key: cord-0041349-sjptvnws
authors: nan
title: Abstracts of the Annual Scientific Meeting of the Australasian College for Emergency Medicine 2003
date: 2004-04-05
journal: Emerg Med (Fremantle)
DOI: 10.1111/j.1742-6723.2004.00606.x
sha: 55922705fc7cffef9bf39ea84c1295cfc5b83a6d
doc_id: 41349
cord_uid: sjptvnws

nan

approach to bed management, so patients with the greatest nursing needs are likely to experience the longest waiting time for bed allocation. This is a fundamentally inefficient method of resource allocation which inevitably leads to overcrowding in the Emergency Department.

Research into overcrowding has been hampered by poor definition of what constitutes normal 'crowding' in an ED. The ACEM definition of access block strong because it is patient-centric, independent of ED size, and reflects change in practice over time. It is relatively weak because it is at best a daily rather than real time measure, and severe access block affects the ED for many hours or days afterwards. The best statistical measure of daily workload yet identified is the total daily patient care time, which corresponds to mean occupancy with patients being treated. Research is beginning to examine this measure over shorter time periods, but there are many other factors that impact whether an ED is 'overcrowded' at any particular moment. The incidence of many adverse events is directly correlated with access block and daily workload, reflecting both increased waiting times and excessive demands placed on staff. There is an urgent need for public discussion about resource allocation within the health system and Emergency Physicians need to represent our patients by bringing these matters into the debate. assessment was well documented and validated the decision rule. D-Dimer testing was appropriately reduced with improved specificity. All radiological tests used show improved diagnostic yield. Pulmonary angiography rates doubled although less were indicated. The pathway is well accepted particularly amongst junior staff. Conclusion: This paper will present information on why diagnosis of PE needs to be standardized and successfully implementing this in an evidence based fashion. Data will be presented suggesting multiple areas of process improvement, validation of the clinical scoring rule and less indeterminate outcomes.

Our institution is currently developing a multidisciplinary stroke pathway. There is level A evidence to show the effectiveness of acute stroke units and thrombolysis in the acute management of stroke. Evidence-based consensus guidelines have now been published in Stroke 2003. In this presentation the ongoing development of this pathway will be referenced to this evidence. The focus will be on major issues relevant to Emergency Medicine. Important Emergency Medicine management issues include the following: supportive care, swallowing and administration of IV fluids, hypertension, aspirin administration, thrombolysis, anticoagulation, surgical intervention for raised intracranial pressure, and resuscitation decisions. Assessment issues that will also be focused on include the following: time to diagnosis, accuracy of diagnosis, eligibility for thrombolysis, diagnosing ischaemic stroke from intracranial haemorrhage, differentiating a TIA from a stroke, appropriate investigations, acceptable time to CT, and appropriate threshold for admission. Emergency medicine stroke key performance indicators (KPI's) are not well described, except for the possible exception of thrombolysis. Possible KPI's and their suggested targets in brackets, are indicated below: • Accuracy of triage status for TL eligible (> 85%) • Accuracy of triage diagnosis • Bedside glucose (100%) • Triage category 2 seen by time compliance (90%) • Door to CT times in TL (85% AHA compliance) • Request to urgent CT scan time (90% < 60 min) • Door to TL times (85% AHA compliance) • Appropriate vs. inappropriate administration of TL • Swallowing evaluation performed in ED or patient kept nil orally with IV fluid (100%) • Hyperglycaemia control • CXR -inappropriate ordering (< 15% of CVA) • ECG A model for measuring the casemix activity and economic costs of hospital access block Peter Stuart Aim: To determine the Emergency Department activity and costs resulting from access block. Methods: Using data from four ACEM accredited hospitals the correlation between casemix activity measured using the Urgency and Disposition Group (UDG) model and degree of access block for the period 1998-2002 was determined. The Access Block adjusted Weighted Occasions of Service (AWOOS) model was developed from the UDG casemix system by incorporating two modifying variables to account for the increased length of stay for admitted patients (Length of Stay Factor) and the cost resulting from this increased workload (Access Block Cost Ratio). The difference between the change to UDG and AWOOS activity over the 5-year period was calculated to estimate the activity and costs of access block not measured by the UDG casemix model. Results: Over the five period the combined data showed that the mean length of stay in ED for admitted/transferred patients (LOS) increased by 93% (range 21% to 183%), UDG activity increased by 0.63% (−5.6% to 6.1%) and AWOOS activity increased by 24.5% (5.1% to 51.4%). In the three hospitals with the largest increase in LOS, UDG activity showed no correlation with access block. The AWOOS model was highly correlated with access block at all four hospitals (r = 0.84-0.99, P < 0.05). The (unmeasured) activity and costs resulting from access block was 23.9% (range 5.1% to 51.4%). Conclusion: The UDG casemix system significantly underestimates the activity in emergency departments experiencing marked access block. The AWOOS model provides a practical tool for measuring the economic costs and increased ED workload resulting from access block.

Fatovich DM, Sprivulis P Despite a modest growth in patient presentations to the three major tertiary Perth Metropolitan Emergency Departments, there has been a significant increase in both the total number of hours of ambulance diversion and the requests for triple diversion (all three hospitals declaring diversion at the same time). A retrospective analysis of data from EDIS and TOPAS (admitted patient administration system) was undertaken for 2001 and 2002 in the three major tertiary Perth Emergency Departments. Using a multivariate analysis, it was found that: • Total diversion time is dependent upon percentage of patients subject to access block (r = 0.830, P < 0.001). No other variable was found to be independent of access block. • Percentage of patients seen within recommended time is dependent upon loss of cubicle space due to access blocked patients (r = 0.840, P < 0.002). Adding total attendances to the model only marginally increases the correlation coefficient (r = 0.844, P < 0.002). • Total ED occupancy is dependent on loss of cubicle space due to access blocked patients (r = 0.970, P < 0.0002). Adding total attendances to the model only marginally increases the correlation (r = 0.975, P < 0.0002). These data suggest that poor waiting times and ED overcrowding will not be improved by reducing ED attendances. Rather, reducing access block should be the highest priority in allocating resources to reduce ambulance diversion, improve waiting times and reduce ED overcrowding. Efforts at reducing attendances will have minimal impact and should be only considered after access block is controlled.

Ambulance diversion is not due to low acuity patients in Perth metropolitan tertiary emergency departments Yusuf Nagree, Grainger S, Sprivulis P Much focus has been directed towards enhancing low acuity patients in Emergency Departments. Multiple strategies are being pursued to reduce low acuity patients as a means of reducing Emergency Department overcrowding and ambulance diversion. Previous studies have demonstrated that low acuity patients are not a significant cause of Emergency Department workload. Using EDIS (HASS solutions version 9) and TOPAS (the admitted patient administration system), a retrospective data analysis for 2002 was performed. Low acuity patient numbers for the three tertiary Perth Emergency Departments were calculated using a previously validated methodology.

A comparison was performed between the average number low acuity patients in the department at-non-diversion times and at the time of calling diversion.

As can be seen, there is an increase in approximately 12 patients in the Emergency Department between normal and diversion states, however, only 1.8 of these patients are low acuity. Therefore, strategies to reduce the already low numbers of low acuity patients are unlikely to prevent ambulance diversion.

Andrew George-Gamlyn Access block and ambulance bypass has been described as the greatest issue facing emergency medicine. Record rates of ambulance bypass and access block have been experienced in major teaching hospitals, and indeed many smaller regional hospitals across Australia. Royal Hobart Hospital, the major teaching hospital for the University of Tasmania, and the tertiary referral centre for Tasmania, has not been immune to such overcrowding issues. The Royal Hobart Hospital is a 450-bed teaching hospital, and has 40 000 new presentations per annum. Towards the end of 2002, access block and elective theatre cancellations threatened to bring the Tasmanian health system to its knees. Royal Hobart Hospital cannot go on bypass so this was not an option. Drastic measures were taken by the CEO and senior clinicians towards the end of 2002, and plans were drawn up to ensure that there were at least 10 free beds in the hospital by COB each day. This paper will describe the results, which show that only three admitted patients have stayed overnight on a trolley in the Emergency Department since October 2002; an exceptional result. Elective cancellations (for lack of beds) is a rarity, and elective surgery throughput is comparable to benchmarked institutions nationwide. This paper will describe the actions taken by the senior executive and clinicians at Royal Hobart Hospital. These actions successfully turned around the ED overcrowding issues and has led to a sustained effects through the Winter of 2003.

Background: Prolonged emergency department length of stay (EDLOS) is endemic in Australasia. This study examined the association between EDLOS and inpatient length of stay (IPLOS) among admitted patients in Melbourne, Australia. Methods: Retrospective review was undertaken of emergency department (ED) presentations which required admission at a major metropolitan health service, from 1/7/2000 to 30/6/2001, inclusive. EDLOS was defined as total time of ED stay; IPLOS as time from initiation of treatment in ED to hospital discharge. Logistic regression analysis was used to examine the associations between excess IPLOS (IPLOS exceeding state average LOS (SALOS) for the relevant diagnostic-related group) and EDLOS, age, gender and time of ED presentation. Results: 17 954 admissions were included. Mean IPLOS for four EDLOS categories (= 4 h, 4-8 h, 8-12 h and > 12 h) were: 3.73, 5.65, 6.60 and 7.20 days, respectively (P < 0.001). The corresponding mean values for (IPLOS -SALOS) were 0.39, 1.30, 1.96 and 2.35 days (P < 0.001). Compared to EDLOS 4-8 h, odds ratios (95% CI) for excess IPLOS associated with other EDLOS categories were: = 4 h: 0.68 (0.63-0.74); 8-12 h: 1.20 (1.10-1.30); and > 12 h: 1.49 (1.36-1.63), after adjusting for age, gender and time of ED presentation. Conclusions: EDLOS correlates with IPLOS, and predicts if IPLOS exceeds the state benchmark for the relevant DRG, independently of age, gender and time of ED presentation. Compared to patients with EDLOS of 4-8 h, those staying 8-12 h are approximately 20% more likely to have IPLOS exceeding state average; 50% more likely if EDLOS exceeds 12 h; and 30% less likely if EDLOS is £4 h.

Objective: This study aimed to identify whether the recently reported increased average ward length of stay (LOS) in AB patients is due to different casemix in these patients. Methods: Retrospective descriptive cohort study of all patients admitted to a ward bed through a tertiary hospital mixed adult/ paediatric ED in 2001. Start of admission was taken as the time of leaving ED for the ward. Standard definitions were used: LOS = days from admission to discharge, or 1 if on same day, Access Block = Time from ED arrival to admission more than 8 h, DRG = Australian National Diagnosis Related Group version 4 assigned by trained coders after discharge. Caseweight and Predicted LOS were taken from national DRG averages, and the difference between LOS and predicted LOS was calculated. Results: 11804 admissions had valid data (100%), with the following means (95% CI).

The effect of increased LOS occurred across a wide range of subgroups, though it was greater in adult than paediatric patients and it was concentrated in those with AB whose admission started outside office hours (0800-1800 Mon-Fri). Conclusions: The access block effect of increased LOS is not due to significantly different casemix in access block patients by standard measures. LOS averaged 0.91 day longer in access block patients after adjusting for casemix, amounting to an excess of 2200 bed days annually.

Matthew Chan, Drew Richardson Objectives: Access Block (AB) affects ED function and has been shown to affect quality measures outside the ED such as length of hospital stay (LOS). This study aimed to investigate the effect of individual and daily AB on time to surgery in orthopaedic patients requiring operation. Methods: Retrospective cohort study in a mixed adult/paediatric tertiary hospital. Records of all patients treated in the ED and subsequently discharged after surgery from the orthopaedic unit in 2001 were reviewed, and other data were obtained from existing ED databases. For each patient the total ED time (TEDT) and the time to surgery from ED arrival to start of operation were calculated. AB was defined as TEDT greater than 8 h and delay to surgery (DTS) was defined as time to surgery greater than 24 h. Daily AB was expressed as a proportion of all admissions. Results: There were 1172 presentations to ED resulting in acute orthopaedic admission of whom 952 had surgery. AB occurred in 183 admissions (19.2%) and was associated with increased DTS (41.5% vs. 36.3%, P = 0.001). LOS for patients with DTS was 1.93 days (95% CI 1.14-2.71) greater than national DRG averages compared to 0.31 days (− 0.38-0.94) for those without DTS. Subgroup analysis showed the proportion of DTS increased with daily AB except for very high AB days (> 45%).

The association of AB with delay to surgery indicates an important effect of AB outside the ED. Further study should examine the relationship between AB and other quality measures.

Introduction: Approximately 22% of adult patients bitten by a redback spider (RBS) require treatment with antivenom.

Objective: This study tests the hypothesis that a patient's symptoms resolve more quickly and require less antivenom when given intravenously rather than intramuscularly. Methods: A multicentred double blind randomised prospective trial recruiting patients with severe local symptoms or systemic symptoms of RBS poisoning. Patients were randomly allocated to have antivenom administered intravenously or intramuscularly. A second dose was administered by same route if required. Subsequent doses were given intravenously. Those requiring 3 or more doses were given a short course of prednisolone. Patients were followed up within 48 h of discharge, at 7 days and one month. Results: Thirty-three patients were recruited from five institutions. Eighteen patients received antivenom intravenously and 15 intramuscularly. The average dose of antivenom required in the intramuscular and intravenous group, respectively, was 2.3 95% confidence interval (1.6-3.0) and 2.5 95% confidence interval (2.1-2.9). Both routes of administration were effective within one hour and there was no statistical difference in the improvement of pain scores. One dose of antivenom was effective only in 24% of cases. Adverse reactions such as arthralgia, nausea, local symptoms and generalized itch occurred in three patients of the intramuscular group and nine of the intravenous group.

Conclusions: There is no statistical difference between the intravenous or intramuscular route in the amount of antivenom given or speed of resolution of symptoms. At least two doses are required to be effective in over 50% of patients.

The emergence reaction and ketamine for paediatric procedural sedation in the emergency department Greg Treston, Gavin Fincher Introduction: The safe conduct of paediatric procedural sedation is a prerequisite skill for all Emergency Physicians (EPs), and parenterally administered ketamine has proven to be a drug which achieves paediatric sedation with a wide safety margin. However many EPs resist using it, stating they fear the complication of 'Emergence Delirium', which is said to be commonplace. Objectives: To determine the true incidence of emergence complications when using intravenous ketamine for paediatric procedural sedation, and to determine the relation of drug dose and patient age to emergence phenomena.

Paediatric patients aged 1-12 years who presented to the ED with a condition requiring procedural sedation were prospectively enrolled after written informed consent of a parent or caregiver. Intravenous ketamine was given as per existing departmental protocol, and cardiorespiratory observations recorded 5 minutely during the procedure and 10 minutely during the recovery period. As well, specific complications said to be characteristic of ketamine sedation were sought and recorded if they occurred. Fig. 2 ) and the proportion of Min2 presentations (r = 0.98, r 2 = 0.97, Fig. 3 ).

The bimodal distribution of complexity in relation to PICsum suggests that complexity may be better measured by partitioning emergency department presentations against a threshold number of procedures and investigations and consultations rather than against a list of specific high intensity procedures or investigations. A seemingly natural partition is identified at up to one procedure, one investigation and one consultation. Patient age is highly correlated with complexity and emergency department age distribution could potentially be used as a non-gameable proxy for complexity, particularly if used in conjunction with validated age vs. complexity tables.

A prospective trial comparing plaster cast and slab for immobilizing greenstick fractures in children Ed Oakley, Keat Ooi, Peter LJ Barnett, George Staubli Introduction: Torus or buckle fractures of the distal forearm are very common among children. The use of plaster of paris cast and backslab are both standard practices of management. Fracture outcome is similar in each group, but it unknown which is the preferred method of immobilization of the patient and family. Aims: We aimed to prospectively investigate the difference in parental satisfaction, ease of maintaining the plaster, and pain experienced with these two methods of treatment. Methods: 84 patients, aged 17-year-old-or less, presenting with torus/buckle fracture of the distal radius and ulna were prospectively randomised to management in a below elbow plaster cast or backslab. They were reviewed after 2 weeks of immobilization and followed up by Tel. 2 weeks after plaster removal. Results: Patients in the slab group experienced an average of 7.6 days of pain compared to cast patients with 4.8 days (P = 0.009). Similarly, the slab group experienced worse minor pain (P = 0.006) and lower arm function (P = 0.04) during the first 4 days. However, we found no difference in parental satisfaction, based on ease of plaster care, future use of treatment and comments. There were no complications in outcome. Slab immobilization was associated with better scores for versatility. Conclusion: We concluded that despite use of a slab being associated with increased intensity and duration of pain and reduced arm function while immobilized, both methods of treatment are equally acceptable to parents and patients, and safe to be used. Implementation of the Canadian C-spine rule in a community emergency department reduces X-ray ordering for alert patients with potential neck injury Debra Kerr, Anne-Maree Kelly, Luke Bradshaw Objectives: 1. To determine the impact of implementation of the Canadian C-spine rules on X-ray ordering for alert, adult patients with potential neck injury. 2. To determine whether implementation of the rule reduced time in hard collars for patients with potential neck injury. Methods: Before and after study of all adult patients presenting to the emergency department of Western Hospital with potential neck injuries who were immobilized in hard cervical collars. Data collected included demographics, mechanism of injury, X-ray rate and time in hard collar. Data analysis was by chi square test for proportions and Mann-Whitney U-test for continuous variables. Results: 211 patients were studied. The X-ray ordering rate decreased from 67% to 50% [25% relative reduction, P = 0.0191]. Time in hard collar also reduced from a median of 128 min to a median of 104.5 min [effect size 23.5 mins] but this did not reach statistical significance. Conclusion: Implementation of the Canadian C-spine rule reduced X-ray ordering by 25% and has the potential to reduce uncomfortable time in hard collars for patients. Future work needs to look at application by nurses and paramedics.

The potential impact of interventions to reduce times to thrombolysis Debra Kerr, Steve Goodacre, Anne-Maree Kelly Objective: To estimate the life-saving potential of interventions to accelerate the administration of intravenous thrombolysis for myocardial infarction. Methods: Design Prospective, observational study and subsequent modelling. Setting: Twenty hospitals and two ambulance services in Victoria, Australia. Patients: All patients transported to hospital by ambulance who subsequently received intravenous thrombolysis (N = 1147). Interventions: Regression models estimated the association between predictor variables age, gender, route of referral, symptom onset-to-call time, ambulance prenotification of the receiving hospital, emergency department thrombolysis, and the outcome, time-to-thrombolysis. Further modelling estimated the number needed to treat to save one life by several recommended interventions to reduce time delays. Main outcome measures: Components of the overall time to thrombolysis, modelled to estimate expected mortality. Results: Presentation via a rural hospital or general practitioner was associated with an approximate doubling of the onset-to-call time (2.08 and 2.30, respectively). Ambulance-hospital prenotification and emergency department thrombolysis reduced door-to-needle times by 21% and 27%, respectively. Modelling showed that each of the following interventions would be expected to save one life: 1069 hospital prenotifications, 714 cases of emergency department thrombolysis, 184 cases of prehospital thrombolysis, 340 cases to bypass their rural hospital, or 50 cases to bypass their general practitioner. Conclusion: Hospital prenotification and emergency department thrombolysis reduce time delays, although the mortality impact appears to be modest. Pre-hospital thrombolysis has the potential to save lives, although validation in real practice is required. Advising patients to call directly for an ambulance, rather than the general practitioner, has the greatest potential to save lives.

Alan Tankel, Glynn Derwent-Smith Introduction: It has been previously established that a significant amount of a clinician's time is spent on documentation. We postulated that the use of Pocket PC's would reduce documentation time thereby improving efficiencies in management, reducing waiting times and improving benchmarks. The project also examined the ability of the Pocket PC to improve patient care with the use of Clinical Decision Support tools. Study Objectives: This study was designed to assess the impact of Pocket PC's on time spent on documentation as well as on legibility and accuracy of notes. In addition, clinicians were questioned about the value of immediate access to reference data bases. Methods: Pre and post implementation audits were performed to compare the two systems. Clinicians were asked to complete a questionnaire addressing issues of Point-of-Care electronic technology and Clinical Decision Support as provided in this model. Results: Clinical data entry using computerized means in the recording of the Medical History, Examination, Investigations and Management strategies is more accurate and legible. This model is simple to use and time efficient. Concerns regarding flexibility of narrative were raised. Conclusions: Advances in miniaturizing computer technology provide the opportunity to deliver improved legibility and accuracy of medical notes, as well as a useful Clinical Decision Support model. Consists of ETT and EOA combined into one tube A single use device, inserted blindly, devised to provide sufficient ventilation whether the tube is placed in the trachea or oesophagus. Indications: As an alternative to endotracheal intubation in the prehospital and in-hospital setting. An esophageal detector device may also be used to determine which placement. Contraindications: Patients under 16 years of age or under 5 feet tall. Responsive patients with an intact gag reflex. Patients with known esophageal disease. Patients who have ingested caustic substances. Potential complications: Facial/dental trauma. May result in tearing of the cuffs. Blind insertion may lead to broken teeth entering the airway.

A large tube with an inflatable shallow mask at the distal end that forms a seal around the glottic opening Reusable; Can autocloave for at least 10 cycles Available in several sizes to cover all patient ages May be used to temporize before laryngoscopy and endotracheal intubation, or may be used as the definitive airway Indications: To provide ventilation and oxygenation when a patient cannot be endotracheally intubated and when percutaneous techniques are contraindicated or unable to be performed. Proper placement is with the mask with its tip in the upper esophageal sphincter, the sides facing each pyriform fossa, the upper portion of the mask posterior to the base of the tongue and the open end of the tube aimed directly at the glottic opening Replacement with an endotracheal tube should be considered as soon as feasible Contraindications: Pharyngeal/laryngeal abscesses Tumors Airway oedema Airway haematoma Potential complications Misplacement Seen in downfolding of the epiglottis, shallow or deep placement, torsion or folding of the mask Aspiration Does not guard against aspiration or regurgitation Air leak/hypoventilation/gastric insuffliation Seen in obese patients, those with high airway pressures, or with reactive airway disease or pulmonary oedema If high pressure cause gastric insufflation, the LMA should be repositioned Intubation Devices FAST-TRACH LMA (Intubation LMA) Version of LMA through which an ETT can be passed: Longer learning curve compared to LMA unique Lighted stylets: Allows for endotracheal intubation without direct visualization Can be used in neutral position and in patients with difficultly opening mouth Distorted anatomy makes placement more difficult Fiberoptic intubating laryngoscopes: Expensive Requires dry, clean airway Learning curve required Takes time to perform Percutaneous Devices General principles Cervical spine immobilization is as critical when using one of these techniques as when performing usual airway maneuvers in the patient who may have a spinal injury. When using percutaneous techniques, aseptic technique and local anaesthesia should be used whenever possible and appropriate.

Uses a Seldinger technique to percutaneously place cricothyrotomy tube PerTrach A prepackaged, single-use kit which allows for percutaneous access to the trachea. Uses a splittable needle and a Seldinger technique provides rapid percutaneous access to the airway. Comes in both adult (5.6 mm I.D., 7.4 cm length) and paediatric sizes (three sizes, depending on age).

Rapid percutaneous airway management in patients unable to be endotracheally intubated.

Altered neck anatomy Coagulopathy Potential complications: Bleeding Infection Perforation of posterior trachea

Single use colourimetric end-tidal CO 2 detector for in line use. Detects approximate ranges of end-tidal CO 2 by colour comparison.

To determine tube placement in patients with spontaneous circulation after intubation and during transport. To detect approximate ranges of end-tidal CO 2 . Can continue to observe colour changes for up to 2 h.

Yellow -tube in airway Purple -tube not in trachea of patient with adequate perfusion Tan -need alternative ways to check placement of tubeconsider reintubation AmbuTubeChek and AmbuTube Chek -B Disposable, single-patient use devices to determine endotracheal tube placement Based on anatomy, not cilrculation; may be more accurate than colourimetric testing in the patient without circulation Accuracy has been reported as high as 100% Ambu-TubeChek -Uses a syringe attached to an ETT adaptor Ambu-Tube Chek-B -Uses a bulb attached to an ETT adaptor DISCLAIMER: This lecture is not intended to be a comprehensive review of all products available to aid in airway management.

The priority for monitoring in the future will not just be to assist Emergency Physicians in evaluating and treating their patients but in keeping patients out of the hospital environment altogether. The rapid developments in areas such as silicon technology and wireless communications means that monitoring devices will continue to shrink in size, enhance their capabilities and perhaps even become relatively cheaper. The session will discuss current and future trends in medical monitoring with a particular emphasis on how future technologies will streamline every step of the patient care process. long before the patient even reaches the Emergency Department.

Emergency Departments use and generate enormous quantities of data, which can only be efficiently managed electronically. Although often broadly described as clinical or management information, there are really three overlapping categories of data: individual patient related, departmental management information, and support. Changes in information technology are notoriously difficult to predict -the core functionality of ED information systems has not altered in a decade, whilst the internet has invaded every aspect of hospital medicine. Increased decision support and patient data access were widely predicted for many years, but the unifying interface of the internet browser was not, and many EDs still have insufficient desk real estate for their computers. Current technologies such as radiology PACS and medical records scanning will be implemented in from the large to the small centres for economic reasons, with the benefit of improved data availability. Non-sensitive data including educational material, decision support and administrative policies will be available everywhere through intranet and internet. Wireless interfaces and tablet PCs will play a larger role, but adoption is likely to be slow. Bedside data entry only makes sense as part of an integrated electronic medical record, and, despite predictions, this has proven as problematic as voice recognition. Privacy concerns become important once electronic data is transferred between institutions. As the market matures, the trend to commoditization of simple software will continue, as will the pressure on vendors to meet standards for interoperability. With more complex integration, issues of access control will increase.

Michael Schull An informal session in which Dr Schull's experience with MSF will be reviewed as a backdrop to a discussion on the role of medical aid organizations and aid workers in a changing world, and the particular strengths and weaknesses emergency physicians can bring to medical relief work.

A medical myth is a commonly held belief, repeated frequently in lectures or rounds that turns out not to be supported in the literature or common sense. Medicine, I suggest, is mostly founded on myth. Many myths ultimately have some basis in truth, but many do not. We should hold onto the truths with a very light grip. Examples of prevalent cardiology myths include: heparin is a very effective therapy in acute coronary syndromes, beta-blockers are well studied in unstable angina, there have been great advancements in thrombolytic therapy since 1988. The most important myth in Emergency Cardiology is that the large trials of apparently ED based therapy directly relate to the patients we see in the Emergency Department every day. The use of Clopidogrel, IIb/IIIa inhibitors and nitroprusside in severe aortic stenosis inhibitors will also be used as examples of myths in Emergency Cardiology.

Osler passed on to medical lore the dictum that 'More is missed by not looking than by not knowing'. However, many of the physical examination pearls taught in medical school have never been properly evaluated. The investigation of the precision and accuracy of the clinical examination has lagged behind that of laboratory tests. This presents a quandary: should all signs not validated in rigorous studies be cast aside, or should those not yet disproved be used and taught? However, studies have shown that up to 88% of diagnoses are established at the conclusion of the history and physical examination. So, what do we know about the accuracy of the clinical examination? Using likelihood ratios, a review of the examination findings in critical emergency medicine diagnoses demonstrates that: • the 3 classic meningeal signs do not have diagnostic value • abdominal palpation is unreliable for detecting AAA • rectal examination is unnecessary if patients are tested for rebound tenderness • bimanual pelvic examination is unreliable • no combination of history and examination findings confirm the diagnosis of pneumonia • blood chemistry testing is required to confirm hypovolaemia • individual symptoms and signs are not useful to diagnose DVT • physical findings associated with thoracic aortic dissection are present in < 1/3 of cases Robust scientific conclusions regarding the clinical examination are rarely available to assist the emergency physician. Clinicians must critically review whatever data are available and supplement this with their judgement, training, and experience in decision making.

Steve Dunjey Management of traumatic injuries is largely based on historically established algorithms, and many of the therapies we use lack an evidence base. Some treatments which have wide acceptance may not confer any benefit at all. This interactive session will explore 5 sacred cows in Trauma management.

Myths regarding diagnostic tests and their use are common in clinical medicine. Apart from the frequent overestimation of the power of investigations to diagnose serious disease in the ED (such as cardiac biomarkers) myths regarding the application of diagnostic tests may also impair appropriate clinical decision making. Phrases such as 'diagnostic certainty' and 'establishing a diagnosis' give the impression a diagnosis can be proven absolutely, which is rarely the case. Despite advances in diagnostic imaging, significant discrepancies still exist between pre and post mortem diagnoses demonstrating that, even in the presence of severe disease, considerable diagnostic uncertainty may still exist. The way in which clinical decisions are made are also the subject of myth. The model analytical physician who makes their decisions on Bayesian principles is mostly myth, with heuristics, biases and pattern recognition more commonly employed in decision making. A lack of information regarding prior probability estimation, broad confidence intervals, and the questionable validity of existing data restricts the usefulness of a Bayesian approach to diagnosis. In addition there is a lack of information regarding test performance across normally encountered ranges, and intrinsic biases in probability estimation all further hinder the potency of this new Bayesian deity. We should not lose faith because of the wounding of our superhero. Whilst we have our limitations, these can be overcome. What we also have in our favour is an amazing range of senses and the capacity to integrate information provided in multiple different formats. The biggest myth of all is that we cannot learn.

Introduction: Strokes have long been known to interrupt cortical regulation of the cardiovascular system, as evidenced by ECG arrhythmias post stroke. Thrombolysis now exists for ischaemic stroke -but considerable delays occur with getting potential patients reviewed. Study Objectives: Are anterior haemorrhagic strokes associated with ECG arrhythmias more than other stroke types? Do patients with a stroke in the UK attend sooner and receive medical evaluation faster through an Emergency Department (ED) than through a Medical Admissions Unit (MAU)? Methods: Prospective observational study of all patients with acute stroke admitted Addenbrooke's NHS ED and MAU. Data reviewed included patient demographics, ECGs, brain CT/MRI scans, previous and presenting illnesses. Results: 90 patients studied -48 ED, 42 MAU. 70% of patients had abnormal ECG on presentation, new changes in 24%. Most common abnormalities were ischaemic changes (52%), AF (24%) and bundle branch block (14%). Multiple arrhythmias seen in 26%. Follow-up ECGs revealed additional new arrhythmias in 45%. Anterior haemorrhagic strokes were not shown to generate more arrhythmias. ED patients arrived over 6.5 h earlier than MAU patients (median time 1.6 h vs. 8.2 h, P-value < 0.001). Increasing age, previous stroke or ischaemic heart disease not associated with longer delay. No difference in time to medical review from arrival. Conclusions: ECG arrhythmias are common post stroke and dictate intensive monitoring of these patients. Unacceptable delays occurred with the time to arrival for our MAU patients -excluding them from the potential benefits of thrombolysis therapy.

Introduction: Based on strong evidence, tissue plasminogen activator for sub3 h ischaemic stroke is likely to be licensed in Australia soon. Appropriate triage and rapid assessment of these patients is critical if thrombolysis is to be effectively and safely administered. Study Objectives: To determine if acute stroke assessment in a large ED is currently geared towards hyperacute stroke treatment.

We reviewed the John Hunter Hospital Stroke Database, focusing on the ED recording of variables critical to acute stroke assessment, including time to symptom onset, stroke severity, and acute blood glucose, as well as the triage category allocated. All patients with acute ischaemic stroke presenting to John Hunter Hospital, NSW, Australia, between 1999 and 2003 were included. Results: There were 669 patients. Time of symptom onset was recorded in 187 (28%) patients. Of these, 132 patients had stroke onset within 3 h. 19/132 patients (14%) who were recorded as presenting within 3 h were allocated a triage category of 1 or 2. Blood glucose was recorded in the ED in only 368 (55%) of patients. Despite this, an elevated acute blood glucose (> 8 mmol/L) still predicted a worse outcome, with a greater chance of being dependent at discharge (chi 2 = 4, P < 0.05). Acute stroke severity, measured by the Scandinavian Stroke Scale, a simple standardized scale, was recorded in 58 (9%) of patients. Conclusion: Time of stroke onset was recorded in just 28% of patients, and only a small proportion were a high triage priority. As treatment is time critical, time of stroke onset should be determined urgently and patients presenting within 3 h should be triage category 2. Our study suggests that this is not current practice in Australian EDs. Furthermore, acute blood glucose and stroke severity, which predict stroke prognosis and response to thrombolysis, need to be part of the routine ED assessment. Major education and practice change are required.

Aim: To evaluate the pattern of missed radiological abnormalities in patients discharged from the Emergency Department (ED) in a tertiary teaching hospital. Methods: A prospective audit of all formal radiological reports delivered to the ED for review from November 2002 and May 2003. This included plain xrays, CT scans and ultrasound reports. Results: Over the seven-month study period, a total of 10916 imaging requests were made from the Emergency Department. Of these 186 reports (1.7%) were considered to have an abnormality not detected prior to the patient's discharge home from ED. The most common abnormalities were 45 upper limb fractures (24.2%), 38 lower limb fractures (20.4%) and 30 chest abnormalities (16.1%). The average time between the imaging procedure and the report review was 6.4 days. Of the 186 patients, 18 (9.7%) returned to the ED for review. Only 4 patients (2.1%) were admitted to hospital. Two patients were admitted under the neurosurgical team with CT brain abnormalities. No patients with limb injuries required admission. Eighteen patients (9.6%) who did not return to the ED had specialist consultation arranged by their local doctors at the time of the report review. Conclusion: Radiological interpretation by ED staff is generally accurate, with most missed diagnoses being suitable for outpatient follow up. Discharge letters to the patient's local doctor for following up of the formal imaging report may decrease the delay in report reviewing time and subsequent follow up.

Elissa Kennedy-Smith Objective: To test my observational theory that the investigation of pulmonary embolism at my institution was significantly varied, and, often, did not appear to be following recommendations from the current literature.

A retrospective chart review of 101 consecutive patients who had had a V/Q scan performed by the Nuclear Medicine department of RNS hospital in the months of May and June 2002. Results: A total of 31 patients (30.7% of the total) were deemed to need no further investigation based on their pretest probability (PTP) and V/Q scan results being concordantly low or concordantly high. Of the remaining 70 patients, who the current literature suggests needed further investigation, only 41 had any such investigations, leaving 29 patients (28.7% of the total group studied), without the diagnosis of P.E. having been adequately made or ruled out. Conclusion: There is still a significant amount of variation in the investigation of pulmonary embolism at my institution, and a number of patients are still being underinvestigated for this potentially life-threatening condition.

Introduction: A new rapid automated ELISA d-dimer assay ('STA Liatest') replaced the previous whole blood assay in the author's hospital in late 2001. Laboratory and management studies have reported Liatest to have equivalent accuracy to 'gold standard' ELISA tests but this had not been validated in our ED population. Objective: To demonstrate the negative predictive value of a new diagnostic test in excluding pulmonary embolism in a local ED population. Methods: A retrospective cross-sectional analysis. All Liatest assays that were ordered from the ED in conjunction with standard PE investigations (either or both V/Q scan or CT pulmonary angiogram) over a 12-month period were reviewed. PE was diagnosed or excluded by a combination of calculated clinical probability, V/Q, CTPA, Doppler venous studies, and minimum 3 month follow up (by chart review or GP/patient contact). D-dimer result was compared to independent PE work-up result to determine test accuracy. Results: 324 cases were identified with 48 diagnosed as having PE, giving a prevalence of 15%. Test sensitivity was 98%, specificity 44% and negative predictive value 99%. Conclusion: The Liatest d-dimer assay has proven its high sensitivity and negative predictive value in a local ED population. Accuracy was similar to previously published studies. A negative Liatest result can be used to exclude the diagnosis in a defined group of patients presenting to the ED with suspected pulmonary embolism.

Objective: To measure the effects of impedance plethysmography performed by clinicians in the Emergency Department (ED) for suspected cases of DVT on time spent in the ED. To determine the feasibility of providing bedside impedance venous plethysmography run by ED clinicians. Methods: Prospective study of patients presenting with suspected DVT using a historical control group. Results: Fifty-five patients were evaluated with the impedance plethysmography machine. Fifty-two patients evaluated with D Dimer were used as an historical control. The mean ED time for D dimer patients was 9.10 h compared with 4.42 h for the impedance plethysmography group. Application of the t-test found that d dimer cycle times were significantly greater than venometry times (P < 0.0005). Total time as an ED patient included return visits for anticoagulation until definitive testing was available found that the d dimer patients spent a mean time of 33.58 h within the ED and impedance plethysmography patients a mean of 13.54 (P < 0.0005). Conclusion: This study demonstrated that at this institution the use of near patient testing -impedance plethysmography when applied to patients with suspected DVT reduced time within the ED and decreased the number of cases requiring Doppler ultrasound examinations and prophylactic anticoagulation.

The utility of cranial CT in poisonings admitted to the intensive care unit Danielle Unwin, Andis Graudins Introduction: The utility of cranial CT in the assessment of poisoned patients requiring ICU admission is not well delineated. Aims: Define the incidence of abnormal cranial CT and any clinical or historical indicators which predict the necessity for CT in poisonings admitted to a tertiary referral hospital ICU. Methods: Retrospective, descriptive study of poisoned patients admitted to ICU with admission or discharge diagnoses of poisoning from 1/1/97 to 1/3/03. 229 patient records were reviewed, 55 were excluded. Data analysed included: type of poisoning, clinical factors, length of stay and outcome. Patients were divided into cranial CT and non-cranial CT groups. Results: Of 174 presentations, CT was performed in 48% (84). CT patients were more likely to present with unrecognized poisoning (40% vs. 6%, P < 0.0001), had lower median GCS (6 vs. 7, P = 0.012), evidence of trauma (6.4% vs. 0%, P = 0.024), greater length of stay (P = 0.03) and higher morbidity and mortality (20% vs. 6%, P = 0.026). 11.9% of CTs were abnormal (acute abnormalities in 4.7%). Acute CT changes were all related to hypoxic brain injury. No CTs required neurosurgical intervention. Pre existing neurological disease was the only factor predicting the likelihood of an abnormal CT (OR 2.7, P = 0.02). Conclusions: Abnormal cranial CT results are uncommon in unconscious poisoning patients and did not necessitate neurosurgical intervention in this study. The ordering of head CT was more common with unrecognized poisoning, focal neurologic signs, previous neurologic disease, and signs of trauma. Prospective evaluation of these may assist in developing guidelines for cranial CT in poisoning. Lignocaine, ethyl chloride and nitrous oxide reduce the pain of IV cannulation -results of a randomised controlled trial Sarah Carr, PA Robinson, S Pearson Methods: RCT in which the cannulators were not blinded to the study agent. Patient asked to mark on Visual Analogue Scales (VAS) both pain of application of pretreatment and pain of cannulation. 291 patients were randomised into one of four groups: IV cannula inserted after either 0.1 mL intradermal lignocaine, ethyl chloride sprayed for 5 s at approx 15 cm distance, Entonox (nitrous oxide/ oxygen 50 : 50) inhaled for 1 minute or no pretreatment. Patients were selected from triage category 3-5, 16 years and older, able to give informed consent and deemed to require an iv cannula as part of their workup/treatment by their attending Doctor. Patients were excluded if possible diagnoses included bowel obstruction or pneumothorax. Data was collected on patient demographics, diagnosis, seniority of cannulator (consultant, registrar, housesurgeon), site of cannulation, iv size & number of attempts. Setting: Christchurch Hospital Emergency Department -an urban level one emergency department. Results: Comparisons of pain scales of the four groups showed that lignocaine was superior in reducing pain of cannulation (P < 0.001) overall, followed by ethyl chloride and entonox being better than no pretreatment (no significant difference between ethyl chloride and entonox). Age & gender of patient, presence of pain precannulation, size of cannula, or seniority of cannulator made no significant difference in VAS scores. Lignocaine was judged to be the most painful pretreatment (median VAS 0.5) followed by ethyl chloride (median 0.1). Entonox and 'No pretreatment' had median pain scores of zero. Conclusions: This RCT has again demonstrated that while intradermal lignocaine can be painful to apply, it significantly reduces the pain score for insertion of iv cannulas. This study proposes that the two agents entonox and ethyl chloride while not as effective as lignocaine in reducing cannulation pain, are significantly better than no pretreatment and are much less painful to apply than lignocaine -thus another option in reducing distress and pain caused by iv cannulation in the emergency department setting.

Marta Malkiewicz, Anna Holdgate Introduction: Arterial blood gas sampling (ABGS) is a common painful procedure performed in the Emergency Department (ED). Previous studies have suggested that infiltration of local anaesthetic (LA) may reduce the pain of this procedure. Study Objectives: This trial aimed to examine whether the use of LA reduced the level of pain reported by patients during ABGS in the ED, and to determine whether the injection of LA makes ABGS more difficult for the operator. Methods: Adult patients, who presented to the ED and required ABGS as part of the usual management, were randomised into two groups. Group one received 0.25 mL 1% lignocaine infiltration 1 minute prior to radial artery ABGS, group two had ABGS performed without LA. Patients rated the procedure on a 10-point verbal pain scale, and the number of attempts required to obtain an arterial sample was recorded. Results: 102 patients were recruited, 54 of whom received LA. The mean pain score for patients receiving LA was 2.3, compared with 2.7 for patients who did not receive LA. This difference was not statistically significant (P = 0.13). The ABG was successfully obtained on first attempt in 75% of patients receiving LA, compared with 88% in the second group. This difference was also not significant (P = 0.14). Conclusions: Although there is no evidence that LA makes ABG more difficult, we found that LA made no significant difference in the level of pain reported by patients. This study does not support the use of LA in ABGS in ED patients.

James Mallows, Betty Chan, Robert Dowsett, Andis Graudins Introduction: The MIMS contains TGA approved product information supplied by manufacturers. It is not designed as a toxicology reference, however, is widely used by health care professionals. Objectives: To determine how widespread the use of MIMS is as a toxicology reference. To evaluate the quality of poisoning management advice it contains. Methods: Firstly, a survey of 500 consecutive calls to the NSW Poison Information Centre (PIC) was undertaken asking health care workers which toxicology references were consulted prior to calling and which references they would use if the PIC were not available. Secondly, a consensus opinion for poisoning management was obtained for 20 common poisonings determined from the Westmead Hospital Toxicology Database by review of five current toxicology references for contra-indicated treatments, ineffective treatments and specific recommended treatments and antidotes. MIMS poisoning management advice was then compared to the toxicology 'gold standard'. Results: 276 doctors and 222 nurses were surveyed. 22.8% of doctors and 6.7% of nurses consulted MIMS prior to calling the PIC. 26% of doctors and 39% nurses stated they would use the MIMS for poisoning management advice if the PIC were not available. For the 20 drugs assessed, 12 contained inaccurate poisoning management: 2 recommended contra-indicated treatments, 2 recommended ineffective treatments and 10 omitted specific treatments or antidotes. Conclusion: The MIMS is a commonly used toxicology reference. It contains a number of significant inaccuracies pertaining to management of common poisonings presenting to emergency departments and should not be used as a primary reference for poisoning advice.

Nicola Walsham, David McD Taylor, Lufee Wong, Simone Taylor Introduction: Complementary and Alternative Medicines (CAMs), while popular, have been associated with serious adverse reactions and drug interactions. Objectives: To assess the prevalence of CAM use among ED patients, side-effects, interactions with prescription medications, and patients' perceptions regarding CAM safety and efficacy. Methods: A cross-sectional, questionnaire-based survey of ED patients in a major tertiary referral hospital. Data analysis was descriptive.

Results: 404 patients were enrolled: 220 males (54.5%), mean age 50.6 years. 271 (67.1%) patients thought CAMs were safe, 85 (21.0%) that CAMs were more effective than prescription medications, 177 (44.1%) that CAMs were 'drug free' and 115 (28.5%) that CAMs were safe combined with prescription medications. 276 (68.3%) and 182 (45.0%) patients had taken CAMs in the previous year and week, respectively. In the previous week, the most commonly used were Chamomile (97 patients), Green Tea (44), Ginger (35), Garlic (35) and Ginseng (34). GPs were aware of the use of these CAMs in fewer than 25% of patients. Only 12 (3.0%) patients had told their ED doctor of their CAM use in the previous year. Reported side-effects included thrombocytopenia (unidentified CAM, 1 patient), anticholinergic poisoning (Jimsonweed, 3 patients) and palpitations/anxiety (Guarana, 18 patients). Drug interactions included Garlic/aspirin and Garlic/warfarin (bruising). Conclusion: CAMs are widely used. Most are not associated with side-effects but can be toxic. Interactions with prescription medicines occur, and CAM use should be reported to doctors to avoid this. ED doctors should specifically ask about CAM use.

Objective: To determine if chronic alcohol abuse/dependence increases the risk of hepatotoxicity from paracetamol poisoning in the general overdose population. Methods: All paracetamol overdoses presenting to Hunter Area Toxicology Service were reviewed. Cases were included if > 2 g had been ingested for deliberate self poisoning. The following data was extracted: (Age, gender, dose, alcohol coingestion, alcohol dependence, history of alcohol abuse, time to N-acetylcysteine administration, decontamination). Outcomes were hepatotoxicity defined as AST/ALT > 1000 IU/L and pH < 7.3. Results: From January 1987 to August 2002, 1764 cases of paracetamol poisoning were included. Of these, 44 [Mean age 33 (SD 17), 41% male] developed hepatotoxicity. Of patients with hepatotoxicity 11% had alcohol dependence compared to 6% of the other 1720 cases without hepatotoxicity which was not significantly different (P = 0.14). There was a significant difference in mean paracetamol dose and time to N-acetylcysteine (NAC) administration between those with and without hepatotoxicity (P < 0.01). Multivariate analysis demonstrated that only paracetamol dose ingested [OR 1.07, 95% CI: 1.04-1.09 per 1 g] and NAC administration > 16 h after ingestion [OR 44, 95% CI: 9-207] were significant predictors of hepatotoxicity. Multivariate analysis also showed that paracetamol dose and time to NAC were the only significant predictors of pH < 7.3. Conclusion: Chronic alcohol dependence did not cause an increase in the likelihood of developing hepatotoxicity or acidosis following acute paracetamol poisoning. Paracetamol dose and time to treatment with NAC were shown to be the only significant predictors of worse outcome similar to previous studies.

Accuracy of a tympanic thermometer in determining the temperature of crystalloid fluids heated in a microwave oven Andrew Dyall Objective: To determine the accuracy of a tympanic thermometer in determining the temperature of crystalloid solutions after warming in a microwave oven. Methodology: One litre bags of normal saline and compound sodium lactate solution (Hartmann's solution) had their temperatures measured at room temperature, normothermia and at approximately 43°C. Their temperatures were sampled 10 times at each temperature by a FirstTemp Genius 3000 A tympanic thermometer and compared to a thermistor immersed in the fluid. This experiment was performed with the tympanic thermometer in both the oral-equivalent and core-equivalent modes. Results: The correlation coefficient for all groups was > 0.99. For the warmed solutions, with the tympanic probe in the oralequivalent mode the mean difference in reading for the tympanic thermometer was 1.15°C less than the thermistor (95% CI 1.09 -1.20). The 95% limits of agreement were 0.90-1.40°C. For Hartmann's solution the mean difference was 1.3°C less than the thermistor (95% CI 1.08-1.5). The 95% limits of agreement were 0.75-2.05°C. With the tympanic probe in the core-equivalent mode the results for saline were: mean difference 0.36°C less than the thermistor (95% CI 0.17-0.55), 95% limits of agreement − 0.20-0.90°C. For Hartmann's solution the mean difference was 0.51°C (95% CI 0.42-0.60). The 95% limits of agreement were 0.20-0.85°C.

The tympanic thermometer is a useful tool for measuring the temperature of warmed crystalloid solutions. The core-equivalent mode is more accurate than the oral-equivalent mode.

Introduction: The occurrence of congenital diaphragmatic hernia [CDH] is usually detected in infancy. It has a high mortality and mandates early operative repair. However, there have been an increasing number of cases reported in adults. Few, if any, of these reports have been published in the emergency medicine literature. A case of CDH is presented in a lady who has respiratory distress, shock and abdominal pain. No history of current or remote trauma was elucidated. Tension pneumothorax was considered as a diagnosis. Urgent needle decompression was not performed. Instead an urgent chest X-ray was ordered. Interpretation of the X-ray was not simplistic but it was felt to show massive mediastinal shift towards the right caused by gas-filled structures on the left. Laparotomy revealed the entire stomach, splenic flexure and spleen were located in the left hemithorax. No organ ischaemia was identified. These were reduced and a large posterior congenital diaphragmatic hernia was noted and repaired. Literature review: A comprehensive search, up to the time of submitting this abstract, revealed a small number of reports of adult CDH mainly in surgical, radiological and respiratory related journals. Particular reference will be made to those reports of emergent life threatening presentations. Conclusion: Presentations of CDH in adults are rare but they may present as undifferentiated emergencies and resuscitation scenarios. Incorrect diagnosis may lead to complications from unnecessary procedures and delayed diagnosis. It is hoped that this presentation will increase the awareness of this condition amongst the emergency medicine community.

We report a patient who required general anaesthesia for the repair of a simple finger injury, after repeated injections of lignocaine failed to provide digital nerve block. There is a family history of this resistance, with his father also reporting failure of local anaesthesia on several occasions.

To document this resistance we performed an ethically approved, prospective, double blind study involving these patients and volunteer controls. We injected several local anaesthetic agents into the skin of the forearm, then applied painful stimuli to the skin at these sites. Subjects recorded pain using a visual analogue scale, documenting the efficacy of each drug in providing anaesthesia. Resistance to lignocaine as a local anaesthetic has not been described before in the literature. A literature search identifies one case report, in a patient with complex regional pain syndrome, but which does not match this case. The cause of this resistance is unknown, and will require further study. This lignocaine resistance is an uncommon but important reason for failure of local anaesthesia.

John Mackenzie, G Arendts, J Lee Introduction: Acute short stay units run and staffed by the Emergency Department (ED) are increasingly used as a strategy to manage patients requiring hospitalization for brief periods. There is little published literature regarding the follow up of these patients. This study was conducted to assess, after discharge, patients treated in the Emergency Medicine Unit (EMU) at our hospital. Study Objectives: To determine: 1. The adequacy of discharge planning from the EMU 2. The incidence of unplanned medical intervention following discharge from the EMU 3. Patient understanding of, and satisfaction with, the care received in the EMU Methods: All patients discharged home from the EMU over a threemonth period from April 2003 were surveyed by telephone or mail using standardized preformatted questionnaires. No identifying patient data was collected, and results were stored on an electronic database for statistical analysis. Results and Conclusions: 700 patients were discharged from the EMU and were eligible for inclusion in the study. Data collection is ongoing with a current response rate of 25%. Of these, 98% received a discharge letter, and 94% received adequate discharge advice. Only 4% felt their stay in the EMU was of no benefit, however, after discharge 50% made unscheduled visits to their GP and 10% were readmitted to hospital. 60% were inaccurate in the assessment of the level of seniority of their treating doctor. Overall patient satisfaction was high and comparable to that with care in the ED and general hospital wards.

Introduction: Transport of critically ill ED patients within the hospital (for investigation or to an inpatient unit) is potentially hazardous. Little research in this area has been undertaken although there are reports of up to 71% of patients suffering adverse events, often equipment related. Objectives: We examined the frequency and nature of unexpected events during intrahospital transport of ED patients. This will guide interventions to improve transport safety. Methods: A prospective, observational study of 300 critically ill patients was undertaken. A data collection form, completed by the accompanying doctor, collected physiological, equipment and invasive line related events. Consequent interventions or adverse outcomes were recorded. Results: 101 patients have been enrolled to date. 74 transports (73%) were associated with a total of 218 unexpected events. 165 events (76%) related to equipment (oxygen saturation probe displacement, ventilator leaks, ECG monitor artifact). 60 events (28%) involved lines (IV and power cord tangles, arterial line becoming caught). 53 events (24%) were related to patient physiology (hypotension, desaturation, inadequate sedation). 175 events (80%) required intervention (repositioning equipment, untangling lines, administering fluid bolus). 11 transports (10%) resulted in adverse outcomes (severe hypotension, inadvertent extubation, raised intracranial pressure). Discussion: A large number of patient transports experienced unexpected events, most of these being equipment related. These events usually required intervention, but infrequently resulted in an adverse patient outcome. Guidelines for the safe intrahospital transport of ED patients needs reconsideration.

More than half of paediatric emergency department after hours presentations are due to GP unavailability Alexander Hopper, Matthew O'Meara, Gillian Heller Introduction: One of the causes of Emergency Department (ED) overcrowding is the after hours use of paediatric EDs as primary care clinics when General Practice (GP) surgeries are closed. Objectives: To quantify the extent of after hours attendances in a Paediatric ED caused by GP unavailability. Methods: A prospective, cross sectional survey, using a selfadministered questionnaire, of all families presenting to the ED after hours over one week. Demographic and triage data and reasons for presentation were collected. A 'convenience presentation' was identified when all of the following criteria were met: the child was triaged into category 4 or 5, the parent stated the child's complaint was mild, the parent did not have a preference for ED treatment for the presenting condition, the child was not referred by a doctor, the child was resident in the metropolitan area of Sydney, and the child did not suffer from a chronic condition. The data were analysed using SPSS version 11.5. Results: Of 352 eligible families, 182 questionnaires were satisfactorily completed, of which 111 (57%) indicated they attended because their GP was unavailable, even though 172 (95%) had a regular primary care provider. However, only 9% of attendances were identified as convenience presentations. Conclusion: Although the majority of after hours presentations were related to GP unavailability, only a small proportion of presentations could safely be diverted to other providers. ) had primary psychiatric or altered conscious states due to drugs and alcohol as the presenting problem. At least 90 of these 500 frequently presenting patients died during the study period. Conclusion: The majority of the presentations by the heaviest users of an ED in a adult inner-city teaching hospital are not suitable for diversion to General Practice. Attempting diversion of the heaviest repeat ED users to General Practice in this setting may not be successful due to the severity, acuity and nature of casemix of the presentations and would have minimal impact on crowding in similar emergency departments.

The impact of a physician-driven rapid emergency assessment team on the key emergency department clinical performance indicators Alexander Tzannes, Adam Chan, Anna Holdgate Objectives: To assess the impact of the introduction of an Emergency Physician (EP) specifically rostered to provide rapid initial assessment of Emergency Department (ED) patients in a tertiary referral hospital. Methods: An additional EP was rostered between 10 : 00 and 18 : 00 h on selected weekdays to provide rapid assessment after patients were triaged. Data was collected prospectively to measure waiting times, lengths of stay and the proportion of patients who did not wait (DNW) for medical assessment. Comparison was made between weekday shifts when a rapid assessment EP was on duty (REAT shifts), and the weekday shifts 10 : 00-18 : 00 with normal ED staffing (non-REAT shifts). Results: A total of 59 REAT shifts and 43 non-REAT shifts were identified during the 5-month period from February to June 2003, during which 5390 patients presented. The number of presentations and the distribution of triage codes were similar between the two groups. During REAT shifts, the average waiting time for triage codes 3 and 4 were significantly shorter (3 and 6 min, respectively) than the non-REAT shifts. For the 2161 patients who were admitted to hospital, the decision to admit was made on average 36 min earlier during REAT shifts compared with non-REAT shifts. There was no significant change in the length of stay for patients who were discharged from ED, and no difference in the proportion of DNW. Conclusion: Rapid assessment by EP has improved the waiting times for triage code 3 and 4, and reduced the decision times for admitted patients.

Paediatric burn injury and assessment in children less than 5 years at an adult tertiary level emergency department: how good are we at child at risk assessment? Andrew Watson, Anne Piper, John Sammut Introduction: Liverpool Hospital Emergency Department (ED) is one of the busiest trauma centres in Sydney. Total presentations for 2002 were 45 475 with 11 171 being children. Burns are the fourth most common childhood injury requiring hospitalization in Australia, most common in children aged less than 5. Literature suggests that from 1.2 to 25% of childhood burn injuries are nonaccidental. Emergency staff have a critical role in detecting Non-Accidental Injury (NAI), especially in ambulatory presentations. This may represent the only opportunity for intervention and possible prevention of re-abuse. Study Objectives: To evaluate the quality of performance of an adult tertiary level centre in assessing childhood burns: Specifically: 1. Assess adequacy of burn injury documentation in the ED 2. Determine whether NAI was considered and appropriately referred.

3. Was quality of assessment and treatment affected by the ED doctor's seniority? Methods: Retrospective analysis of 100 consecutive cases of children < 5 years who presented to Liverpool ED 2000-01 with Burns Injuries. Results: Documentation overall was poor. 63% were scald injury. NAI was considered in 14%, referred in 7% and diagnosed in only 2% of cases. As stated up to 25% may have been NAI. In cases of assessment by an ED Consultant, the trend was toward a more thorough assessment. Conclusions: To effect positive change in an adult ED assessing paediatric burn injuries, documentation needs improvement. Further education regarding NAI should be a priority, especially for junior staff. Results: 354 cases were included. 85 used no form, while 269 used a preformatted form. The use of the form showed improvement in documentation in recording of; past history 86% to 98%, past anaesthetic 9% to 76%, fasting state 11% to 67%, consent 11% to 75%, pulse oximetry 40% to 85%, blood pressure 35% to 78%, conscious level 22% to 59%, oxygen used 14% to 32%, time medication given 82% to 95%, post procedure instructions given 5% to 27%. Two doctors involved improved from 44% to 72%. Conclusion: The introduction of a preformatted form has significantly improved the documentation for conscious sedation, facilitating Auckland Hospital Emergency Department to meet the ACEM standards.

As an emergency registrar, a devastating adverse event occurred on my shift. This started my questions on quality and safety in our work place. I completed a three month term with Central Coast's Quality Resource Unit. My objective for the term was to improve medical quality programs for our area health service. As a result, I have learnt the essence of quality and now have a passion to further its cause. My term was divided into three stages. Firstly, I interviewed a clinician from each specialty to ask their opinion about quality programs in their specialty. I documented their meetings, how useful they were in improving patient care, problems and impedances in implementing quality improvements. I then sought what were the best ways to carry out quality programs and what other health services were doing. This consisted of talking to experts in the field, attending conferences, researching journals and visiting other hospitals. With this information I reached a conclusion as to what our Area needed to improve medical quality programs. We have a long way to go. I presented my findings to our area executives and our quality councils. My recommendations are being considered for approval. My goal is to help emergency departments and other specialties to improve on their quality programs. Thus making a safer environment for the patient and its staff. My term with the Quality Resource Unit has inspired me to continue with quality work and my involvement has promoted awareness and enthusiasm amongst my peers.

The new antidepressants have largely replaced the older traditional groups due to their improved safety profile and fewer adverse effects. These agent include the selective serotonin reuptake inhibitors; citalopram, fluoxetine, fluvoxamine, paroxetine and sertraline, the serotonin/noradrenaline reuptake inhibitor; venlafaxime, the heterocyclic; mirtazapine, and other miscellanous antidepressants; bupropion and nefazodone. These agents have differing mechanisms of action which determine the clinical syndromes seen in overdose. The emergency physician must be familiar with these new agents as they are now among the commonest pharmaceuticals in overdose. This presentation discusses the pharmacology and current experience in overdose. An approach to assessment and management is discussed.

The new atypical antipsychotic agents have now replaced the older typical agents as first-line agents in the management of schizophrenia largely because of their superior adverse effect profile. These agents include the dibenzoxazepines; clozapine, olanzapine and quetiapine, the benzisoxazole; risperidone, and the benzamide; amisulpride. The different agents have varying affinities for multiple CNS receptors which determine the clinical syndromes seen in overdose. For the emergency physician, the change in prescribing means that these agents are now among the most commonly encountered pharmaceuticals in overdose. This presentation discusses pharmacology of the various agents and the experience-to-date following overdose. An approach to assessment and management is provided. In general, overdose with these agents is not lifethreatening and management focuses on provision of good supportive care and exclusion of non-toxicological differential diagnoses.

Following resuscitation, the most important step in the early management of a patient with deliberate self-poisoning is risk assessment. An accurate risk assessment allows all subsequent management to be refined to the individual patient. Thus, the risk assessment allows the clinician to use a rational approach to decontamination, investigation, enhanced elimination and the use of antidotes. Extended release preparations are now widely employed to improve efficacy, decrease adverse effects and improve compliance. However, ER preparations markedly alter toxicokinetics in deliberate self-poisoning. This influences risk assessment and management. A brief description of ER mechanisms will be followed by a discussion of several clinically important examples, including calcium channel blockers, salicylate, valproic acid, gliclazide, lithium and paracetamol.

Interest in short stay units has re emerged over the last few years, as a result of increasing access block in emergency departments and the search for alternatives to inpatient management. There is confusion regarding nomenclature and purpose for short stay units. In some hospitals they have been introduced without sufficient planning, resources.or administrative structure and protocol. Acronyms abound -including SSU (Short Stay Unit), CDU (Clinical Decision Making Unit), MAPU (Medical Assessment and Planning Unit), FT (Fast Track), Holding Bays, SOU (Short Stay Observation Unit) EDOU (ED observation Unit) and RAU (Rapid Assessment Unit). Although often grouped together, these units perform different functions, ranging from early discharge of ED patients to ensuring adequate planning of prolonged inpatient admissions. Unfortunately introduction of the unit often occurs before the purpose has been established. There is also insufficient attention to establishing and monitoring KPIs. There is some evidence that SOUs can increase patient satisfaction, reduce length of stay, improve cost effectiveness and ED efficiency. Although benefits ascribed to the unit may be the result of better clinical protocols that are introduced at the same time. There is certainly the potential to streamline patient care and improve quality of care if SOUs are introduced with a clear aim, clinical protocols and adequate resources.

In the 1960s physicians in Edinburgh recommended poisoning treatment centres be established, to be adjacent to Emergency Departments, to be self contained, to be overseen by doctors trained in the management of poisoning, and have close liaison with psychiatric & social work services. Sounds like the Emergency Department observation ward of the 21st century, but is this occurring throughout Australasia? The SCGH Emergency Department re opened its observation ward and has changed the way it runs over the last 6 years. Currently ∼25% of admissions to the observation ward are toxicology admissions. The use of the observation ward as a toxicology treatment centre has reduced patient length of stay, produced closer liaison with psychiatric services, and improved the profile of the poisoned patient in the hospital. This presentation will look at the SCGH experience, discussing suitable cases, strategies and traps.

Chest Pain Evaluation Units (CPEU) have been developed across the UK, USA and Australia for the past 10 years. Whilst there is still some discussion concerning the protocol management of patients with chest pain, there are more confronting issues from emergency physicians. For example, the physical location of such units, the cost of standalone CPEU, the hospital service (e.g. cardiology, emergency or general medicine) that is best equipped to manage such patients, follow up issues of patients, sharing of resources with short stay units. Current trends in the development of chest pain units will be discussed in this paper.

The most talked about developments in Emergency Cardiology of the last few years include: amiodarone, vasopressin and hypothermia for cardiac arrest, biphasic defibrillators, glycoprotein inhibitors, clopidogrel and magnesium for ACS. PCI vs. thrombolytic therapy for ST segment elevation myocardial infarction, the AFFIRM trial of rate control vs. conversion for atrial fibrillation and nesiritide for CHF therapy to name a few. This talk will concentrate the lessons learned from the MAGIC trial, the implications of the ongoing PCI vs. thrombolytic therapy debate and the concerning aggressive marketing of nesiritide for CHF therapy in the ED. This publication represented significant international collaboration in applying an evidence based framework in establishing resuscitation guidelines. This culminated with the levels of evidence and subsequent class of treatment recommendation being articulated with these guidelines. The Guidelines 2000 process was a great start!! Work is now underway under the auspices of ILCOR to produce Guidelines 2005 -An international consensus on the science. This presentation seeks to illustrate the process being used to achieve consensus on resuscitation science that forms the basis of the 2005 document. Importantly the methodology used to assess the evidence pertaining to key topic areas in Basic, Advanced, Paediatric and Neonatal resuscitation will be discussed.

Aspects of intensive care practice are of relevance to the emergency physician. Like emergency medicine, intensive care is a young speciality in which clinical practice has been increasingly influenced by research and evidence based medicine, particularly over the last 10 years. Translating research findings into evidence based medical practice is not always straightforward. There are instances where widespread changes in practice, have occurred based on the results of 'landmark' meta-analyses, with the results subsequently contradicted in large prospective randomised trials. In other studies, particularly large, multicentre randomised controlled trials, there is often an appreciable time lag between study design and implementation. Subsequently, there is the possibility that the management protocol assigned to the control arm is not consistent with 'standard practice' at the time the study is completed and results released. The concept of ventilator induced lung injury, steroids in septic shock, ulcer prophylaxis and 'renal dose dopamine' are examples of intensive care practice that have undergone change over the last few years. These areas will be briefly reviewed and the 'chain of evidence' examined.

Diagnostic testing in the emergency department is commonplace. Indeed, the very nature of the specialty involves the management of patients with undifferentiated medical conditions for whom targeted investigations are often indicated. In recent decades, the diagnostic testing options available to emergency physicians have expanded considerably and have contributed significantly to the accuracy of discharge diagnoses. Important developments include CT, MRI and ultrasound scanning, rapid bacterial antigen analysis, cardiac troponin assay and on-site blood gas analysis. Whilst the advantages of these tests are obvious, consideration needs to be given to their potential drawbacks. In particular, test validity and repeatability need to be considered in result interpretation, especially the variables of sensitivity, specificity, and positive and negative predictive values. Also, there is considerable anecdotal evidence that physicians may lose some clinical diagnostic acumen as greater reliance is placed upon diagnostic testing. This may also have financial implications and, in many circumstances, guidelines have been developed that aim to improve the rational ordering of diagnostic tests. The nature and function of the health system generally is changing rapidly with many traditional in-house services are now being 'front-loaded' to emergency departments. Consequently, it may be that emergency departments will assume some responsibility for disease screening as well as diagnosis. This possibility needs to be considered as well.

Stop -please stop. Before we, as an Emergency Medicine community, read, write or propose one more paper on: how, what or where to 'rule out' acute coronary syndromes in the Emergency Department we must stop! As a specialty, along with cardiology, we have failed to ask the most basic questions about the 'rule out' process. What is an acceptable 'miss' rate? What is a 'miss'? What are the outcomes that matter, and over what time period? Do we care about missing MI or only death, or need for acute intervention? What amount of money are we prepared to spend in order to reach the acceptable miss rate? How many false positives are acceptable?

The reason that the literate on cardiac enzymes, and markers, and chest pain units and on and on is so confused is that we have not asked these fundamental questions. Until we know what the questions are, we cannot possibility evaluate the literature as it stands, nor guide it into the future. So please let's stop and ask some fundamental questions before we completely lose sight of the road ahead.

This talk will review pearls and pitfalls in the diagnosis and management of acute onset headaches in the ED, and suggest a sensible approach. The roles of various diagnostic tools, such as CT and MRI, will be reviewed, and we will take a detailed look at an old standby, the lumbar puncture.

Three scenarios will be discussed. The investigation of choice in early pregnant or non-pregnant patients with pelvic pain is ultrasound scanning (USS). A transvaginal USS will identify a developing uterine pregnancy at b-hCG levels of 1000 IU/L or more, although the rare heterotopic pregnancy (intrauterine plus ectopic) in 1 in 15 000-1 in 30 000 necessitates exclusion of free fluid in the Pouch of Douglas in the unstable patient. In the non-pregnant patient, fibroids, tubo-ovarian abscess, ovarian cysts, endometriomata or tumours are visualized; however, laparoscopy remains the diagnostic gold standard. One in five laparotomies for suspected appendicitis are negative (normal appendix), rising to 40% in females or the elderly. USS has a poor negative predictive value, with limited usefulness in RIF pain particularly when the appendix is not visualized. Conversely, CT scanning has excellent sensitivity, specificity, positive and negative predictive values for appendicitis. Importantly, alternate diagnoses such as colitis or diverticulitis may be seen. There is disagreement over the need if any, for oral, intravenous or even rectal contrast. A negative appendicectomy rate as low as 5% is achievable, although CT has yet to dramatically influence this rate. Finally, non-contrast helical CT scanning (NHCT) achieves better accuracy than the traditional intravenous pyelogram (IVP) in suspected urolithiasis. NHCT is more rapid, avoids contrast reactions such as anaphylactoid or nephrotoxic, visualizes radiolucent stones and picks up alternate diagnoses such as appendicitis, diverticulitis and abdominal aortic aneurysm (AAA). USS is less accurate than either at demonstrating a stone or estimating the degree of obstruction, but is non-invasive, and most useful in investigating urolithiasis in pregnancy, or ruling out AAA in the unstable patient.

Ian Jacobs It has been said that 'clinicians require 95% of their information in 2-3 min!!'. This workshop to be hosted by Associate Professor Ian Jacobs will focus on the application of the principles of EBM as they pertain to therapy and diagnosis. The workshop will cover the principles of EBM, developing answerable questions, accessing and using the synthesized literature, interpreting clinical effect measures, understanding meta-analysis and applying the evidence to clinical practice. Emphasis of the workshop will be on the application and integration of EBM into daily clinical practice. While the workshop is designed for those with little experience with EBM, it may also be useful for those wishing to revisit these issues. 

Severe hyponatraemia and cerebral oedema resulting in death or permanent neurological impairment have been reported during intravenous fluid therapy for gastroenteritis, all associated with the use of hypotonic saline solutions. Similar cases have been reported in children with medical illnesses and following surgery. Fluid rates and the use of hypotonic fluids have often been cited, however, the apparent inability of these children to excrete a free water load suggests that Antidiuretic Hormone (ADH) is acting despite low plasma osmolality. The current recommendations for paediatric maintenance fluid requirements are scarce, and to a large extent based on data from the 1950s on energy requirements in well children. The recommendation for hypotonic saline (0.225% saline) is based on the electrolyte composition of human milk. Clinical signs of dehydration occur at 3-4% and features previously considered to indicate 8% dehydration correlate with 5% dehydration. As a result rehydration volumes may be excessive. In health, ADH secretion is tightly linked to plasma osmolality, however, osmotically independent stimuli of ADH secretion in hospitalized children are common, including extracellular fluid contraction, metabolic stress, nausea and vomiting, pain, and diseases of the respiratory and central nervous systems. Two recent studies we have performed studied electrolyte and ADH during rehydration of children for gastroenteritis. Rehydration with 0.45% saline solution resulted in frequent persistence or development of hyponatraemia, whereas with 0.9% saline solution, most hyponatraemic children corrected, and normonatraemic children remained stable. ADH levels remained elevated in many cases despite hyponatraemia and rehydration. The combination of non-osmotic ADH release, hypotonic fluids and excessive rehydration volumes may account for the rare but catastrophic occurrence of hyponatraemia and cerebral oedema in children receiving intravenous fluids. Rehydration should be undertaken with caution and children should be carefully monitored biochemically. Estimates of dehydration should be consistent with the data supporting more conservative figures. Rehydration fluid should be 0.9% saline with glucose.

Paul Porter Fever is a major precipitant for paediatric presentations to emergency departments however, the severity of illness and the subsequent clinical course cannot be judged by this parameter alone, particularly in the young child. Clinical and laboratory based approaches are employed to determine which children need directed treatment and which will have self limiting illnesses that only require conservative supportive management. As purely clinically based approaches have been shown to have limitations, additional laboratory tests including white blood cell counts, microbiological cultures and acute phase reactants have been extensively investigated to determine if they increase the accuracy of diagnosis. Serum acute phase reactant concentrations have been found to increase in a wide variety of diseases including infectious and inflammatory disorders. Plasma levels of acute phase reactants have been studied to determine their utility in the diagnosis of disease, determination of aetiology and for possible predictive value of clinical course. This session will examine the role of the acute phase reactants ESR, CRP, IL-6 and Procalcitonin in the assessment of the febrile child, concentrating on their use in differentiating bacterial from viral infections.

Workplace or fiefdom? Peter Cameron Hospital workers are constrained by a workplace based on 19th century concepts. This is despite a century of massive change in healthcare delivery systems, a technology explosion and a revolution in societal values. No single healthcare worker has ownership of the knowledge and skills required to manage a patient presenting with an acute severe illness. Family values and feminization/casualization of the workforce have also made the concept of 'wholistic care', as promulgated by some nursing academics and general practice organizations a noble but misguided concept. Whole cadres of doctors and nurses have been trained for jobs that don't exist -this is reflected in the low morale and high fall out rate in recent graduates. Solutions: 1. Acknowledge that there is a limit to the number of people willing to undertake training in healthcare skills (esp. traditional nursing). Delegate low skilled/repetitive tasks to others. 2. Utilize various skill levels of workers in the community and pay accordingly. Create a flexible workforce. Use technicians and volunteers. Possibly commence generic degrees in healthcare with subsequent specialization -doctor/nurse/pharmacist, etc. 3. Build up team models for patient care that work and train workers in team management. No worker 'owns' the patient. 4. Utilize existing institutional resources to 'umbrella' community integration of services. 5. Change funding to reflect desired outcomes. Fee -for -service and case mix payments encourage 'useless' activity and procedural skills at the expense of 'carers'. 6. Coordinate funding streams (esp state/federal). Conclusion: Healthcare must become a team sport rather than a collection of fiefdoms.

Through some previous attempts to produce guidelines for ED medical staffing and for wider workforce requirements, lessons have been learnt about both the processes and pitfalls. Relevant factors include the wide variation across Australasia of the scope of ED work, departmental casemix, existing staffing, clinical and operational policies, and degree of bed access block. The lack of a practical and reproducible measure of ED case complexity has also made it very difficult to base a staffing formula on a realistic measure of workload. It is proposed that a measure of complexity be developed through collaboration, including measures of diagnostic complexity and staff intensity as well as urgency. The discussion will then progress to the development of alternative workpractice models for EDs, and the principles of workpractice review. Principles include task re-allocation or deletion, creative use of ancillary staff and communications technology, and re-design of clinical roles. The potential barriers to achieving sustainable change will be discussed, with examples given. Issues include professional boundaries, HIC regulations and industrial awards.

Workforce and workpractice issues are closely linked -one cannot predict workforce requirements without knowing what work is to be done, and by whom. Efficient and effective workpractice models need to be developed in order to make ED work sustainable. It is on the basis of the model of care, together with a reproducible measure of workload complexity, that progress can be made in the development of staffing guidelines.

The key element of successful ED redevelopment is the early input into the planning process by effective negotiators for the ED. Once site and access selection has been made, choices of layout are limited. Ensuring adequate space allocation for the department is critical. Frequently regional health services underestimate the space requirements and attempt to use calculations based on mean levels of ED activity, rather than higher percentiles. Not surprisingly, these cause the ED to be inadequate for the demand approximately 50% of the time. A quick illustrative history of the recent development of emergency medicine may be helpful in establishing an adequate allocation of space. Storage space, office numbers and design of communication systems are areas of design that are often troublesome. The redevelopment of an entire department is a different type of change to the incremental changes that usually occur in the ED workplace. From a staff member's perspective, moving Department is not optional, occurs at a time outside of their control, and involves simultaneous change to virtually all tasks normally performed. Change of this magnitude requires significant resources to effect, and this is commonly overlooked when the redevelopment is planned. Redevelopment does not finish on the day of the move -it takes months to years for the full impact on the operations of the Department to stabilize.

Medicine and ethics had a stable relationship based on the Hippocratic principles of trying to do good things and trying not to do harmful things. However, an acrimonious divorce saw medicine label the old ethics 'paternalism', and then run off with the youthful 'respect for autonomy'. Whereas the old ethics was somewhat ill defined and largely internalized, the new ethics is made explicit in laws and codes of practice. Unfortunately the new relationship is somewhat superficial with little exercising of the heart or mind, and consequently there remains a certain yearning for the moral fulfilment of old. This shift of weight from an internal morality to an external morality is leading us to a moral wasteland. Now, more than before, patients are clients for whom we provide a service. We come to understand them and their context no more thoroughly than a plumber might, and trust is based on a contract rather than a relationship. Emergency Medicine has struggled to accommodate respect for autonomy due to confounders such as urgency and impaired patient competence. In this struggle we have considered ways of respecting autonomy, other than simply providing information and asking what the patient wants. In so doing we have discovered the true ethics, which is neither physician based, nor patient based, but is based on the bit in between.

While there has been an explosion of multimedia products in education in general and in Emergency Medicine, many of these products sell poorly and miss the mark. This has caused us the question what we really need from this technology, what can it provide that we have, until now, lacked. The best multimedia products allow us to 'see' things in real time that cannot be easily explained in text books. Ultrasound multimedia programs are a great example of how this technology is superior to 2-D representations in a text book. Procedure videos show, in video form, angles, concepts, steps and instruments that are extremely difficult to describe with plain pictures and words. Even specific physical examination techniques can be far better presented in a multimedia format that in standard text books. The error in multimedia education has been too simply 'convert a book to CD-ROM' -a failed idea from the beginning. The future of multimedia technology may well lie in the 'palm' of your hand. Imagine also, a bedside consult with a recognized expert on specific clinical issues in a 'virtual format'.

Fundamental Initial Resuscitation of Severe Trauma (FIRST) is an internet-based trauma education program designed for medical practitioners in Victoria working in rural and remote settings. It is a scenario based interactive program. It arose because of the recognized deficiencies in remote and rural trauma education, namely: it is near impossible to disseminate protocols state-wide; it is difficult to get rural doctors to education sessions and also to confirm the uptake of educational messages and finally, there is no mechanism for annual certification and re-certification. This presentation will give an overview of the FIRST program and look at what has been achieved in the first 12 months.

For many years the pass rate in our fellowship exam has rated at the lower end of the scale in comparison to other colleges that have a similar training structure. In 2001 for instance, our pass rate overall was only 50.5% compared to 74.4% for the intensive care medicine faculty and 82.6% for the anaesthetics college. For all of us, trainees, trainers and the college, this is a problem that requires urgent attention. The first question must be whether our general training programs are providing the necessary experience to allow a new graduate to practise at the mandated level of 'the independently practising consultant emergency physician'. Should this be the case then the college must ask itself does the fellowship exam adequately and fairly test this standard and is the form of the exam adequately communicated to those involved. Finally responsibility then falls to the trainees and trainers who must understand the current form of the exam and focus their preparation around this, rather than some poorly informed version of what the exam once was or what they wish it would become. In this presentation I will present a number of examples of what the college is doing in an attempt to demystify and clarify the exam. In addition a number of educational strategies and exam preparation techniques will be discussed.

Our aim as a group should be to see our fellowship exam pass rate approach 100% sooner rather than later.

On Saturday 18th January 2003, bushfires swept through the southern suburbs of Canberra, destroying 504 houses. This was the medical staff changeover weekend at The Canberra Hospital, which received virtually all casualties. Some 139 patients presented in 6 h, corresponding to 1 additional patient every 4 min above normal. In total, there were 235 fire related presentations during the weekend. Numerically this appears to be the largest single ED disaster workload since Cyclone Tracy, but the total burden of injury was relatively low, with only 36 fire related admissions. The commonest presentations were breathing problems, followed by eye injuries, burns, medication issues, and falls. 60% of patients, including the two most critically ill, arrived by private vehicle. The major problems were communication between agencies, staff recall difficulties, and infrastructure degradation due to power outages. Minor problems exposed in the existing disaster plan included a poorly located control room, inadequate relatives facilities, and lack of credentialing process for volunteers. From an ED perspective, triage was best performed by experienced nurses, and overflow areas needed to be better identified. Although the risk was small, fire came to within 2 km of the hospital, and an evacuation would have been problematic. The immediate health outcome was excellent, with no deaths in hospital and only 4 overall, due to vigorous evacuation by Police, the lowest ratio of deaths to property damage recorded in a large fire. The lessons learnt will be valuable in future extensive disasters.

Australian Defence Force (ADF) Health personnel, both regular and reservists, have been deployed to several United Nations Missions in the past decade. The work is often challenging from a medical, operational, and personal perspective. These deployments have the potential to enrich an individual's professional development, through exposure to problems and solutions different to those in developed countries. This presentation will focus on the experiences of an ADF Emergency Physician working as part of United Nations missions in Rwanda, Bougainville, and East Timor.

The article is a presentation of the events in Bali on October 13th 2002. Several Australian medical practitioners were in Bali on holiday on 12 October 2002. On learning of the disaster, they went to Sanglah Hospital to assist. With the limited resources of the hospital, they provided emergency medical and surgical treatment, stabilized patients, prepared patients for evacuation and coordinated the evacuation. It details the role they played in managing the initial treatment and coordinating the evacuation of a large number of seriously injured and major burns victims under difficult conditions. It is a detailed hour by hour account of the situation in the hours following the bombing.

After the terrorist attack in Bali on 12 October 2002 the Royal Darwin Hospital became the initial receiving centre for the evacuated victims. In total 62 persons were evacuated to the hospital, one died in transit, one died soon after arrival. This presentation describes the first 72 h of the response by the Royal Darwin Hospital including preparation, receiving and stabilization of victims and subsequent evacuation to other centres throughout Australia. The emphasis is on an Emergency Department perspective.

As the 2 first century starts its early years it has become increasingly apparent that the twentieth century, which opened with the promise of the eradication of most infectious diseases, closed with the spectre of the re-emergence of many deadly infectious diseases that have a rapidly increasing incidence and geographical range. Equally, if not more alarming is the appearance of new infectious diseases that have become major sources of morbidity and mortality. Among recent examples are the SARS coronavirus, HIV/AIDS, hantavirus pulmonary syndrome, Lyme disease, haemolytic uraemic syndrome (caused by a strain of E. coli), Rift Valley fever, Nipah virus, vancomycin resistant enterococci and Staphylococcus aureus, cryptosporidiosis and cyclosporiasis. The reasons for emergence and re-emergence of infectious diseases are many and complex. They include such things as permissive use of antibiotics including industrial and feed use, demographic change, societal behaviour patterns, changes in ecology, global warming, the inability to deliver minimal health care and the neglect of wellestablished public health priorities. To date Australia has been rather fortunate in its experience with these problems but unless we improve our responses and behaviour on many fronts the situation will only deteriorate.

Peter Cameron Introduction: The first major outbreak of SARS outside mainland China occurred at Prince of Wales Hospital in Hong Kong. This study aims to describe the epidemiology, clinical aspects and consequences of this outbreak. Methods: PWH is a 1400 bed tertiary, teaching hospital in Hong Kong a Special Administrative Region (SAR) of China with population 7 million. An outbreak resulted from one unrecognized index case on a medical ward admitted March 4, 2003. An epidemiological study of the contact cases (staff, patients and visitors) including demographics, contact history, clinical course and follow up was undertaken. The hospital and political response was also studied. Results: Within 2 weeks of the first staff becoming affected, 138 hospital cases were reported, the hospital was closed and spread to the community had become apparent. Clinical features of SARS (esp. respiratory symptoms) required by the WHO definition were not prominent, with fever, chills, myalgia, abdominal pain and malaise being the only defining features. The typical course of the illness was over 2 weeks with 20 30% of patients requiring ICU for respiratory failure and 15-20% of patients dying. Infection control procedures were based on droplet spread of the virus. The economic and political impact of this disease was immediately apparent. Conclusion: This was a rapidly evolving epidemic, that had a profound impact on the world over a 3-month period. It now appears to have disappeared however, the lessons learnt from this epidemic are important for emergency medicine.

Peter Pereira Australia was first exposed to dengue and its vector through the voyages of the royal barque HMS Endeavour. Since then epidemics have been recognized and controlled through vector management. However, with the recent explosion in international visitors, Australia and in particularly Cairns is poised to encounter a recurrence of the Dengue epidemics of past years. Of even greater concern, North Queensland is poised to encounter the fatal forms of the disease: Dengue Haemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS). This talk will cover the recent controlled 'encounters' with Dengue in Cairns and discuss what is around the corner as Cairns becomes the second most popular international destination in Australia.

Meningococcal sepsis has a 30% mortality rate and causes the majority of deaths from invasive meningococcal disease. Attempts to halt the fulminant course of endotoxin-mediated cardiovascular collapse have included the use of haemostatic therapy (fresh frozen plasma, antithrombin-III concentrate), heparin, endotoxin-blocking agents such as rBPI21, and activated protein-C. Disappointing results in some trials may reflect delayed drug administration after arrival in the intensive care unit, long after the peak in inflammatory mediator activation. The key to improving survival is likely to remain prompt antibiotic therapy before the inflammatory activation takes hold, however, early clinical recognition is notoriously difficult. Typical features of meningococcal sepsis include agitation, nausea, vomiting, myalgia, abdominal pain, tachycardia, and peripheral circulatory compromise. Purpuric rash is usually a late sign. Widely available laboratory tests (toxic blood film changes, thrombocytopenia, markedly elevated CRP, and mild coagulation abnormalities including elevated D-Dimer) may give a clue to the presence of meningococcal disease. PCR identification of bacterial DNA is expensive and not normally available outside daytime working hours. Serum procalcitonin has been investigated during a sustained outbreak in New Zealand and shows promise as a rapid screening tool. Careful clinical assessment, observation, investigation (blood cultures and PCR), and a low threshold for empirical antibiotic therapy remain the safest approach to dealing with suspected meningococcal disease. However, this approach has significant resource implications when a concurrent influenza outbreak, media hype, and community panic cause ED presentations to increase by 50% or more, and may require a coordinated hospital response.

Poster Board: 1 Biphasic cardioversion of acute atrial fibrillation Godfrey Lo Objectives: There is a trend towards accelerated management of acute atrial fibrillation (AF) in young and well patients in the Emergency Department (ED). This study reviews the effectiveness and outcome of biphasic cardioversion of acute AF in the ED. Methods: This prospective, descriptive study was conducted at a teaching hospital ED over a 6-month period. Patients who received biphasic cardioversion for acute AF were enrolled. Data collected and studied included: patient demographics, past medical history, details of biphasic cardioversion, outcome, complication(s), disposition and length of stay. Follow up was conducted at 3 months. Results: 37 patients were enrolled. The mean age was 56 ± 15 years and 24 (65%) of the patients were male. Biphasic cardioversion was successful in 34 (92%) patients.100 J was selected as the initial energy level in 26 (70%) patients. This was successful in 23 (88%) patients. There were three minor complications relating to sedation. No thromboembolic complications were observed. The mean length of stay in the ED was 5.5 ± 2.7 h and 14 ± 24 h in the hospital. Patients who failed to revert were older and had underlying cardiovascular disease. Follow up was conducted in 33 (89%) patients. Recurrence of AF occurred in 9 (27%) patients in the follow up period. The majority of patients (32, 97%) were satisfied with biphasic cardioversion.

Biphasic cardioversion of acute AF in the ED appears to be effective and safe. An initial energy level of 100 J is usually effective. The high discharge rate, short hospital stay and patient satisfaction makes this modality attractive to the emergency physician.

Poster Board: 2 The significance of serum troponin in syncope Rosslyn Hing, Roger Harris Study Objectives: To investigate the hypothesis that a random troponin T level taken greater than 4 h after a syncopal event is a poor predictor of adverse cardiac outcome. Methods: We prospectively enrolled 82 adult patients who presented to our Emergency Department after a syncopal event. Each had a troponin T level taken at least 4 h after the event. Relevant history of the syncope, background medical history and ECG were collected at presentation. Patients were followed up via Tel. 3-6 months later to ascertain further history of adverse cardiac outcome. The reviewers then examined each medical record and based on this and the follow-up information grouped all the patients according to the cause of their syncope, following the American College of Physicians' guidelines 1997(1). The data collected was then analysed with the aid of a statistician for the predictive value of troponin T in syncope. Results: Of our 82 patients, 36 were male and 46 were female. The age distribution was from 20 to 90 in years. Approximately 25% were felt to have a cardiac cause for their syncope, which is consistent with previous studies. Of the 82 cases, only 2 had positive troponin T levels. Conclusion: A normal serum troponin T has a poor negative predictive value for adverse cardiac outcomes, following presentation to the Emergency Department following syncope.

Poster Board: 3 Drugs: Cure or catastrophe? Nalini Nainthy Introduction: Many studies, both from Australia and abroad have emphasized the growing number of medication errors occurring in our hospitals. But what is the true size of this problem and is it an evil that is growing unnoticed? Objectives: To assess the incidence and severity of Adverse Drug Events (ADE) in a Melbourne teaching hospital. To seek and implement strategies to decrease their incidence. Methods: A Retrospective review of incident forms collected over a 2-year period. Results: 628 ADEs were reported over a 2-year period from 91 122 separate patient admissions. This represents a rate of 0.69% of all patient episodes over this period. Numbers of ADEs in each category are given below:

A low rate of ADEs was identified in this study. The most commonly occurring error was IV fluids being infused at a rate faster than prescribed causing fluid overload. A policy has thus been adopted in this hospital of using a burette when any fluids are being infused. A follow up study will be undertaken by the author in Poster Board: 4 Rat renin-angiotensin system activity during tricyclic antidepressant overdose Joanne Dalgleish, John G Benitez, Thomas L Pangburn, Brian D Check Introduction: Tricyclic antidepressants are a leading cause of hospitalization and death following overdose. Arrhythmia after TCA overdose is attributed to sodium channel blockade, manifested as QRS prolongation. Recent evidence shows that angiotensin-II acts as a modulator of arrhythmia in rats. Development of QRS prolongation took longer in rats preloaded with captopril during an infusion of desmethylimipramine compared to rats without captopril. How angiotensin-II affects desmethylimipramine induced cardiotoxicity is not well understood. Angiotensin-II increases coupling of ionic currents and regulates other potential modulators such as sodium, intracellular calcium and has been implicated in facilitating noradrenaline release. Pretreating rats with captopril, thus inhibiting angiotensin-II production, demonstrated no significant QRS prolongation after 30 min of desmethylimipramine infusion. Captopril may prevent cardiotoxicity by inhibition of the renin-angiotensin system. No studies have addressed whether TCA activate the renin-angiotensin system. The purpose of this study was to see if TCA infusions cause an increase in renin production. Methods: Rats were administered an infusion of desmethylimipramine and compared with a control group and a sham group. Renin measurements were obtained at 0, 30 and 60 min QRS, renin levels, blood pressure, and heart rate were compared. Results: QRS duration increased with the desmethylimipramine infusion in the experimental group, while QRS duration remained unchanged in the other groups. Renin levels increased in all groups compared to baseline but there was no significant difference across groups except at 30 min where the sham group was higher. Conclusions: Desmethylimipramine does not appear to cause an increase in renin levels.

Poster Board: 5 Procedural skills quality assurance amongst ACEM fellows and trainees Glenn Harrison, David McD Taylor Introduction: Presently, there is no objective quality assurance mechanism monitoring procedural skills among ACEM trainees. Aims: To determine trainee and fellow experience and perceived proficiency in 23 procedures, participation in accredited training courses, and support for a procedural logbook. Methods: A cross-sectional mail survey of ACEM fellows and Advanced/Provisional trainees was performed. Results: 202 fellows and 264 trainees responded (overall response rate 39%). Considerable variation in procedural experience existed within and between fellow and trainee groups e.g. central cannulation (range: fellows 5-1000, trainees 0-1000), bladder aspiration (0-1000, 0-100), intubation (5-2000, 0-1000). For most procedures, perceived proficiency varied from very poor to very good. However, both groups generally reported poor proficiency for FAST, DPL and Sengstaken tubes. Trainees generally reported poor proficiency with Donway splints and intraosseous needles. Level of experience and proficiency generally increased with seniority. Limited experience generally correlated with less perceived proficiency. Perceived experience (number of procedures) required for proficiency varied considerably within and between both groups e.g. intubation (fellows 5-300, trainees 2-500). There were wide ranges especially within the trainee group e.g. central cannulation (2-100), intercostal catheter (1-100). Both groups showed similar participation for EMST (65%) and APLS (47%) courses. However, more fellows had taken a FAST course (49% vs. 25%) but fewer had ACLS accreditation (16% vs. 23%). The majority of trainees (59%) and fellows (75%) supported a procedural logbook. Conclusion: Procedural experience, perceived proficiency and perceived experience required varied widely. Logbook support is considerable and may assist in more objectively monitoring experience.

Poster Board: 6 Assessment of the effectiveness of a project to decrease access block from the emergency department using a multifaceted approach Kavi Haji, Graeme R Thomson Introduction: In Victoria, the Department of Human Services sets performance targets for admission of patients from emergency departments to inpatient beds within 12 h of presentation. Our Emergency Department was chronically unable to meet those performance targets. Objectives: Our objectives were to analyse the factors that contributed to access block from our Emergency Department, to institute a program to reduce access block using a multifaceted approach and to assess the impact of that program. Methods The setting is a tertiary-level department treating patients of all ages. Statistical records were examined to identify factors that correlated with periods of access block. Paediatric figures were excluded because access block for paediatric patients was a minor problem. A program was then introduced that included streamlined processes in the Emergency Department and in the wards to facilitate admissions. Performance figures were then analysed to assess the effectiveness of the program and to identify factors that remained barriers to admission. Results: Initial analysis revealed no factor that strongly correlated with access block. It was concluded that multiple areas had to be addressed. After introduction of our program we were able to demonstrate marked improvement in performance. The number of adult inpatient beds available at 0900 h each day now strongly correlates with access block figures and can be used to predict daily problems and to initiate steps to relieve those problems. Conclusion Access block can be reduced by improvement in departmental and hospital procedures but bed availability remains the underlying factor that slows admission.

Muir Wallace, L Giles Chanwai Introduction: Waikato Hospital is a tertiary hospital serving a large rural catchment encompassing a 100 kilometre radius with a population of 320 000. The region is a playground for outdoor sports including motocross. The hospital trauma database identified motocross as a sport producing significant numbers of injuries. In the 12 months preceding the study they accounted for 222 inpatient days among 23 patients with an ISS ranging from 4 to 34. Objectives: To determine the pattern of injuries in all motocross riders presenting to the Emergency Department, and to assess the type and effectiveness of protective equipment. Aims: To demonstrate that use of this training module will enable junior doctors to -1. diagnose common fractures in children 2. describe fractures accurately to the orthopaedic surgeons 3. reduce the risk of adverse events from missed fractures. In addition, secondary aims are -1. to improve the quality of referrals to the orthopaedic service 2. to reduce unnecessary after-hours call-ins.

Methods: This was a prospective, randomised trial involving 30 subjects. A search of the Emergency Department database (HAS solutions) revealed a list of the 20 most common orthopaedic injuries seen over a 5-year period in children aged from zero to 16 years. Using this information as a base, a teaching module was formulated incorporating these 20 common fractures/injuries. In addition, we also included low incidence/high clinical impact such as slipped upper femoral epiphysis. The module was designed to be incorporated into resident and registrar orientation programmes, which would be completed prior to working in the paediatric Emergency Department. The teaching module consists of a pretest, an interactive teaching module and a post-test. The pre-and posttest involve the subject identifying and describing a series of both common and less common orthopaedic injuries and conditions in children. The learning module takes the subject through a step-bystep guide to fracture identification and description using Xrays, line drawings and text. The same set of Xray images is used for the pretest and the post-test. Subjects were randomised into two groups. The study group completed the pretest, the training module and the post-test. The control group completed the pre-and post-tests alone without the training module. Statistical analysisof the pre-and posttest scores was completed and comparison of the study and control groups was made. Results: To be advised. weeks (1 semester) in the department where they are mentored by a registrar. Students are supplied with a workbook which guides but does not limit their experience. The workbook is based around ACEM guidelines and includes: resuscitation, assessment and management of the undifferentiated patient, procedural skills, and professional and personal development. Weekly round table meetings are held where students discuss patients and scenarios, and receive training in the management of resuscitation and common emergency conditions. Study Objectives: To ascertain the effectiveness of the program and its acceptance by students, and whether participation in the program created a favourable impression of emergency medicine as a specialty. Methods: Questionnaire sent to previous participants in the Advanced Studies Program at RHH. Results: Most students found that the program enhanced their clinical skills and preparedness for intern practice and considered emergency medicine to be a possible future career choice.

A 'hands-on' structured term in EM during the medical course has a positive impact upon students and enhances clinical skills and creates goodwill towards the specialty. (5) specific Learning Objectives tailored to residents' level of experience were compulsory, and five (5) were chosen by the resident. The Learning Objectives were documented, with an agreed review date. Formative evaluation of the program was performed by surveys of the Residents to assess the impact of the program on their experience in the ED, and on their professional development.

Results: Residents identified their perceived benefits from involvement in the program, based on improvements in their educational experience, understanding of the ED, encouragement of high levels of performance and provision of feedback, and rated the overall impact on their professional development.

The results of our study suggest that the Mentoring program helps to establish formal learning objectives for an emergency medicine rotation for junior staff, and facilitates the feedback process. Further evaluation of the program will focus on its potential to enhance residents' overall professional development. Summary: A prospective, single blinded study was performed on a convenience sample of adult patients requiring procedural sedation. Patients had standard monitoring and procedural sedation as determined by the treating doctor. Treating staff were blinded to BIS values. Serial readings of BIS values were recorded along with OAAS scores. Upon recovery, patients were asked about recall of events while they were sedated. Twelve patients (7 male) were enrolled. The mean age was 58 years (range 20-94). There were 110 paired readings. There was little difficulty with the use of the monitor in the ED. There was no correlation between OASS and BIS values (r = 0.115). Subgroup analysis of the propofol group resulted in a strong correlation (r = 0.92, P < 0.01). There was no suggestion of recall after the procedure. BIS monitoring is feasible in the ED. However, there was poor correlation between BIS values and OASS. Further studies and developments in brain monitoring technology are needed before this form of monitoring becomes clinically useful. The issue of recall in patients sedated for procedures in ED requires further study.

Poster Board: 16 A randomised double blind trial of intranasal ketamine and fentanyl alone and in combination for analgesia in children with forearm fractures Peter Francis, Natalie Hood, Adam West Painful conditions are common in the paediatric emergency department. We undertook a randomised double blinded trial of intranasal delivery of 1 microgram/kg fentanyl, 0.1 mg/kg ketamine or both at the above concentrations compared to intranasal placebo (normal saline) in children aged between 6 and 12 years with forearm fractures. The drugs were delivered via a metered aerosol nasal spray. Pain scores were recorded predelivery and at 5 minute intervals for 20 minutes for patient, carer and doctor. Tolerance scores were recorded for each delivery of the drug. Results: Intranasal delivery of the medication is well tolerated with 92% of the administraions having no complaints. The pre treatment pain scores for all groups were not significantly different. The group that received the combination drug had a significantly improved pain score at 20 minutes (P < 0.03). The other drugs were not demonstrated to have benefit over placebo. Conclusion: Intranasal ketamine 0.1 mg/kg combined with 1 microgram/kg fentanyl provided effective well tolerated analgesia in children with forearm fractures.

An exploratory observational study of the effect of age on D-dimer levels in an emergency department population Gillian Groom, Sally S Separovic, David Mountain, Kerryn Butler-Henderson Introduction: D-dimer (DD) testing with a normal level (< 0.5 µg/ L) is used to exclude pulmonary embolus (PE). VIDASÓ DD is used in our Emergency Department as part of a formalized diagnostic pathway for suspected PE. However specificity is low, as many conditions can elevate DD levels. There is some evidence that age is associated with increasing DD levels. Objectives: To explore the hypothesis that D-dimer levels increase with advancing age, and to look at the effect of age on D-dimer specificity. Method: Prospective data was collected from patients entering the PE pathway with a VIDAS DD. All patients were followed up. Data was collected on alternative causes for DD increase (surgery, cancer, etc.), prolonged symptoms and eventual PE status. Statistical analysis including age correlation, regression analysis, and ROC curves, was performed for all patients, and a subgroup without PE or confounding conditions. Results: 591 patients had a DD performed. 462 patients were eligible for linearity analysis (age range 16-95). A significant linear correlation was shown for age and DD level (Pearsons correlation r = 0.301, P < 0.0001). Specificity of DD progressively decreased for every decade of life (65% (< 35 years) to 10% (> 85 years) P < 0.0001). This effect was still statistically significant at the decade level. ROC curves showed sensitivity was maintained even with higher cut-off levels for older patients.

We have shown that D-dimer levels (in an ED population) rise in a linear fashion with age. Additionally there is a marked difference in specificity of D-dimer with each decade of life. The use of different 'normal DD' levels at different ages should be explored.

Emergency ultrasound on the international space station Rob Hart Introduction: Orbiting approximately 400 km above the Earth, the International Space Station (ISS) is classified as a remote location for medical purposes. Medical practice on ISS is characterized by a paucity of resources and expertise, and is complicated by the physiological and logistical difficulties inherent to the microgravity ('zero-g') environment. Unlike many terrestrial equivalents, however, ISS has a high-end ultrasound scanner (Philips/ATL HDI5000). Study Objectives: This project is designed to maximize the clinically useful output of the scanner for a range of emergency conditions under the following constraints: lack of trained operators, lack of continuous Earth communications, paucity of management options. Methods: NASA's Patient Condition Database (PCDB), l; ist of all medical conditions likely to be encountered on orbit, was reviewed to identify those conditions which are both likely, and for which ultrasound is useful. From a list of 157 alternatives, four were chosen as highest priority: renal colic, abdominothoracic trauma, ocular trauma and deep vein thrombosis. Abdominothoracic trauma was subclassified as intra-abdominal bleeding, penetrating chest injury and pneumothorax. Results: Using a checklist-based approach, ultrasound scanning protocols for renal colic, blunt abdominothoracic injury, ocular trauma and deep vein thrombosis have been developed. These are specifically designed to allow the untrained practitioner to produce clinically useful results. In February 2004, these protocols will be flown, using porcine models of injury, to determine their efficacy in the microgravity environment. Conclusion: This work will yield a higher level of management confidence than currently possible during medical contingencies on ISS.

Poster Board: 20 A computer-based, interactive triage teaching package Peter Heinz, Jenny Cullen, Diane Langman Introduction: Due to shift patterns, teaching in ED can be a challenge. Computer-based learning has great potential as an aid in nursing education, with regard to meeting student's educational requirements more effectively, achieving these requirements more efficiently and providing students who have different learning styles with an alternative presentation of learning materials. We present a newly developed computer-based, interactive teaching package for ED nurses. It is a 6 module training program incorporating triage education resources provided by the Commonwealth Department of Health. Objectives: In order to assess it's acceptance by staff, all nurses who had completed the modules were asked to rate their satisfaction. Methods: An anonymised questionnaire was used with ratings for the individual modules and the whole program as such on Likert scales. Participants were also asked to state their level of computer literacy. Results: 24 triage-nurses completed all six modules and gave their ratings. Overall 42% (n = 10) rated the program as 'very useful', 50% (n = 12) as 'useful' and 8% (n = 2) as being 'of some use'. The level of computer literacy did not influence the ratings. Conclusions: Computer-based teaching programs do seem to have a high level of acceptance amongst our ED nursing staff. Their effectiveness with regard to the acquisition of knowledge needs further evaluation.

Is an elevated erythrocyte sedimentation rate associated with mortality in acute ischemic stroke? Elizabeth Jacobson, Latha G Stead, Amy L Weaver, Wyatt W Decker Objective: To determine whether the serum erythrocyte sedimentation rate (ESR) level is associated with mortality in acute ischemic stroke (AIS). Methods: A retrospective review of 206 consecutive patients presenting between December 15, 2001 and June 30, 2002 to the Saint Marys Hospital Emergency Department for AIS was conducted. Data on initial serum ESR (within 48 h of presentation), and dates of death and last follow-up were abstracted. All consecutive patients in the mentioned time period were captured; there were no missing charts. Patient survival was estimated using the Kaplan-Meier method and survival curves were compared using the logrank test. Results: Among the 206 patients, 107 had a serum ESR drawn within 48 h of emergency department presentation. Of these 107, 24 (22%) had an elevated serum ESR, defined as > 29 mm in 1 h. Using the Kaplan-Meier method, the estimated survival for those with an elevated serum ESR at 90 and 183 days was 60.6% and 49.6%, respectively, compared to 94.6% and 91% for those with a normal serum ESR. There was a statistically significant association between an elevated serum ESR and overall survival (logrank test; P < 0.001). Conclusion: An elevated serum erythrocyte sedimentation rate in the first 48 h after AIS is associated with poorer survival. . For the safety study, there were 110 subjects. There were no cases of respiratory depression [95% CI 0-4%] and 2 minor allergic reactions. Three patients had a fall in systolic blood pressure to between 80 and 90 mmHg, of whom two required no intervention. Conclusion: NINA administered according to protocol is safe and reduces time from arrival to first dose of analgesia and time to pain control.

Can nurses apply the Canadian C-spine rule? Anne-Maree Kelly, Luke Bradshaw, Debra Kerr Objective: This study aimed to determine the interrater agreement between doctors and nurses for eligibility for application of the Canadian C-Spine rule (CCR) and assessment of the criteria of the CCR. Methods: This prospective observational study was conducted in an adult community emergency department. Data collected included independent assessments by doctors and nurses of eligibility for application of the CCR, agreement on each criterion of the CCR and overall agreement regarding interpretation of the rule. The outcomes of interest were the interrater agreement between nurse and doctor regarding eligibility for application of the rule and for assessment of each component of the rule, assessed by weighted kappa analysis. Results: 88 cases were eligible for analysis. Doctors and nurses agreed on which patients were eligible to have the CCR applied to them in 96.6% of cases. Inter-rater agreement for most of the criteria of the CCR was good (kappa statistics > 0.69) with the exceptions of the assessment of midline tenderness [kappa 0.58] and range of motion that most nurses did not test. The kappa statistic for agreement between doctors and nurses for interpretation of the rule in individual patients was 0.69. Doctors would have cleared 35% of cases using the rule while nurses would have cleared 25% [P < 0.001]. Conclusion: Nurses can reliably apply most of the criteria of the CCR but are uncomfortable assessing range of movement. With further education and support, nurses should be apply to safely apply the CCR.

Fast, but too late? Arian Lasocki, Drew Richardson, Howard Galloway Aims: To determine the number of patients in the last 3 years who had an urgent laparotomy (within 6 h of presentation) following an abdominal CT scan demonstrating free fluid. This will help identify the potential role for FAST (focused assessment with sonography for trauma) in blunt abdominal trauma at our hospital. Method: This is a retrospective descriptive study of abdominal CT scans performed from 2000 until 2002 following patients presenting to a tertiary mixed adult/paediatric emergency department with suspected blunt abdominal trauma. Computer records were reviewed on all emergency department patients recorded in the imaging database as having an abdominal CT during this 3-year period. Results: 662 CT scans were performed, of which 648 (97.9%) had reports. 141 (21.8%) scans were positive for intra-abdominal and/or intrapelvic fluid. 25 patients had urgent laparotomies, of which only 40% had a large amount of fluid on CT. Sensitivity of free fluid on CT scan as a predictor for the need for urgent laparotomy was 96.0%, and specificity was 81.1%. Positive predictive value was 16.9%. The most common organ injuries at laparotomy were small bowel and spleen. Conclusions: FAST has the potential to play an important role in the management of about two patients every three months presenting to this hospital. However, this is likely a substantial overestimate because of FAST's inherent lower sensitivity in identifying free fluid. In our hospital therefore FAST should not replace CT, but rather be a useful adjunct in a small proportion of trauma patients.

Derek Louey, Don Moyes, John Moran Previous research has suggested that the peak fluoride level following continuous methoxyflurane level should not exceed 50 micromol/L, beyond which the risk of polyuric renal insufficiency may become apparent. Methoxyflurane has been largely abandoned within anaesthetic practice but it continues to hold a place in prehospital care where it is employed as an analgesic modality in the form of the Penthrox inhaler®. A study was performed on 3 consecutive patients arriving at The Queen Elizabeth Hospital Emergency Department requiring admission who received 6 mL (the manufacturer's recommended maximum dose) of intermittent methoxyflurane via Penthrox inhaler®. In our small series, all three patients demonstrated levels above 50 µmol/L including one with a recording of 110 µmol/L. Subsequently, a study was conducted on healthy volunteers who were also given 6 mL of methoxyflurane. Preliminary results showed 3 of the 13 subjects returned values equal or above 50 micromol/L with the highest recorded value of 79 micromol/L and a mean value of 41.4 micromol/L. This study raises concerns about the maximum dose recommended by the manufacturer and suggests caution in the use of this dose and the need for further clinical evaluation.

® Penthrox inhaler -Medical Developments Australia Pty Ltd.

Poster Board: 26 Pediatric emergencies on commercial airlines Brian Moore, Jennifer M Sato, David W Claypool Objectives: The purpose of this investigation is to determine the incidence and character of paediatric emergencies on commercial airlines. Methods: The Department of Emergency Medicine at an academic medical centre provides flight consultations to a major United States based international airline (10% of U.S. passengers). Consults were collected into a database that contains 2425 calls, representing > 4 million flights flown from 1995 to 2002 (5.2% were international departures). This is an observational retrospective review of the database. The database was queried for all passengers between the ages of 0-18 years from January 1, 1995 to December 31, 2002. Results: 222 paediatric consults were identified, representing one paediatric call per 20 775 flights. The mean age was 6.8 years. 51 emergencies were preflight calls and 171 were in-flight paediatric consults. The most common in-flight consults were Infectious (27%), Neurologic (14.6%), and Respiratory (12.8%) emergencies. Nineteen flights (11.1%) were diverted (1 per 240 000 flights), most commonly due to Neurologic and Respiratory emergencies. There were 53 emergency consults (31% of in-flight consults) and 6 diversions (32% of diversions) from international flights. International flights had a higher incidence of consults and diversions for paediatric emergencies than did domestic flights (P < 0.0001).

In-flight paediatric emergencies represent 9.2% of all medical consults. This is a retrospective study and the true incidence of in-flight emergencies is likely higher. The most common in-flight emergencies were infectious, neurologic and respiratory. The total number of paediatric emergencies was higher on domestic flights, but occurred with greater frequency on international flights.

Emergency department versus inpatient unit admission diagnostic accuracy Ed Oakley, George Braitberg Introduction: The two major methods used to make the admission decision to hospital are inpatient review in the Emergency Department (ED) or admission decisions made by the ED physician. Accuracy of admission diagnosis is important and has not been previously explored. Objective: To compare ED physician admission diagnostic accuracy, inpatient consultation diagnostic accuracy, and the safety of an ED physician directed admission process. Methodology: Admission diagnostic accuracy of inpatient directed admission was retrospectively determined by chart review. A change in the admission process to ED physician directed admission then enabled assessment of the ED diagnostic accuracy. The discharge diagnosis was used as the comparison for both groups.

Results: The incidence of error was higher in the group admitted by the inpatient unit. There was an error rate of 1 in 8.8 for the inpatient unit admission and 1 in 10.4 for ED physician admission (P = 0.23). However most of the errors in both groups can be attributed to further investigation and progress of the illness while an inpatient. The group admitted via the ED physicians had a slightly shorter length of stay, 7.42 days (95% CI 5.37-9.47) compared with 7.65 days (5.51-9.79) for the inpatient unit admitted group. The median length of stay was 4.0 days for both groups.

with a 6-point lower NPOS at the end of one year (P < 0.05). However after a similar adjustment, there was no apparent effect on the change in VAPS. Consulting a lawyer was associated with a 7-fold lesser chance of claim settlement (P < 0.01) and a 7-fold greater chance of still having treatment (P < 0.01) after one year, but there was no significant association with rate of return to work. The degree of damage to the vehicle was not a significant predictor of delayed settlement.

The SF-36 scores for bodily pain and role emotional are useful means of identifying subjects who are at risk of prolonged disability. These scores may also be a useful marker for identifying subjects who will benefit most from targeted treatment. The findings also support the implementation of an insurance system designed to minimize litigation and which may have a beneficial effect on prognosis of whiplash injury. Where litigation is inevitable, early settlement may aid recovery by removing legal issues. . 20 surfers reported long-term disability from acute injuries, mainly unstable/ stiff/painful joints. Only 12 (1.9%) surfers routinely wore protective headgear with others reporting there was no need (33.9%), discomfort (17.9%) or that it affected their senses/balance (9.6%). The perceived likelihood of a head injury while surfing was significantly less (P < 0.001) than a range of other sports. 136 surfers reported chronic surfing-related problems including chronic/recurrent otitis externa and exostoses, muscle and joint pain/stiffness and pterygium. Conclusion: Surfing may result in a range of injuries. Although head/face injury is common, the perceived risk is low and few surfers wear protective headgear. Interventions to increase the use of headgear are indicated.

Poster Board: 33 Improving acute pain management in ED: A comprehensive approach Simone Taylor, Margaret Ferma, Michael Geluk, Cyril Dixon Objectives: To develop a multidisciplinary approach to improving acute pain management in ED and measure the outcomes using a sustainable quality assurance process. Methods: A multidisciplinary group consisting of medical, nursing, pharmacy, aged care and physiotherapy staff developed a comprehensive program to improve acute pain management. This included reintroduction of a nurse initiated analgesia program enabling nurses to initiate a variety of analgesics in accordance with a detailed algorithm, patient developed posters to encourage greater patient participation in their pain management and improved availability of non-pharmacological measures. Pre and post intervention, patient satisfaction using the American Pain Society's questionnaire and the time to achieve adequate analgesia (pain score < 4) were measured for 50 consecutive patients identified by the ED pharmacist with a pain score at triage of 5 or greater. Results: Time to achieve adequate pain control was reduced from 3.8 h to 2.3 h (P = 0.0034), largely due to improved titration of analgesics. Most patients required more than one dose of analgesic to achieve adequate pain relief. Patients reporting that they were satisfied/very satisfied with their pain management increased from 64% to 89%. Conclusions: A comprehensive approach to acute pain management in ED has yielded significant improvements. This evaluation process has been found to be more valuable than solely determining time to first dose of analgesia, as it measures the adequacy of analgesic titration and the role of non-pharmacological measures.

Poster Board: 34 Improving antibiotic prescribing in ED: An intervention targeting both ED prescribers and admitting units Simone Taylor, Sharmila Melvani, M Lindsay Grayson Introduction: Antibiotic prescribing in ED is a complex process involving both ED doctors and those of other medical specialties.

Numerous studies have suggested that antibiotic prescribing in ED is suboptimal. Objective: To evaluate a multifaceted approach to improve empirical antibiotic prescribing in ED. Methods In-services were provided to ED medical staff to discuss resistance issues, the hospital's electronic antibiotic approval and advice system and the Pneumonia Severity Index calculator for community acquired pneumonia. Similar in-services and consensus building sessions were undertaken with all admitting units. Name badge cards outlining recommended empirical treatment of common indications were provided to all medical staff. During the intervention period, ED pharmacists provided concurrent prescriber feedback to all prescribers in ED. Pre-and post intervention data was collected for 100 consecutive patients receiving intravenous antibiotics in ED for selected common indications. Regimens were evaluated for concordance with hospital antibiotic guidelines and appropriateness according to expert opinion (ID physician blinded as to which group the patient was in). Results: Concordance with hospital antibiotic guidelines at the time of ED discharge improved from 25% to 65% of regimens (P < 0.001). Appropriateness of regimens increased from 50% to 75% ( P = 0.025) according to expert opinion. Conclusion: A multifaceted approach has successfully improved empirical antibiotic prescribing in ED.

Objective: To determine the clinic therapeutic effect of prehospital intravenous thrombolytic therapy with rt-PA in AMI patients, and to verify the safety and practicability of intravenous thrombolytic therapy to AMI patients. Methods: The trial enrolled 119 AMI patients presenting with STsegment elevation (within 6 h of symptom onset). Sixty AMI patients receiving prehospital intravenous thrombolytic therapy with rt-PA (50 mg) were included as the prehospital group, and 59

The rt-PA was administered by an intravenous bolus of 10 mg followed by infusion of 40 mg within 30 min. The effect of the interval from presentation to thrombolytic therapy on the clinic therapeutic affection of prehospital intravenous thrombolytic therapy was evaluated. Result: The number of AMI patients whose interval from symptom onset to thrombolytic therapy was w!

The interval from symptom onset to presentation was significantly different between two groups (2.1 ± 1.2 h vs. 3.2 ± 2.3 h, P < 0.05) & #65307; The total reopening rate of coronary blood vessel was 91.7% in prehospital group, and similarly 77.8% in inhospital group ( P < 0.05). 79 AMI patients were received coronary angiography. The prehospital group had significantly higher patency rates than the inhospital group (TIMI 2 and 3: 92.6% vs. 65%, P < 0.05); There were not severe bleeding incidence occurred in both groups. Conclusion: Prehospital intravenous thrombolytic therapy with rt

Conclusion: ED Physician directed admission is both a safe and accurate way to diagnose patient's illness and arrange admission to hospital.Poster Board: 28 Using video recording to identify potential adverse events in paediatric trauma resuscitation Ed Oakley, Sergio Stocker, George Staubli, Simon Young Introduction: Trauma management problems have previously been shown to contribute to death. Videotape has been used to evaluate resuscitations. Can it help us manage trauma better? Aims: To investigate the utility of videotaping in identifying treatment errors made by the trauma team in the resuscitation of injured children. To determine if any of these treatment errors lead to adverse outcomes for the children. To asses the need to develop a teaching package to correct the frequent errors. Methods: All children who presented to the Emergency Department (ED) of the Royal Children's Hospital, between 19 February 2001 and 18 August 2002, for whom the trauma team was activated, were to be videotaped. The ED staff started the videotaping via a remote activation switch. Resuscitation was measured against EMST/APLS guidelines. Deviations from these guidelines were classed as management errors. Results: 90 videotaped trauma resuscitations were reviewed. Trauma team personnel present within 15 min of the patient: general surgery -55%; neurosurgery -70%; and radiographer -60%. There were on average 3.5 management errors per patient, these were fewer in the more seriously injured (ISS > 11). History review adds to videotape analysis but detected only 30% of errors. No causative effect for adverse events found could be established. Conclusions: Videotape review should be an integral part of resuscitation review and the problems of confidentiality can be overcome.

Is emergency department leukocytosis in transient ischemic attack associated with poorer survival? Benjamin Peake, Latha G Stead, Amy L Weaver, Wyatt W Decker Objective: To determine whether an initial elevated white blood cell count in the emergency department (ED) correlates with mortality in transient ischemic attack (TIA). Methods: The records of all 72 patients with a final diagnosis of transient ischemic attack (ICD-9 code 435) presenting to the Saint Marys Hospital Emergency Department in a six month period was performed. Data on ED complete blood count values, and dates of death and last follow-up were abstracted. All consecutive patients in the mentioned time period were captured; there were no missing charts. Associations with survival were evaluated based on fitting univariate Cox proportional hazards models and summarized by calculating risk ratios (RR, risk per a 10 unit decrease) and 95% confidence intervals (CI). This study was approved by the authors' institutional review board. Results: Of the 72 patients, 69 had laboratory analysis performed in the ED. A total of 7 patients had an elevated white blood cell count defined as > 10.5 × 109/L. Among these 7 patients with leukocytosis there were 3 deaths at 17, 377, and 431 days. Using the Kaplan-Meier method, the estimated survival at 6 months was 80.0%. Among the 62 patients without leukocytosis there were 5 deaths at 17, 61, 145, 201, and 321 days; the estimated survival at 6 months was 94.5%. There was a statistically significant association between leukocytosis and overall survival (logrank test; P = 0.003). Conclusion: An initial elevated white blood cell count (leukocytosis) in the ED appears to be associated with poorer survival in TIA.

Objective: This study aimed to identify how the recently reported increased average ward length of stay (LOS) in AB patients is confounded by patient age in a diagnostic subgroup identified in the ED. Methods: Retrospective, descriptive study of all patients admitted through ED to an inpatient bed in a tertiary hospital with a recorded ED diagnosis of obstructive airways disease (including asthma) (ICD10 J40.0-J45.9) or pneumonia (ICD10 J12.0-J18.9) in 2000-01. Standard definitions were used: LOS = days from admission to discharge, or 1 if on same day, Access Block = Time from ED arrival to admission more than 8 h. LOS was described as 'long' if more than 4 days or 'short' otherwise. Results: LOS was longer in AB patients for both diagnoses (Asthma: 4.65 vs. 3.82, n = 887, P = 0.05, Pneumonia: 6.78 vs. 5.46, n = 710, P = 0.02). However, both LOS and rate of AB were correlated with age, and there was no significant difference between LOS with and without AB in each age group (95% CI):Conclusions: In this sample, the access block effect on LOS is caused by the confounding effect of age on rates of AB and LOS. Recorded ED diagnosis is not an appropriate means of controlling for casemix in a mixed age population. Future studies of LOS for ED patients should use validated inpatient casemix measures to account for age related variations.

A prospective study to identify risk factors predictive of prolonged disability from whiplash injury James Smyth, O Osti, A O'Riordan, G Eckerwall, F Mpelasoka, R Gun Study Design: A prospective study of 135 subjects with whiplash injury. Objectives: To identify factors predictive of prolonged disability following whiplash injury. Introduction: Whilst subjects with whiplash associated disorders lack demonstrable physical injury, a significant percentage exhibit prolonged disability. Moreover disability is unrelated to the severity of the collision, measured in terms of vehicle damage. It has been proposed that psychological factors and litigation are mainly responsible for prolonged disability. Methods: 147 subjects with whiplash were recruited within one month of the accident and interviewed for putative risk factors for disability, including physical and mental wellbeing assessed with the SF-36 Health Questionnaire. Of these subjects, 135 were reinterviewed one year after the accident, and recovery was assessed by five outcomes -increase in 'neck pain outcome score' (NPOS), improvement in visual analogue pain score (VAPS), return to work, no longer having treatment and settlement of claim. Bivariate and multivariate analyses were undertaken to measure the association between putative risk factors and measures of outcome. Results: The bodily pain score and role emotional scores of the SF-36 health questionnaire showed a consistent significant positive association with better outcomes. After adjustment for bodily pain score and role emotional scores, consulting a lawyer was associated Age (year) Asthma LOS AB% Pneumonia LOS AB% 0-14 1.8 (1.7-1.9) 6.5 2.5 (2.3-2.6) 9.2 15-44 3.0 (2.6-3.4) 18.1 5.7 (4.7-6.1) 25.0 45 7.3 (6.6-8.0) 22.7 9.1 (8.3-9.8) 31.4