The COVID‐19 Delta variant of concern continues to pose significant challenges to health systems globally, with increased transmissibility and different patient populations affected. In Sydney, a virtual model of care was implemented in response to the COVID‐19 pandemic and Special Health Accommodation (SHA) was made available for community patients with COVID‐19 who could not isolate at home or needed health support.

Emergency Medicine AustralasiaVolume 31, Issue 3 p. 495-496 Letter to the Editor Patients attending an emergency department with a general practitioner referral letter who are discharged home have a longer length of stay than those without a letter Michelle T Parsonage, Michelle T Parsonage orcid.org/0000-0001-5080-8225 Emergency Department, Royal Prince Alfred Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorEmily Nash, Emily Nash Basic Physician, Royal Prince Alfred Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorDane Chalkley, Dane Chalkley Emergency Department, Royal Prince Alfred Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorCharlotte Hespe, Charlotte Hespe School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, AustraliaSearch for more papers by this author Michelle T Parsonage, Michelle T Parsonage orcid.org/0000-0001-5080-8225 Emergency Department, Royal Prince Alfred Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorEmily Nash, Emily Nash Basic Physician, Royal Prince Alfred Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorDane Chalkley, Dane Chalkley Emergency Department, Royal Prince Alfred Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorCharlotte Hespe, Charlotte Hespe School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, AustraliaSearch for more papers by this author First published: 18 March 2019 https://doi.org/10.1111/1742-6723.13284Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume31, Issue3June 2019Pages 495-496 RelatedInformation

ObjectiveThe present study describes patients with acute behavioural disturbance presenting to the ED, the impact they have on the department and any complications that occur. MethodsWe performed a prospective observational study of adult patients (>17years old) requiring parenteral sedation for acute behavioural disturbance over a 13month period. Demographic data, mode of arrival, indication, drug type and dosing used for sedation were collected. Departmental data were recorded including the staff type and numbers involved and the condition of the department. The main outcomes were complications from sedative medication and injury sustained to patients or staff. ResultsOver the study period 173 patients met inclusion criteria, the majority (n=104, 60%) were men with a mean age of 38.5 years (standard deviation 14.4); 51% of patients had more than one indication for sedation (n=89), the commonest being mental health related plus drug intoxication (n=30, 33.7%). Intoxication was frequently from either alcohol (n=62, 47%) or methamphetamine (n=41, 31%). The median number of staff involved was 10 (interquartile range 8-12). Staff members received an injury in 12% (n=20) of sedations, with only 1% (n=2) of patients receiving any physical injury; 12% (n=20) had a minor complication from the sedation medication. No patient had any major complication (apnoea, intubation, arrhythmias or cardiac arrest). ConclusionPatients with acute behavioural disturbance often have a history of mental illnesses and are commonly intoxicated. These patients have impacts on healthcare resources and pose risks to staff safety, but significant complications to patients do not occur frequently.

Objective: To evaluate population trends in presentations for mental health problems presenting to emergency departments (EDs) in New South Wales during 2010-2014, particularly patients presenting with suicidal ideation, self-harm, or intentional poisoning. Design, setting and participants: This was a retrospective, descriptive analysis of linked Emergency Department Data Collection registry data for presentations to NSW public hospital EDs over five calendar years, 2010-2014. Patients were included if they had presented to an ED and a mental health-related diagnosis was recorded as the principal diagnosis. Main outcome measures: Rates of mental health-related presentations to EDs by age group and calendar year, both overall and for the subgroups of self-harm, suicidal ideation and behaviour, and intentional poisoning presentations. Results: 331 493 mental health-related presentations to 115 NSW EDs during 2010-2014 were analysed. The presentation rate was highest for 15-19-year-old patients (2014: 2167 per 100 000 population), but had grown most rapidly for 10-14-year-old children (13.8% per year). The combined number of presentations for suicidal ideation, self-harm, or intentional poisoning increased in all age groups, other than those aged 0-9 years; the greatest increase was for the 10-19-year-old age group (27% per year). Conclusions: The rate of mental health presentations to EDs increased significantly in NSW between 2010 and 2014, particularly presentations by adolescents. Urgent action is needed to provide better access to adolescent mental health services in the community and to enhance ED models of mental health care. The underlying drivers of this trend should be investigated to improve mental health care.

ObjectivesTo describe population based trends and clinical characteristics of injury related presentations to Emergency Departments (EDs).Design and settingA retrospective, descriptive analysis of de-identified linked ED data across New South Wales, Australia over five calendar years, from 2010 to 2014.ParticipantsPatients were included in this analysis if they presented to an Emergency Department and had an injury related diagnosis. Injury severity was categorised into critical (triage category 1–2 and admitted to ICU or operating theatre, or died in ED), serious (admitted as an in-patient, excluding above critical injuries) and minor injuries (discharged from ED).Main outcome measuresThe outcomes of interest were rates of injury related presentations to EDs by age groups and injury severity.ResultsA total of 2.09 million injury related ED presentations were analysed. Minor injuries comprised 85.0%, and 14.1% and 1.0% were serious and critical injuries respectively. There was a 15.8% per annum increase in the rate of critical injuries per 1000 population in those 80 years and over, with the most common diagnosis being head injuries. Around 40% of those with critical injuries presented directly to a major trauma centre.ConclusionCritical injuries in the elderly have risen dramatically in recent years. A minority of critical injuries present directly to major trauma centres. Trauma service provision models need revision to ensure appropriate patient care. Injury surveillance is needed to understand the external causes of injury presenting to hospital.

Objective: The objective of the present study is to demonstrate a novel method of mapping ED activity to analyse patterns presentations, occupancy and performance trends.Methods: This was a retrospective, descriptive analysis of de-identified and linked ED presentations across NSW, Australia, over five calendar years, 2010-2014. It was undertaken as part of the Demand for Emergency Services Trend in Years 2010-2014 (DESTINY) study. The DESTINY project analysed 10.8 million presentations during 2010-2014. Hourly Emergency Activity Tracking (HEAT) maps were generated to visually represent and analyse the number of emergency arrivals to ED occupancy and proportion of patients leaving the ED within 4 h per hour of day across consecutive months of the year.Results: HEAT maps provided a means of visually representing ED activity to demonstrate hour-to-hour trends in presentations, occupancy and performance between 2010 and 2014. This analysis has shown that the most marked increase in presentations per hour has occurred during the 10.00-14.00 hour period, associated with an improvement in ED performance during the same period.Conclusion: HEAT maps may be used to facilitate further analyses of ED demand, patterns of patient presentations and patient flow and future health system redesign.

ObjectiveThe objective of this study is to describe the trends and characteristics of short-term and frequent representations to EDs in New South Wales, Australia.MethodsThis was a retrospective analysis of a linked population-based registry of ED representations in New South Wales, conducted as part of the Demand for Emergency Services in Years 2010-2014 project. Trend analysis of unplanned representations to ED within 3days of discharge from ED, readmission to an in-patient unit within 30days of index in-patient admission from ED and demographic data and trends for frequent and very frequent ED presenters is discussed.ResultsA total of 10798797 ED presentations were identified from 4188283 individual patients. Within 1year, 48.9% of ED presentations had a previous presentation, and 4.9% had represented within 3days of a previous presentation. The readmission rate within 30days was 2.8%, the proportion of frequent (representing 5212 [0.1%] individual patients) and very frequent representations (representing 1186 [0.03%] individual patients) were 1.7% and 1.0%, respectively. The overall rate of representations within 3days has decreased from 5.1% in 2010 to 4.7% in 2014 (P<0.001). The rate of readmissions within 30days has increased from 2.4% in 2010 to 3.1% in 2014 (P<0.001).ConclusionsIn this population-based study, short-term representations were highest in the infant patient population, in-patient readmission rates were highest in the elderly and very frequent representations to ED were characterised by middle-aged patients with mental health or drug and alcohol related presentations.

OBJECTIVE:The present study aims to use a statewide population-based registry to assess the prevalence of low acuity emergency department (ED) presentations, describe the trend in presentation rates and to determine whether they were associated with various presentation characteristics such as the type of hospital as well as clinical and demographic variables.DESIGN AND SETTING:This was a retrospective analysis of a population-based registry of ED presentations in New South Wales (NSW). Generalised estimating equations with log links were used to determine factors associated with low acuity presentations to account for repeat presentations and the possibility of clustering of outcomes.PARTICIPANTS:Patients were included in this analysis if they presented to an ED between January 2010 and December 2014. The outcomes of interest were low acuity presentation, defined as those who self-presented (were not transported by ambulance), were assigned a triage category of 4 or 5 (semiurgent or non-urgent) and discharged back to usual residence from ED.RESULTS:There were 10.7 million ED presentations analysed. Of these, 45% were classified as a low acuity presentation. There was no discernible increase in the rate of low acuity presentations across NSW between 2010 and 2014. The strongest predictors of low acuity ED presentation were age <40 years of age (OR 1.77); injury or musculoskeletal administrative and non-urgent procedures (OR 2.96); ear, nose and throat, eye or oral (OR 5.53); skin or allergy-type presenting problems (OR 2.84).CONCLUSIONS:Low acuity ED presentations comprise almost half of all ED presentations. Alternative emergency models of care may help meet the needs of these patients.

This perspective article summarises the experience of conducting a multicentre research project. We describe expected and unexpected hurdles we experienced as well as suggesting possible solutions for researchers embarking on multicentre studies.

Disposition decisions are critical to the functioning of Emergency Departments. The objectives of the present study were to derive and internally validate a prediction model for inpatient admission from the Emergency Department to assist with triage, patient flow and clinical decision making.

Objective: This study aims to describe the general characteristics and data definitions used in a population-based data set of ED presentations in New South Wales (NSW), used to form the basis of future-trend analyses.Methods: Retrospective analysis of the Emergency Department Data Collection registry, which provided clinical and demographic information of ED presentations across all EDs in NSW between 2010 and 2014. Presenting problems and ED diagnoses were classified using broad clinical categories including injury/musculoskeletal, respiratory, cardiovascular, ear nose and throat, and mental health. Presentations were linked by patient to allow for analysis of representations, and population data were obtained from the Australian Bureau of Statistics.Results: There were 11.8 million presentations that were analysed from 150 EDs (80.6% of all EDs). The rate of ED presentations was highest in those aged 85 years and older and appears to increase across all age groups between 2010 and 2014. The most common ED diagnosis categories were injury/musculoskeletal (27.5%) followed by abdominal/gastrointestinal (12.3%), respiratory (9%) and cardiovascular (8%). Both the Systematised Nomenclature of Medicine Clinical Terms (66%) and the International Classification of Diseases (24%) were used to code ED diagnoses.Conclusions: The elderly population had the highest rate of ED attendances. The use of diverse diagnosis classifications and source information systems may present problems with further analysis. Patterns and characteristics of ED presentations in NSW were broadly consistent with those reported in other states in Australia.

ObjectivesOur primary aim was to analyse the quality of letters from general practitioners (GPs) to the ED as defined by two checklists: the authors' own nine-item list and a template published in 2013 by the New South Wales Agency for Clinical Innovation. The secondary aim was to determine if referral quality was influenced by letter format (handwritten or computer-generated) or urgency of the patient's condition (defined by triage category).MethodsThe present study is a retrospective audit of records of patients presenting to Royal Prince Alfred Hospital ED from a GP during February and March 2014.ResultsOut of 12199 ED presentations, 575 (4.7%) were recommended by a GP and 414 (72.0%) had a letter. Greater than 60% completion was achieved in 80.9% of letters compared to our own checklist, and in 6.3% compared to the Agency for Clinical Innovation checklist. Computer-generated letters were more likely to be fully legible and include an accurate medical history and medication list. Handwritten letters were less frequent (11.9%) but of poorer quality and legibility. Overall, less than half of letters contained results, psychosocial history or vaccination history. Referrals for patients assigned an urgent triage category were more likely to contain examination findings, but there was otherwise no difference in quality.ConclusionsReferral quality was influenced by letter format but not by urgency of the patient's condition. Omission of information from referral letters potentially risks patient safety. Handwritten referrals should be abandoned. Comprehensive electronic letter templates and regular updating of medications, comorbidities and allergies are encouraged.

Abstract Objectives: The study aimed to analyze ambulance transportations to Emergency Departments (EDs) in New South Wales (NSW) and to identify temporal changes in demographics, acuity, and clinical diagnoses. Methods: This was a retrospective analysis of a population based registry of ED presentations in New South Wales. The NSW Emergency Department data collection (EDCC) collects patient level data on presentations to designated EDs across NSW. Patients that presented to EDs by ambulance between January 2010 and December 2014 were included. Patients dead on arrival, transferred from another hospital, or planned ED presentations were excluded. Results: A total of 10.8 million ED attendances were identified of which 2.6 million (23%) were transported to ED by ambulance. The crude rate of ambulance transportations to EDs across all ages increased by 3.0% per annum over the five years with the highest rate observed in those 85 years and over (620.5 presentations per 1,000 population). There was an increase in the proportion of category 1 and 2 (life-threatening or potentially life-threatening) cases from 18.1% to 24.0%. Conclusion: Demand for ambulance services appears to be driven by older patients presenting with higher acuity problems. Alternative models of acute care for elderly patients need to be planned and implemented to address these changes.

ObjectivesThe objectives of the present study were to describe the injury profiles of cyclists presenting to an ED and determine the risk of significant head injury associated with bicycle helmet use.MethodsThis was a retrospective single trauma centre study of all adult cyclists presenting to an inner city ED and undergoing a trauma team review between January 2012 and June 2014. The outcome of interest was significant head injury defined as any head injury with an Abbreviated Injury Scale score of two or more. Variables analysed included demographic characteristics, helmet use at time of incident, location, time and the presence of intoxication.ResultsThe most common body regions were upper limb injuries (57%), followed by head injuries (43%), facial injuries (30%) and lower limb injuries (24%). A lower proportion of people wearing helmets had significant head injury (17% vs 31%, P = 0.018) or facial injury (26% vs 48%, P = 0.0017) compared with non-helmet users. After adjustment for important covariates, helmet use was associated with a 70% decrease in the odds of significant head injury (odds ratio 0.34, 95% confidence interval 0.15, 0.76, P = 0.008).ConclusionsHead injuries were common after inner city cycling incidents. The use of helmets was associated with a reduction in significant head injury.

OBJECTIVE:To contrast long-term population-based trends in general practice (GP) presentations and acute inpatient admissions from the emergency department (ED) in the elderly population within the Greater Sydney Area.METHODS:This was a retrospective analysis of population-based ED presentation data over 11 years, between January 2001 and December 2011, conducted within the Greater Sydney Area in Australia. De-identified data were obtained from the New South Wales Emergency Department Data Collection database on all patients presenting to 30 public hospital EDs located within the Greater Sydney Area. The outcomes of interest were GP presentations to ED (triage category 4 or 5, self-referred and discharged from ED) and of acute inpatient admissions from ED per 1000 population.RESULTS:Over 11 million presentations were identified. Around 40% of presentations were classified as a GP presentation and 23% were classified as acute inpatient admissions. There was a 2.9% per annum increase in acute inpatient admissions per 1000 population in those ≥80 years of age and no appreciable change in other age groups. Rates of GP presentations were higher in those <65 years of age. GP presentations increased 1.9% per annum in those aged <65 years of age.CONCLUSIONS:The increase in ED demand appears to be driven by the elderly presenting with acute problems requiring inpatient admission. There has been a modest increase in the rate of GP presentations to ED.

Objectives: We aimed to provide 'adequate analgesia' (which decreases the pain score by >= 2 and to < 4 [0-10 scale]) and determine the effect on patient satisfaction.Methods: We undertook a multicentre, cluster-randomised, controlled, intervention trial in nine EDs. Patients with moderate pain (pain score of >= 4) were eligible for inclusion. The intervention was a range of educational activities to encourage staff to provide 'adequate analgesia'. It was introduced into five early intervention EDs between the 0 and 6 months time points and at four late intervention EDs between 3 and 6 months. At 0, 3 and 6 months, data were collected on demographics, pain scores, analgesia provided and pain management satisfaction 48 h post-discharge (6 point scale).Results: Overall, 1317 patients were enrolled. Logistic regression (controlling for site and other confounders) indicated that, between 0 and 3 months, satisfaction increased significantly at the early intervention EDs (OR 2.2, 95% CI 1.5 to 3.4 [P<0.01]) but was stable at the control EDs (OR 0.8, 95% CI 0.5 to 1.3 [P=0.35]). Pooling of data from all sites indicated that the proportion of patients very satisfied with their pain management increased from 42.9% immediately pre-intervention to 53.9% after 3 months of intervention (difference in proportions 11.0%, 95% CI 4.2 to 17.8 [P=0.001]). Logistic regression of all data indicated that 'adequate analgesia' was significantly associated with patient satisfaction (OR 1.4, 95% CI 1.1 to 1.8 [P<0.01]).Conclusions: The 'adequate analgesia' intervention significantly improved patient satisfaction. It provides a simple and efficient target in the pursuit of best-practice ED pain management.

Dear Editor, We read with interest the article by Fogarty et al , and agree that distraction has an important role in the management of children in distress.1 Their success of distraction was not influenced by the model of rubber glove created, …

Introduction Trauma data collection by UK hospitals is non-mandatory and data regarding trauma mortality are deficient. Our aim was to provide a contemporary description of mortality in a maturing trauma-receiving hospital serving an inner-city population. Methods A prospectively maintained registry was analysed for demographics; injury mechanism; and time, location and cause of death in trauma patients admitted via the Emergency Department between 2004 and 2008. Results 4986 trauma team activations yielded 4243 complete cases. The number of patients rose from 784 in 2004–2005 to 1400 in 2007/8. 302 (7%) of these died. All-cause mortality fell from 8.8% to 5.8% (p=0.0075). Blunt trauma (predominantly falls from height and road traffic collisions) accounted for 79% of admissions but 87% of mortality. Penetrating trauma accounted for 21% of admissions and 13% of mortality. Most penetrating injury deaths were from stabbing injury (31/40) as opposed to gunshot wounds (8/40). The biggest cause of death was central nervous system injury (47.7%) followed by haemorrhage (26.2%). Penetrating injury death was associated with marked shock and acidosis compared to blunt mechanisms—mean (SD) admission systolic blood pressure 25.4 (45.7) versus 105.5 (60.5) mm Hg; mean (SD) base excess −21.84 (7.2) versus 9.71 (8.45) mmol, respectively. No classical trimodal distribution of death was observed. Conclusion Despite current focus on death from knife and gun crime, the vast majority of trauma mortality arises from blunt aetiology. Maturation of our systems of care has been associated with a drop in mortality as institutional trauma volumes increase and clinical infrastructure develops.

A case of an ascending aortic injury caused by a fall from height is presented. The patient had a suspicion of this injury identified on chest x ray and computed tomography (CT) scan. Subsequent aortography was necessary to clarify further the type and location of injury. This case highlights the potential difference in management between ascending aortic injuries and more common descending aortic injuries (in which diagnosis and choice of treatment can be based on CT alone). After CT has identified a possible ascending aortic injury, aortography is needed because CT images of this region are less diagnostic and clear.

A case is presented in which a knife wound to the head was initially assessed as inconsequential and later proved to be significant. This case illustrates the necessity of exploring scalp wounds to assess for possible skull fractures and of using the history to direct management. It also highlights the requirement for thorough guidelines for use by junior staff and for the staff to apply them with some degree of latitude.