORACS group received primary reperfusion (P < .001). In the usual care group, 12-month mortality was 10.3% (n = 8) vs 6.5% (n = 3) in the MORACS group (relative risk, 0.64; 95% CI, 0.18-2.23). Patients with missed STEMI diagnoses had a mortality of 25.9% (n = 7) compared with 2.0% (n = 1) for those with accurately diagnosed STEMI (relative risk, 13.2; 95% CI, 1.71-102.00; P = .001). Overall, there were 6 patients who did not have STEMI as a final diagnosis; 5 had takotsubo cardiomyopathy and 1 had pericarditis. There was no difference between groups in the rate of alternative final diagnosis. Conclusion and Relevance: The findings indicate that MORACS diagnostic support service reduced the proportion of missed STEMI and improved the rates of primary reperfusion therapy. Accurate diagnosis of STEMI was associated with lower mortality. Trial Registration: anzctr.org.au Identifier: ACTRN12619000533190.

High-flow oxygen in patients undergoing procedural sedation in the emergency department: A retrospective chart review.

OBJECTIVE: Hypoxia is a recognised complication of procedural sedation. This study sought to determine whether there was an association between the use of high-flow oxygen delivery by a non-rebreather (NRB) mask during ED procedural sedation and decreased rates of hypoxia when compared with alternative oxygenation methods. METHODS: Records of all procedural sedations performed over a 12 month period in an Australian tertiary ED were reviewed retrospectively. The primary outcome was whether recorded oxygen saturations fell below 90%. Specifics of the oxygen delivery method were noted and data collected included sex, age, indication for sedation, drugs and doses administered, time of day sedation was commenced and staff grade of sedationist. RESULTS: A total of 755 procedural sedations were reviewed. Two hundred and five (27.1%) patients were administered oxygen via NRB mask from the outset of their sedation. NRB administration was associated with a statistically significant decreased rate of hypoxia (1/205 patients vs 23/550 [odds ratio: 0.112; 95% confidence interval: 0.003-0.0702]; P = 0.0090). This association remained statistically significant when adjusted for confounders. CONCLUSIONS: This study demonstrates an association with a statistically significant reduction in hypoxia when high-flow oxygen via NRB mask is administered during emergency procedural sedation. This intervention is simple, safe and inexpensive, and we would advocate that it be evaluated further in prospective trials.

Opportunistic childhood vaccinations in emergency--are we really missing anyone?

OBJECTIVES: Every health service presentation of a child should be considered an opportunity to ensure optimal immunisation. Measures to limit missed opportunities for vaccination in local emergency departments (ED) should reflect the scale of opportunity and parental support of immunisation service delivery strategies. METHODS: The vaccination status of every child aged less than seven years that presented to a tertiary hospital ED over a three month period was identified using the Australian Childhood Immunisation Register (ACIR). Contra-indications to vaccination were determined from medical records. A telephone survey or posted survey was conducted with parents of eligible children to confirm ACIR status and whether they would have consented to receiving vaccinations during their presentation. ED records were reviewed for vaccination history recording and ACIR records were reviewed, after interview, to confirm parental reports that initial ACIR status was incorrect. RESULTS: Nine per cent (215/2399) of children were identified as incompletely vaccinated according to ACIR. Forty-seven children were excluded. Of the remaining 168 children, 95 parents (57%) participated. Thirty-eight children had no contra-indications and their parents would have consented to vaccination during their ED presentation. The vaccination status of 82% (78/95) was recorded in ED records, but was incorrect in 35 cases. Forty parents indicated that the ACIR record was incorrect and this was confirmed in 36 cases (90%). CONCLUSIONS: There were missed opportunities to vaccinate a small proportion of children in ED. Parents provided a more accurate timely history of immunisation status than ACIR and thus ED staff should ensure that parents are always asked whether their child is fully vaccinated and provide or encourage vaccination.

Point of care troponin decreases time in the emergency department for patients with possible acute coronary syndrome: a randomised controlled trial.

OBJECTIVE: To determine the effect of cardiac troponin I testing with a point-of-care (POC) device versus central laboratory on length of stay (LOS) in emergency department (ED) patients presenting with possible acute coronary syndromes (ACS). METHODS: A 12-week randomised controlled trial at two metropolitan ED in eastern Australia with a combined annual census of 80,000. Participants were all patients presenting with possible ACS. Exclusions were a diagnosis of ACS before arrival, ST elevation and failure to wait for complete assessment. Randomisation was by week when POC was made available. Primary outcome was LOS from patient arrival to physical departure from the ED. The proportion of patients meeting a government target of less than 8 h stay was compared. Analysis was by intention to treat. RESULTS: Despite underutilisation of POC, LOS was shorter during weeks when it was available. The time savings translates into approximately 48 minutes (95% CI 12 to 84) per average LOS of almost 7 h, which did not reach statistical significance (p=0.063), or an absolute increase of 10% (95% CI 4.3 to 16.6) in the number of people discharged from the ED within the target LOS of less than 8 h, which did reach significance (p=0.007). These savings were more pronounced in the setting without 24 h central laboratory availability. CONCLUSIONS: POC testing for troponin in the ED tended to reduce the LOS for possible ACS patients. The degree of this benefit is likely to be markedly dependent on its acceptance and uptake by attending personnel, and on the ED setting in which it is used.

Adverse outcomes following emergency department discharge of patients with possible acute coronary syndrome.

OBJECTIVE: To determine the proportion of adverse events in patients discharged after ED assessment for possible acute coronary syndrome. METHODS: Prospective observational cohort study enrolling consecutive patients presenting with symptoms suggestive of coronary syndrome. Main outcome was the proportion of adverse coronary events (defined a priori) within 30 days. RESULTS: Of 2627 patients, 1819 (69%) were discharged without a diagnosis of coronary syndrome and 808 (31%) were admitted for further investigation and treatment. Of these, 385 (14.7%) were given a final diagnosis of acute coronary syndrome. On 30 day follow up, 18 of the discharged patients were diagnosed with acute coronary syndrome (0.7%; 95% confidence intervals [CI] 0.4-1.1%), 10 with unstable angina (0.4%; 95% CI 0.2-0.7%) and 8 with non-ST elevation myocardial infarction (0.3%; 95% CI 0.2-0.6%). There were no cases of ST elevation infarction or death. The sensitivity for diagnosis of acute coronary syndromes was 95.5% (95% CI 92.9-97.3%). Average length of stay was 7 h for discharged patients. Forty-six per cent of patients with diabetes and 47% with a past history of coronary disease were discharged. Subsequent outpatient stress testing was performed in 13.6%. CONCLUSIONS: In a large Australian ED, less than 1% of patients presenting with symptoms suggestive of coronary syndrome were discharged and subsequently had a 30 day adverse event. Reducing this proportion by admitting patients with traditional risk factors would markedly increase hospital workload. Opportunities exist to improve both the safety and efficiency of chest pain assessment in the ED.

Validation of a point of care troponin assay in real life Emergency Department conditions.

OBJECTIVE: To validate the accuracy of a Point of care (POC) troponin device (Abbott i-Stat) in real life ED conditions. DESIGN: A three-way comparison between troponin I results obtained by experienced POC operators, inexperienced ED staff and central laboratory criterion standard. PARTICIPANTS: Convenience sample of 332 patients presenting to the ED with possible coronary syndromes. RESULTS: Spearman correlation coefficient for experienced versus laboratory was 0.83 (95% CI 0.78-0.87), occasional users versus laboratory was 0.76 (95% CI 0.71-0.81), and experienced versus occasional users on POC was 0.82 (95% CI 0.76-0.87). Using local troponin cut-off of 0.1 ng/mL, kappa coefficient was 0.94 for occasional users versus laboratory, 0.91 for experienced versus laboratory and 0.94 for experienced versus occasional users. Bland-Altman plots showed good agreement across the range of measured values. The sensitivity of i-Stat (vs laboratory as criterion standard) was 92.2% (95% CI 83.8%-97.0%) with the local cut-off but only 70.1% (95% CI 60.5%-78.6%) using the lowest cut-off associated with acceptable reproducibility (10% coefficient of variation). CONCLUSIONS: The i-Stat POC device produces similar results in the hands of experienced and occasional operators in ED. There is good agreement between the POC and laboratory at levels used to diagnose infarction by older, more specific criteria. When compared using new lower cut-offs, the i-Stat had poor sensitivity.

A randomised controlled trial of hot water (45 degrees C) immersion versus ice packs for pain relief in bluebottle stings.

OBJECTIVE: To investigate the effectiveness of hot water immersion for the treatment of Physalia sp. (bluebottle or Portuguese Man-of-War) stings. DESIGN: Open-label, randomised comparison trial. Primary analysis was by intention to treat, with secondary analysis of nematocyst-confirmed stings. One halfway interim analysis was planned. SETTING: Surf lifesaving first aid facilities at two beaches in eastern Australia from 30 December 2003 to 5 March 2005. PARTICIPANTS: 96 subjects presenting after swimming in the ocean for treatment of an apparent sting by a bluebottle. INTERVENTIONS: Hot water immersion (45 degrees C) of the affected part versus ice pack application. MAIN OUTCOME MEASURES: The primary outcome was a clinically important reduction in pain as measured by the visual analogue scale (VAS). Secondary outcomes were the development of regional or radiating pain, frequency of systemic symptoms, and proportion with pruritus or rash on follow-up. RESULTS: 49 patients received hot water immersion and 47 received ice packs. The two groups had similar baseline features, except patients treated with hot water had more severe initial pain (VAS [mean +/- SD]: 54 +/- 22 mm versus 42 +/- 22 mm). After 10 minutes, 53% of the hot water group reported less pain versus 32% treated with ice (21%; 95% CI, 1%-39%; P = 0.039). After 20 minutes, 87% of the hot water group reported less pain versus 33% treated with ice (54%; 95% CI, 35%-69%; P = 0.002). The trial was stopped after the halfway interim analysis because hot water immersion was shown to be effective (P = 0.002). Hot water was more effective at 20 minutes in nematocyst-confirmed stings (95% versus 29%; P = 0.002). Radiating pain occurred less with hot water (10% versus 30%; P = 0.039). Systemic effects were uncommon in both groups. CONCLUSIONS: Immersion in water at 45 degrees C for 20 minutes is an effective and practical treatment for pain from bluebottle stings.