OBJECTIVE:Acid-base patterns and their association with clinical outcomes have not been characterised using venous-specific reference ranges in a sedative-specific cohort. We aimed to characterise acid-base phenotypes in sedative toxidrome using venous-specific thresholds, examine agent-specific associations and evaluate relationships to adverse outcomes. METHODS:Retrospective cohort study of 374 consecutive patients referred to a toxicology service with sedative poisoning between November 2022 and November 2023. VBG data (pH, pCO2, HCO3 and lactate) were classified into acid-base phenotypes using venous-specific reference ranges (venous respiratory acidosis: pH < 7.31, pCO2 > 51 mmHg; hypercapnia with preserved pH: pH 7.31-7.41, pCO2 > 51 mmHg). Outcomes of interest were endotracheal intubation, ICU admission and in-hospital complications. Associations were assessed using chi-squared tests, Mann-Whitney U tests and ROC curve analysis. RESULTS:VBG was obtained in 330 of 374 patients (88.2%). Venous respiratory acidosis occurred in 54 patients (16.4%), hypercapnia with preserved pH in 81 (24.5%) and normal venous pH in 153 (46.4%). Opioid exposures had the highest hypercapnic burden (59%) compared with anti-psychotic exposures (20%; p < 0.001). Venous respiratory acidosis was associated with ICU admission (40.7% vs. 17.0%, p = 0.001) and complications (64.8% vs. 32.7%, p < 0.001). Among hypercapnic patients, pCO2 ≥ 65 mmHg was associated with ICU admission in 50.0%. Venous pH had the strongest discriminative performance across outcomes (AUC 0.631-0.683). CONCLUSIONS:Venous respiratory acidosis identifies a high-risk subgroup. Hypercapnic burden varies substantially by agent class. These findings support routine early VBG measurement in sedative overdose and highlight the importance of venous-specific thresholds when interpreting point-of-care acid-base results.
OBJECTIVE:To investigate whether the Sydney Triage to Admission Risk Tool with Artificial Intelligence (START-AI) model could be used to predict specific inpatient admitting teams based on clinical notes. METHODS:This was a pre-trained language model analysis using electronic medical record data from an inner-city tertiary referral hospital emergency department (ED) in Sydney, Australia. All adult patients who were admitted to an inpatient ward between January 2023 and June 2025 were included. A fine-tuned Bidirectional Encoder Representation of Transformer (Bio-ClinicalBERT) used in the original START-AI analysis was trained on ED medical case history notes to predict one of twenty specialist inpatient admitting teams. RESULTS:A total of 40,054 cases were analysed. The overall weighted average area under receiver operating characteristic curve (AUROC) was 0.97 (95% CI: 0.96, 0.98). For individual classes of inpatient admitting teams, AUROC ranged from 0.91 for infectious diseases to 0.99 for psychiatry and gynaecology. The overall weighted average precision (positive predictive value) was moderate at 0.71 (95% CI: 0.71, 0.72). The model correctly classified around three quarters of the dataset (accuracy 0.75 (95% CI: 0.74, 0.076)). Accuracy in correctly assigning one of the two most probable admitting teams by the model was 0.88 (95% CI: 0.88, 0.89). CONCLUSIONS:A pre-trained language model used in START-AI was able to accurately predict the inpatient admitting team for ED patients requiring admission based on ED medical case history notes in a single centre study. Further exploration and validation are warranted to assess clinical utility and broader feasibility of the modelling approach.
Bronchiolitis is the leading cause of hospital presentation and admission for infants in Australasia. We aimed to synthesise current evidence on the effect of discharge criteria for infants (aged < 12 months) who are presenting to or are admitted to hospital with bronchiolitis, to inform a binational guideline recommendation update. Systematic searches were conducted on MEDLINE, EMBASE, PubMed, Cochrane Library and CINAHL (last search 19 February 2025) for non-randomised studies evaluating hospital discharge criteria in bronchiolitis. The primary outcomes were length of stay (LOS) and readmission rates. The risk of bias (ROBINS-I) and certainty of the evidence (GRADE) were appraised, and findings were narratively synthesised. GRADE evidence-to-decision methodology, expert consensus voting and interest-holder consultation were used to finalise the recommendation update. Two retrospective observational studies were included (N = 2697) (low to very low quality), reporting on unique discharge criteria. In both studies, use of the discharge criteria was associated with a significant reduction in LOS relative to alternative protocols. There was no significant difference in readmission rates observed in either study. There was low to very low certainty evidence across outcomes due to risk of bias, indirectness and imprecision. The review findings informed a recommendation update for safe discharge criteria in the 2025 Australasian Bronchiolitis Guideline update. Updated, prescriptive discharge criteria and flow chart were developed, covering clinical stability, oxygen saturation/support, feeding difficulties, caregiver confidence and education on deterioration, social factors and follow-up. The revised criteria provide clinicians with increased certainty in decision-making in bronchiolitis, albeit with further research needed.
OBJECTIVE:Image archiving is one of the least developed aspects of emergency department ultrasound (ED-US) in Australasia, despite its recognised role in governance, education, quality assurance (QA) and medicolegal protection. A middleware-based ED-US image workflow solution was installed at Nepean Hospital ED in October 2021. We describe our implementation and 4-year experience with a dedicated ED-US archiving solution at a tertiary Australian ED. METHODS:Single-centre retrospective analysis of service implementation, technical requirements, governance, QA and operational outcomes over a 4-year period. RESULTS:Archived 7281 ED-US studies across 15 modalities between October 2021 and April 2026, with annual volume growing from 1083 (2022) to 2224 (2025). Bidirectional EMR connectivity, worklist generation, seamless DICOM image transfer, segregation of clinical from educational studies, structured reporting, interdepartmental image access, automated trainee logbooks and structured QA review are implemented. No failures occurred, and no data were lost. Costs of implementation and maintenance depend on vendor negotiation and local IT costings; the dominant recurring cost is clinician time, not software. The most challenging aspects were IT resource allocation, multivendor integration and governance workload. The automated logbook alone saves each trainee approximately 2 h/week. No medicolegal incidents were reported. CONCLUSIONS:A structured ED-US archive and workflow are achievable and sustainable in an Australian tertiary ED. In our case, it strengthened accountability, quality of scans, education, research, interdepartmental collaboration and institutional risk management. Our experience provides Australasian EDs with a practical starting point for planning their own implementation.
OBJECTIVE:Territory Day is celebrated annually on 1st July in the Northern Territory, the only time and place in Australia with unrestricted access to fireworks. While fireworks contribute to the festive atmosphere, they also pose significant risks, particularly to ocular health. This study investigates the incidence, injury types, and outcomes of firework-related eye injuries on Territory Day for the last 17 years. METHODS:Retrospective case series of firework-related eye injuries from 2008 to 2024 presenting to top end hospitals on Territory Day, with 24th July used as a comparison day. Data was collected from electronic and paper-based medical records. Patient demographics, injury type/mechanism, treatment, and visual outcomes were analysed. RESULTS:Forty-eight cases of firework-related eye injuries were identified. 77.1% were male, with a mean age of 25.2 years. Eye injuries involved the eyelid/adnexa (58.3%), anterior segment (87.5%) and posterior segment (16.7%). The median ED length of stay was 3.0 h (IQR: 2.0-4.8 h). Posterior segment injuries were seven-times more likely to be admitted to hospital (p = 0.024). Most injuries (60.4%) occurred in spectators rather than firework operators. 83.3% of injured individuals lacked eye protection. Firework-related eye injuries accounted for 35.0% (95% CI: 27.0%-43.0%) of all ocular injuries across Territory Days. One hundred and thirty seven ocular injury presentations were recorded on Territory Day, compared with 95 on the comparison day. CONCLUSIONS:Firework-related eye injuries represent a preventable cause of ocular morbidity. Public education, appropriate regulation, and community-based interventions may help reduce the risk of firework-related ocular injury and support safer celebrations.
OBJECTIVE:Evaluate prehospital care quality and outcomes for traumatic brain injury (TBI) patients in Vietnam. METHODS:We conducted a retrospective multicentre audit at three tertiary Hanoi hospitals (January-August 2025), including adults with moderate-severe TBI. Prehospital care was assessed against five EPIC-TBI standards and in-hospital mortality recorded. RESULTS:Of 80 cases, 45 (56.3%) were transported by EMS; 14 (17.5%) received oxygen or saturation monitoring and 11 (13.8%) had blood pressure management. In-hospital mortality was 22/80 (27.5%), with 14/22 (63.6%) of deaths potentially preventable. CONCLUSION:Major prehospital TBI care gaps support the need for enhanced resources, training and quality assurance.
The aims of debriefing can be diverse and may include psychological support, departmental quality improvement or an educational focus. There has been increased attention on 'hot debriefs', however, competing clinical and departmental demands can limit the ability of response teams to meaningfully reflect on critical cases. 'Cold debriefs' are a delayed form of debriefing, occurring days to weeks after the critical event. This article reflects on the implementation of a cold debriefing model within a tertiary emergency department in Australia utilising Lewin's Theory of planned change. Over a 12-month period, 16 referrals for cold debriefs were received, of which 11 were selected to proceed to a formal debrief, with all clinical and non-clinical staff involved in the critical event invited to participate. A standardised and reproducible framework was introduced for facilitators to ensure psychological safety. By offering a cold debriefing process for specific critical events, cold debriefs not only support the clinical team but may also harness opportunities for systems improvement. Ensuring the sustainability of the Cold debrief program required integration and familiarisation within the emergency department, building a stable pool of facilitators and providing remuneration for participants attending outside of rostered work hours.
OBJECTIVE:Alcohol and drug use is an established factor contributing to traumatic injury globally, yet regional and remote prevalence and impact are poorly characterised. This study examines associations between alcohol and drug use and clinical outcomes among major trauma patients in North Queensland. METHODS:A retrospective audit of major trauma patients in Townsville University Hospital Trauma Registry between October 2022-2023. Patients were classified by alcohol and drug use based on toxicology results and electronic medical record. Demographic, injury and outcome variables were compared using descriptive and non-parametric analysis. RESULTS:Of 319 eligible patients, 110 (34.4%) patients were identified within the alcohol and drug cohort. Alcohol was most frequently detected (82.7%), followed by cannabis (20.0%) and amphetamines (12.7%), with 18.2% demonstrating polysubstance use. Alcohol and/or drug-positive patients were significantly younger (40.7 vs. 49.0 years, p = 0.002) and more likely to sustain assault-related injuries (OR 6.9 (95% CI: 3.1-15.3), p < 0.001). No statistical significance was found between groups for ICU admission rate, ICU LOS or hospital LOS. Discharge and mortality outcomes did not differ between groups. CONCLUSION:This study highlights the impact of alcohol and drug use in regional major trauma patients. Standardised testing, targeted prevention and tailored clinical pathways may improve outcomes and reduce the burden of alcohol and drug-related trauma. Inconsistent screening practices mean the true prevalence remains uncertain, warranting further research to determine the impact and guide interventions.
OBJECTIVE:To inform in-event health service (IEHS) delivery and harm minimisation strategies for the planned youth mass gathering event (MGE) known as 'Leavers' in the Southwest region of Western Australia. This study aimed to describe patient emergency department (ED) presentation characteristics and outcomes for Leavers WA. METHODS:A retrospective observational study of patient presentations by Leavers to the Busselton ED at the 2022 MGE. This included 4 days with IEHS operation (7 pm to 1 am), 2 days prior to and 3 days post the MGE. Data analysis included descriptive and inferential statistics. RESULTS:Of 9621 Leavers, 121 (1.26%, PPR 12.6/1000) presented to ED: 12 prior to, 85 during and 24 post the MGE. The majority of presentations were from the community (n = 103, 85.1%). Of 557 Leavers who presented to the IEHS, 18 were transported to hospital (TTHR 1.87/1000). The majority of presentations were ATS 3 and ATS 4 (43.8%, 42.1%). Medical illness was the most common presentation category (n = 59, 48.8%). 51.2% of presentations were related to alcohol/illicit substance use. 85.6% of Leavers were seen and allocated a discharge disposition within 4 h. CONCLUSIONS:Leavers WA celebrations introduced a significant burden on the regional ED with over half the presentations drug and alcohol related and the majority of patients requiring urgent or semi-urgent assessment. The IEHS likely reduced this burden during operational hours. Future research should focus on standardisation of data collection, comparing IEHS and ED presentations, and measuring effectiveness of harm minimisation strategies.
Acute traumatic cardiac tamponade is a time-critical-but potentially reversible-cause of circulatory collapse. The surgical, operative, nursing and anaesthesiology staff most capable and best trained to perform the procedure are often not immediately available, requiring emergency medical staff to perform this life-saving intervention. When tamponade causes refractory shock or peri-arrest, left anterolateral thoracotomy remains the preferred technique for definitive pericardial decompression, with extension to a clamshell thoracotomy when required.
Accurate emergency care depends not only on selecting appropriate investigations and treatments, but also on recognising when they are unnecessary. This article introduces Manufactured Clinical Risk (MCR), a cognitive phenomenon in which non-instrumental information generated by low-utility investigations is reinterpreted as genuine clinical risk and incorporated into subsequent decision making. MCR is proposed as the predictable consequence of relief-based decision making, whereby clinicians seek relief from uncertainty rather than rational assessment of clinical probability. Once established, MCR initiates ambiguity cascades that generate further investigations, referrals, admissions and treatments despite little meaningful change in the patient's underlying probability of disease. This framework provides a plausible explanation for why strategies that accelerate clinical activity do not always produce proportional improvements in emergency department performance. Improving threshold-based decision making may represent an alternative model of performance improvement by safely reducing unnecessary clinical activity before it occurs.
OBJECTIVES:We aim to describe characteristics, assessments and outcomes of pregnant trauma patients (PTP) in South Australia (SA). METHODS:The SA Trauma Registry was utilised to identify PTP from 1 July 2018-30 June 2023. Registry data and patient electronic medical records were analysed using descriptive statistics. RESULTS:Four hundred two patients were included. The mean maternal and gestational ages were 28 years and 27 weeks, respectively. 80% had no comorbidities. Blunt trauma accounted for 98% of injury type. The mechanism of injury for 60% of patients was Motor Vehicle Crash; 16% were uninjured; 58% sustained minor soft tissue injuries only. Despite the low mean ISS (1.6, SD 2.87), trauma teams were activated in 95% of cases. A primary survey was documented in 34%. An obstetric clinician was documented as present in 4% of cases. 96% did not require a medical procedure; three patients underwent emergency Lower Segment Caesarean Section. 93% were discharged directly from ED. Admitted patients had a mean hospital LOS of 21.8 h. There were no maternal deaths. Two patients suffered trauma-related intrauterine foetal demise. The mean gestational age at delivery was 38 weeks; 12% had preterm delivery. No trauma-related neonatal deaths were recorded. CONCLUSIONS:PTP presentations in SA are infrequent, primarily resulting in minor injuries. Trauma assessments are incompletely documented, and along with investigations, often do not adhere to local guidelines. Good trauma care for PTPs should involve an obstetrician and follow ATLS principles. Guidelines should be implemented and followed to ensure standardised comprehensive care of PTPs.
OBJECTIVE:Townsville, North Queensland, experienced record rainfall in the 2024-2025 wet season with an associated surge in the number of patients with melioidosis. A large proportion presented to the Townsville University Hospital (TUH) emergency department (ED), presenting an opportunity to assess the surge from an ED perspective. METHODS:This was a retrospective case series of all patients with melioidosis that presented to TUH ED between 1 November 2024 and 30 April 2025. Cases for the entire region were sourced from the Statewide Reference Laboratory, and then individually assessed to ascertain whether they first presented to the TUH-ED. RESULTS:There were 57 patients with confirmed melioidosis that presented to the TUH ED in the 2024-2025 wet season, 40 males and 17 females. Risk factors for melioidosis were present in 51 (88%), with diabetes being the most common (47%). ED blood cultures were taken in 54 patients and were positive in 36 (67%). All patients were admitted, with a median length of stay of 11 days; 12 (21%) patients had an intensive care admission, and hospital mortality was eight (14%). Pulmonary involvement was evident in 79% and prostatic involvement in 30% of males. Meropenem was administered in ED to 53% overall, and 80% of those with severe illness. CONCLUSIONS:The surge of patients with melioidosis demonstrated a wide spectrum of infection foci and severity of illness. In melioidosis endemic regions following significant rainfall, we recommend to culture widely, administer meropenem for severe infections and consider melioidosis as a cause for unusual presentations.
OBJECTIVE:To evaluate camera-based, advanced sensor technology for contactless vital sign monitoring (versus standard monitoring) posttriage in adult emergency department patients. METHODS:A single-site, prospective, observational study was conducted at Townsville University Hospital Emergency Department between May 2025 and August 2025. Adult (≥ 18 years) walk-in patients were eligible. A convenience sample of consenting participants was recruited. Two sets of vital signs-blood pressure, heart rate, respiratory rate, oxygen saturation, temperature-were obtained. The first set was measured immediately after triage using a dual-camera system comprising a thermographic camera and a second camera with proprietary software. The second set was obtained immediately posttriage using standard monitoring equipment. Reliability and acceptability were the primary and secondary outcomes respectively. Reliability (accuracy and precision) was determined through a Bland-Altman analysis to assess agreement between the two sets of vital signs. Acceptability of technology was assessed using a participant questionnaire. RESULTS:A total of 300 patients were recruited, of whom 288 had complete data on paired vital signs and were included in the Bland-Altman analysis. Minimal bias was observed across most vital signs, indicating limited systematic error. Respiratory rate, oxygen saturation and temperature showed the closest agreement, whereas systolic blood pressure and heart rate exhibited the widest limits of agreement. Acceptability was high, with most participants reporting comfort, ease of use and overall satisfaction. CONCLUSION:Compared with standard vital sign monitoring, camera-based technology demonstrated good accuracy but variable precision across vital signs. Further algorithm refinement is required before reliable clinical integration.
OBJECTIVE:Nephrotoxicity has been reported with prolonged use of aminoglycosides but is considered low-risk with single-dose empirical therapy. However, limited data exist in patients with chronic kidney disease (CKD). The aim of this study was to determine the safety of single-dose aminoglycosides (SDA) in Emergency Departments (ED) in patients with and without CKD. METHODS:A retrospective cohort study was performed in four tertiary hospitals within a multi-site Australian metropolitan hospital network. Electronic medical records of all adult patients who presented to ED and received SDA between August 2019-July 2024 were screened for inclusion. The primary outcome was AKI incidence within 1 week of SDA. RESULTS:Overall, 6636 aminoglycoside administrations were identified, 1835 screened and 660 patients were included. Patients received gentamicin (74.1%), tobramycin (25.6%), or amikacin (0.3%). Patients with CKD were older (81.3 vs. 64.1 years, p < 0.001) and had more comorbidities. AKI incidence within 1 week of hospitalisation was higher in patients with vs. without CKD (30.9% vs. 13.4%, p < 0.001). Patients with CKD had more severe AKI (stage 2: 10.1% vs. 2.6%, p < 0.001) and had numerically, but not statistically, higher mortality and intensive care unit admission rates compared to patients without CKD. CKD was associated with a higher likelihood of AKI incidence (OR 2.88 [95% CI: 1.76-4.71], p < 0.001). CONCLUSIONS:Patients with CKD who received single-dose aminoglycosides were more likely to have AKI compared to patients without CKD. Clinicians should carefully balance the risks and benefits of empiric aminoglycosides in patients with CKD and consider such therapy only if no other suitable alternatives exist.
BACKGROUND:Family, domestic and sexual violence (FDSV) is a global health issue affecting one in four women. Emergency departments (EDs) are often the first point of healthcare contact for people experiencing FDSV. Virtual emergency departments have been introduced in Australia to improve access to care and reduce pressure on physical EDs, but little is known about FDSV presentations in this setting. This study aimed to identify and describe FDSV presentations to the Victorian Virtual Emergency Department (VVED). METHODS:A retrospective cohort study examined FDSV presentations to VVED between 1 July 2023 and 30 June 2024. Cases were identified using VVED, injury surveillance, and clinician documentation data. Records were filtered by age, sex and injury intent, followed by file review to confirm eligibility. Demographic and presentation characteristics were summarised using descriptive statistics. RESULTS:Twenty-one FDSV presentations were identified among 173,936 VVED presentations (0.012%). All were female, median age 37 years. Most were born in Australia (86%) and lived in socioeconomically disadvantaged areas (62%). Intimate partner violence was the most common form of FDSV (81%), and injuries above the clavicle (head, face and neck injuries) were the most frequent presentation (53%). Most patients were referred via healthcare professionals (76%). One-third were directed to physical EDs, while most were managed virtually with follow-up arranged through general practitioners or other healthcare providers. CONCLUSIONS:FDSV presentations were rarely identified in the virtual emergency setting, suggesting under-detection. Virtual EDs offer opportunities to support people experiencing violence, but improved clinician training, documentation and referral pathways are needed.
Vaccine-preventable diseases (VPDs) are re-emerging worldwide, with declining vaccination coverage since the COVID-19 pandemic resulting in outbreaks of previously rare infections in Australasia. Emergency departments are increasingly at the forefront of recognising and managing these diseases while responding to their broader public health implications. This editorial examines the factors contributing to the resurgence of VPDs and declining immunisation rates, and their implications for ACEM training and EM practice. The accompanying articles in this issue provide practical perspectives on managing diphtheria and measles in the emergency department, addressing vaccine hesitancy and preparing for VPD-related examination questions.
