Qualitative evaluation of a formal bedside clinical teaching programme in an emergency department.

BACKGROUND: Bedside clinical teaching in emergency departments is usually opportunist or ad hoc. A structured bedside clinical teaching programme was implemented, where a consultant and registrar were formally allocated to teaching and learning roles separated from the usual departmental management or clinical roles. Themes emphasised included clinical reasoning, practical clinical knowledge, communication, physical examination, procedural and professional skills. AIM: To evaluate the perceived educational value, effects on patient care and areas for ongoing development. METHODS: The study setting was an urban, tertiary referral, university-affiliated emergency department with prospectively allocated educational shifts of 4 or 5 h duration over a 6-month period. Evaluation was by session and course evaluation questionnaires, with respondents ranking predetermined themes and giving free-text responses. Qualitative presentation of results allowed exploration of the themes identified. RESULTS: Learners ranked history taking and physical examination technique as the most frequently learnt item, but clinical reasoning as the most important theme learnt. Informal discussion and performance critique or constructive feedback were the most frequent teaching methods. The biggest obstacle to learning was learner apprehension. The most frequent positive effect on patient care was faster management, decision making or disposition. Most often, no negative effect on patient care was identified. CONCLUSION: Formal bedside teaching is effective if organised with adequate staffing to quarantine the teacher and learner from routine clinical duties, and concentrating on themes best taught in the patient setting. Clinical reasoning and clinical knowledge were perceived to be most important, with positive effects on patient care through more thorough assessment and faster decision making.

Changes in respiratory function during a wilderness multisport endurance competition.

OBJECTIVE: To document the changes in respiratory function seen in competitors during a typical wilderness multisport endurance event. METHODS: A prospective observational cohort study measuring forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) at baseline, midrace, and end of race in competitors in a 105-km ski/run/cycle/paddle race held midwinter in the mountains of Victoria, Australia. RESULTS: Twenty-five adult subjects (22 men) between 20 and 42 years of age were studied. The mean decline in FEV1 was 15.1% (95% CI 10.3-19.8) and for FVC was 13.0% (95% CI 8.1-17.9). Fourteen (56%) of the 25 subjects had a >10% decline in FEV1 and FVC, and 7 (28%) of the 25 subjects had a >20% decline. In 9 control subjects, aged between 21 and 55 years, there was no significant change in FEV1 or FVC from prerace to end of race. CONCLUSIONS: Significant declines in FEV1 and FVC are common during wilderness multisport endurance events. The focus of future research should be the etiology, which as yet remains speculative.

Fluid balance during and after an ironman triathlon.

OBJECTIVE: To record weight changes, fluid intake and changes in serum sodium concentration in ultradistance triathletes. DESIGN: Descriptive research. SETTING: Ironman triathlon (3.8 km swim, 180 km cycle, 42.2 km run). Air temperature at 1200 h was 21 degrees C, (relative humidity 91%). Water temperature was 20.7 degrees C. PARTICIPANTS: 18 triathletes. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Subjects were weighed and had blood drawn for serum sodium concentration [Na], hemoglobin, and hematocrit, pre-race, post-race, and at 0800 h on the morning following the race ("recovery"); subjects were also weighed at transitions. Fluid intake during the race was estimated by athlete recall. RESULTS: Median weight change during the race = -2.5 kg (p < 0.0006). Subjects lost weight during recovery (median = -1.0 kg) (p < 0.03). Median hourly fluid intake = 716 ml/h (range 421-970). Fluid intakes were higher on the bike than on the run (median 889 versus 632 ml/h, p = 0.03). Median calculated fluid losses cycling were 808 ml/h and running were 1,021 ml/h. No significant difference existed between pre-race and post-race [Na] (median 140 versus 138 mmol/L) or between post-race and recovery [Na] (median 138 versus 137 mmol/L). Plasma volume increased during the race, median + 10.8% (p = 0.0005). There was an inverse relationship between change in [Na] pre-race to post-race and relative weight change (r = -0.68, p = 0.0029). Five subjects developed hyponatremia ([Na] 128-133 mmol/L). CONCLUSIONS: Athletes lose 2.5 kg of weight during an ultradistance triathlon. most likely from sources other than fluid loss. Fluid intakes during this event are more modest than that recommended for shorter duration exercise. Plasma volume increases during the ultradistance triathlon. Subjects who developed hyponatremia had evidence of fluid overload despite modest fluid intakes.

Exercise-induced hyponatremia in ultradistance triathletes is caused by inappropriate fluid retention.

OBJECTIVE: To study fluid and sodium balance during overnight recovery following an ultradistance triathlon in hyponatremic athletes compared with normonatremic controls. CASE CONTROL STUDY: Prospective descriptive study. SETTING: 1997 New Zealand Ironman Triathlon (3.8 Km swim, 180 Km cycle, 42.2 Km run). PARTICIPANTS: Seven athletes ("subjects") hospitalized with hyponatremia (median sodium [Na] = 128 mmol L(-1)). Data were compared with measurements from 11 normonatremic race finishers ("controls") (median sodium = 141 mmol L(-1)). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Athletes were weighed prior to, immediately after, and on the morning after, the race. Blood was drawn for sodium, hemoglobin, and hematocrit immediately after the race and the following morning. Plasma concentrations of arginine-vasopressin (AVP) were also measured post race. RESULTS: Subjects were significantly smaller than controls (62.5 vs. 72.0 Kg) and lost less weight during the race than controls (median -0.5% vs. -3.9%, p = 0.002) but more weight than controls during recovery (-4.4% vs. -0.8%, p 0.002). Subjects excreted a median fluid excess during recovery (1,346 ml): controls had a median fluid deficit (521 ml) (p = 0.009). Estimated median sodium deficit was the same in subjects and controls (88 vs. 38 mmol L(-1), p = 0.25). Median AVP was significantly lower in subjects than in controls. Plasma volume fell during recovery in subjects (-5.9%, p = 0.016) but rose in controls (0.76%, p = NS). CONCLUSIONS: Triathletes with symptomatic hyponatremia following very prolonged exercise have abnormal fluid retention including an increased extracellular volume, but without evidence for large sodium losses. Such fluid retention is not associated with elevated plasma AVP concentrations.

The effect on hospital admission profiles of establishing an emergency department observation ward.

OBJECTIVE: To determine the effect of establishing an emergency department observation ward (OW) on admission numbers, average length of stay (ALOS) for the entire hospital and overall bed days for conditions commonly treated in the OW. SETTING: Sir Charles Gairdner Hospital (SCGH), Perth, a tertiary referral teaching hospital. DESIGN: Retrospective analysis of routinely collected hospital data for the 10 most common diagnosis-related group (DRG) categories of patients discharged from the OW for the financial years 1995-96 to 1998-99. Comparison of these data with those for adult patients at the other Perth teaching hospitals over the same period. MAIN OUTCOME MEASURES: For patients in the 10 most common DRGs: numbers of admissions to the OW compared with other inpatient wards; total number of patients admitted to the hospital compared with total bed days; ALOS at SCGH compared with other Perth teaching hospitals. RESULTS: Increased admissions to the OW were paralleled by a decrease in admissions for the same DRG codes to other inpatient wards. ALOS remained approximately the same from 1995-96 to 1998-99 for patients in the OW (one day) and other inpatient wards (4.38 to 4.20 days). However, overall ALOS for patients in these DRGs fell by over a third (from 3.97 to 2.59 days) over this time. The total number of patients in these DRGs treated by the hospital increased by 19% over the four years, but the total number of bed days fell by 23%. By contrast, the ALOS for patients in the same DRGs treated at the other Perth teaching hospitals rose 8% (from 2.12 to 2.28 days). CONCLUSION: Establishment of a formal emergency department OW results in the more efficient management of certain groups of patients, with a decrease in overall hospital bed days and length of stay.

The accuracy of oral predictive and infrared emission detection tympanic thermometers in an emergency department setting.

OBJECTIVE: To assess the accuracy of an oral predictive thermometer and an infrared emission detection (IRED) tympanic thermometer in detecting fever in an adult emergency department (ED) population, using an oral glass mercury thermometer as the criterion standard. METHODS: This was a single-center, nonrandomized trial performed in the ED of a metropolitan tertiary referral hospital with a convenience sample of 500 subjects. The temperature of each subject was taken by an oral predictive thermometer, an IRED tympanic thermometer set to "oral" equivalent, and an oral glass mercury thermometer (used as the criterion standard). A fever was defined as a temperature of 37.8 degrees C or higher. The subject's age, sex, triage category, and diagnostic group were also recorded. Sensitivity, specificity, positive and negative likelihood ratios, positive and negative predictive values, and corresponding 95% confidence intervals were calculated. Logistic regression was used to identify predictors of fever. RESULTS: The sensitivities and specificities for detection of fever of the predictive and the IRED tympanic thermometers were similar (sensitivity 85.7%/88.1% and specificity 98.7%/95.8%, respectively). The predictive thermometer had a better positive predictive value (85.7%) compared with the IRED tympanic thermometer (66.1%). The positive and negative likelihood ratios for the predictive oral thermometer were 65 and 0.14, respectively, and for the IRED tympanic thermometer 21 and 0.12, respectively, indicating that the predictive thermometer will "miss" 1 in about 7 fevers and the IRED tympanic thermometer will "miss" 1 in about 8 fevers. CONCLUSIONS: Although quick and convenient, oral predictive and IRED tympanic thermometers give readings that cannot always be relied on in the detection of fever. If we are to continue using electronic thermometers in the ED setting, we need to recognize their limitations and maintain the importance of our clinical judgment.

Changing the site of delivery of thrombolytic treatment for acute myocardial infarction from the coronary care unit to the emergency department greatly reduces door to needle time.

OBJECTIVE: To quantify the change in door to needle time when delivery of thrombolytic treatment of acute myocardial infarction was changed from the coronary care unit to the emergency department. DESIGN: A comparative observational study using prospectively collected data. SETTING: Coronary care unit and emergency department of an Australian teaching hospital. PARTICIPANTS: 89 patients receiving thrombolysis in coronary care unit between June 1994 and January 1996, and 100 patients treated in the emergency department between April 1997 and May 1998. INTERVENTIONS: From April 1997, by agreement between cardiology and emergency medicine, all patients with acute myocardial infarction receiving thrombolysis were treated by emergency physicians in the emergency department. MAIN OUTCOME MEASURE: Door to needle time measured from time of arrival at the hospital to start of thrombolysis. Other outcomes included pain to needle time and mortality. RESULTS: Median door to needle times were less for patients treated in the emergency department than in the coronary care unit (37 minutes, 95% confidence interval (CI) 33 to 44 v 80 minutes, 95% CI 70 to 89, respectively; p < 0.0001). Door to needle time was under 60 minutes in 83% of emergency department patients and 26% of coronary care unit patients (57% difference, 95% CI 45% to 69%; p < 0.0001). Median pain to needle time was less for emergency department patients than for coronary care unit patients (161 minutes, 95% CI 142 to 177 v 195 minutes, 95% CI 180 to 209; p = 0.004); times of less than 90 minutes occurred in 18% of emergency department patients v 1% of coronary care unit patients (17% difference, 95% CI 9% to 25%; p < 0.05). Overall mortality was similar in patients treated in the emergency department and the coronary care unit. CONCLUSIONS: With a collaborative interdepartmental approach, thrombolytic treatment of acute myocardial infarction was more rapid in the emergency department, without compromising patient safety. This should improve the outcome in patients with infarcts treated with thrombolytic agents.

A prospective study of exercise-associated hyponatremia in two ultradistance triathletes.

OBJECTIVE: To study fluid and sodium balance in two ultradistance triathletes. DESIGN: Prospective case study. SETTING: An ultradistance triathlon (3.8 km swim, 180 km cycle, 42.2 km run), and during overnight recovery. Ambient air temperature at 12:00 p.m. race day was 21 degrees C, with a relative humidity of 91%. Water temperature was 20.7 degrees C. SUBJECTS: Two female ultradistance triathletes, ages 30 and 39 years, who were participating in a larger study investigating weight and electrolyte changes in the Ironman triathlon. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Subjects were weighed and had blood drawn for serum sodium concentration, hemoglobin, hematocrit, arginine vasopressin, and aldosterone concentration prior to and after the race, and at 8:00 a.m. the following morning. Sodium and fluid intake and urinary output were measured during recovery. RESULTS: Both subjects developed mild hyponatremia (Na 131 and 130 mmol/L) during the race, with a weight gain (0.5 and 1.5 kg). Neither subject had large sodium losses (24 mmol and 20 mmol). Fluid consumption was 733 ml/h and 764 ml/h. Plasma volume increased during the race (25 and 16%). Arginine vasopressin (AVP) levels were not elevated in either subject (1.2 and 1.9 pmol/L). Both subjects demonstrated a water excess during the race (1.5 and 2.5 L), and lost weight during recovery (2.0 and 4.5 kg). CONCLUSIONS: Hyponatremia resulted from fluid retention in the extracellular space, without evidence of large sodium losses or inappropriate AVP secretion.

Diagnosis and prevention of hyponatremia at an ultradistance triathlon.

OBJECTIVE: To evaluate a method of medical care at an ultradistance triathlon, with the aim of reducing the incidence of hyponatremia. DESIGN: Descriptive research. SETTING: New Zealand Ironman triathlon (3.8 km swim, 180 km cycle, 42.2 km run). PARTICIPANTS: 117 of 134 athletes seeking medical care after the triathlon (involving 650 race starters). INTERVENTIONS: A prerace education program on appropriate fluid intake was undertaken. The number of support stations was decreased to reduce the availability of fluid. A body weight measurement before the race was introduced as a compulsory requirement, so that weight change during the race could be included in the triage assessment. An on-site laboratory was established within the race medical tent. MAIN OUTCOME MEASURES: Numbers of athletes and diagnoses, including the incidence of symptomatic hyponatremia (defined as symptoms of hyponatremia in association with a pretreatment plasma sodium concentration [Na] < 135 mmol/L); weight changes; and changes in [Na]. RESULTS: The common diagnoses in the 117 athletes receiving attention were exercise-associated collapse (27%), musculoskeletal complaints (26%), and dehydration (12%). There was a significant reduction in the number of athletes receiving medical care for hyponatremia, from 25 of the 114 athletes who received care in 1997 (3.8% of race starters) to 4 of the 117 athletes who received care in 1998 (0.6% of race starters). Mean weight change among athletes in the 1998 race was -3.1 kg, compared with -2.6 kg in 1997. CONCLUSION: A preventive strategy to decrease the incidence of hyponatremia, including education on fluid intake and appropriate placement of support stations, was associated with a decrease in the incidence of symptomatic hyponatremia.

Using clinical indicators in emergency medicine: documenting performance improvements to justify increased resource allocation.

OBJECTIVES: To demonstrate how emergency department triage scale and thrombolysis indicator data can be used to document the impact of a substantial increase in resource allocation. METHODS: Descriptive study in an emergency department of an adult tertiary hospital in Perth, Australia during similar periods of the year both before and after a substantial increase in emergency department staff, equipment, and system resources. The study group comprised a total of 11,048 emergency department attendances and all cases of emergency department initiated thrombolysis or acute angioplasty. Outcome was measured using numbers seen and percentage seen within indicator threshold time together with admission rates in each of the five triage categories as well as by using time from presentation to initiation of reperfusion treatment in acute myocardial infarction. RESULTS: The proportion of patients seen within the prescribed indicator time increased by 16.4% (95% confidence interval 14.4% to 18.2%). The increase was most pronounced in triage category 2 (32.7%). Median time to thrombolysis fell by 30 minutes to 37 minutes (p = 0.0002). CONCLUSIONS: Use of the Australasian national triage scale and time to thrombolysis clinical indicator data allows a quantitative assessment of the impact of increased emergency department resource allocation.

Re-engineering an Australian emergency department: can we measure success?

In 1996, in response to perceived deficiencies of the Emergency Department, Sir Charles Gairdner Hospital made emergency medicine a key strategic initiative. Major staffing and functional changes occurred as a result, including creation of the first Chair in Emergency Medicine in Australasia. We present a before and after study, using a range of measured variables, including the accepted Australian Council on Healthcare Standards emergency medicine clinical indicators. Clinically, there were great improvements in waiting times, time to thrombolysis in acute myocardial infarction, complaint rate, and misdiagnosed fracture rate. Increased throughput of short stay patients in a re-opened observation ward greatly shortened average length of stay for patients with a range of acute conditions. Data also indicated significant improvements in teaching and research. We conclude that with firm commitment from hospital management, re-engineering an emergency department can be shown to improve the quality-of-care.

Hyponatremia in ultradistance triathletes.

PURPOSE: Hyponatremia ([plasma sodium] <135 mmol x L(-1)) is a potentially serious complication of ultraendurance sports. However, the etiology of this condition is still uncertain. This observational cohort study aimed to determine prospectively the incidence and etiology of hyponatremia in an ultradistance triathlon. METHODS: The subjects consisted of 605 of the 660 athletes entered in the New Zealand Ironman triathlon (3.8-km swim, 180-km cycle, and 42.2-km run). Subjects were weighed before and after the race. A blood sample was drawn for measurement of plasma sodium concentration after the race. RESULTS: Complete data on pre- and postrace weights and plasma sodium concentrations were available in 330 race finishers. Postrace plasma sodium concentrations were inversely related to changes in body weight (P = 0.0001). Women (N = 38) had significantly lower plasma sodium concentrations (133.7 vs 137.4 mmol x L(-1); P = 0.0001) than men (N = 292) and lost significantly less relative weight (-2.7 vs -4.3%; P = 0.0002). Fifty-eight of 330 race finishers (18%) were hyponatremic; of these only 18 (31%) sought medical care for the symptoms of hyponatremia (symptomatic). Eleven of the 58 hyponatremic athletes had severe hyponatremia ([plasma sodium] < 130 mmol x L(-1)); seven of these 11 severely hyponatremic athletes were symptomatic. The relative body weight change of the 11 severely hyponatremic athletes ranged from 2.4% to +5%; eight (73%) of these athletes either maintained or gained weight during the race. In contrast, relative body weight changes in the 47 athletes with mild hyponatremia ([plasma sodium] 130-134 mmol x L(1)) were more variable, ranging from -9.25% to +2.2%. CONCLUSIONS: Hyponatremia is a common biochemical finding in ultradistance triathletes but is usually asymptomatic. Although mild hyponatremia was associated with variable body weight changes, fluid overload was the cause of most (73%) cases of severe, symptomatic hyponatremia.

Severe multi-system failure following delayed presentation with tiger snake envenomation.

A 68 year-old-man presented some twelve hours after a presumed Tiger Snake bite with coagulopathy, paralysis and muscle necrosis. He suffered multi-system failure requiring prolonged ventilation, haemodialysis and supportive care, to be discharged after 26 days. Delays to antivenom therapy after tiger snake envenomation can result in significant morbidity. Australian snakes are the most venomous in the world.

Injury and illness in a wilderness multisport endurance event.

Our objective was to identify patterns of injury and illness and develop possible preventive strategies for competitors in a wilderness multisport endurance event. Using a prospective observational cohort study during the Winter Classic, a 2-day wilderness multisport endurance event held in rugged alpine terrain in Victoria, Australia, we sought details of demographics, pre-, intra-, and postrace injuries and illness. We employed chi-squared tests and iterative multivariate analysis. There were 33 respondents with 26 (78%) aged between 26 and 35 years. Seven (21%) developed symptoms consistent with exposure, and three (9%) developed asthma during the race. Competitors in the marathon pairs class had a 50% risk of exposure vs 12% for the individual class (p = 0.031). The number of times raced, nonsteroidal anti-inflammatory drug use, and increasing age were the other independent significant predictors of exposure. Twenty-three (70%) of the competitors were injured at some time during the race. The day 1 run was more commonly associated with injuries than other stages (39% injured, p = 0.0037). Increased amounts of training, previous musculoskeletal problems, and increased number of previous race attempts were all significant independent predictors of injury. Most competitors (67%) suffered musculoskeletal problems after the race, these typically being of the thighs and calves, but only two competitors required time off from their normal activities. We concluded that injuries in wilderness multisport endurance events are common, particularly in the run stages. These injuries are usually minor, but their frequency makes major injury an ever-present risk. Both injury and illness are more frequent in those who compete while carrying injuries. These events are high risk for the development of injuries and illness and require a high level of competitor preparation and readily available medical support.

Roxithromycin-induced digoxin toxicity.

A 76-year-old women presented with digoxin toxicity four days after starting a course of roxithromycin. In 10%-15% of the population, digoxin is degraded extensively by bacteria in the gastrointestinal tract, and antibiotic-induced changes in the bacterial flora may lead to digoxin toxicity.

Sternal fractures: a retrospective analysis of 272 cases.

OBJECTIVE: To determine the incidence, morbidity, and mortality associated with fractures of the sternum. DESIGN: A retrospective review of the medical records of all patients treated in an emergency department with the radiologic diagnosis of sternal fracture during a 6 1/2 year period between January 1, 1985 and June 30, 1991. SETTING: A level II trauma center in the eastern suburbs of Melbourne, Australia. PATIENTS: 272 patients were eligible for analysis. Only 6 patients of 251 involved in motor vehicle collisions were documented as not wearing seatbelts. RESULTS: The incidence of sternal fracture as a result of motor vehicle collisions was 3%. Sternal fracture is more common in female victims and the elderly and is associated with a very low incidence of cardiac arrhythmias requiring treatment. It has a mortality of 0.7%. CONCLUSIONS: Sternal fracture is a common injury in a population where restraints are frequently used. PATIENTS with an isolated sternal fracture do not require cardiac monitoring and those under 40 years of age may be cared for in a short stay ward.