Culture, conditions and care support mental health of healthcare workers during crises

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has presented immense challenges to health systems worldwide and significantly impacted the mental health of frontline healthcare workers.

AIMS

This study drew on the experiences of frontline healthcare workers to examine organizational strategies needed to support the mental health and well-being of healthcare workers during times of crisis.

METHODS

Semi-structured focus groups or individual interviews were conducted with healthcare workers to examine their perspectives on organizational strategies for enhancing staff mental health and well-being during crises. Data were analysed thematically. Following this, evidence for the identified strategies was reviewed to assess alignment with participant views and recommendations.

RESULTS

Thirty-two healthcare workers from diverse disciplines (10 allied health, 11 nursing, 11 medical) participated in the study. Data analysis identified three broad themes contributing to supporting mental health and well-being. These themes can be encapsulated as the 'Three Cs'-culture (building an organizational culture that prioritizes mental health); conditions (implementing proactive organizational strategies during crises) and care (ensuring fit-for-purpose strategies to support mental health and well-being).

CONCLUSIONS

Study findings underscore the necessity of an integrated and systemic organizational approach to address mental health and well-being in the healthcare workplace. This approach must be long term with the components of the 'Three Cs', particularly cultural change and conditions, viewed as a part of a suite of strategies to ensure crisis preparedness. It is imperative that organizations collaborate with their staff, providing support and fostering a safe and inclusive work environment that ultimately benefits patients, their care and staff well-being.

The impact of electric scooters in Melbourne: data from a major trauma service

BACKGROUND

The proliferation of electric scooters globally has been associated with an increase in related injuries and consequent economic burden. This study aims to assess the injury patterns and the economic impact associated with electric scooter use in Melbourne, Australia.

METHODS

A retrospective cohort study was conducted using hospital and registry data from January 2022 to January 2023. Data collected included demographic details, alcohol and helmet use, injury type and severity, operative treatment provided, and direct medical costs. The economic impact (in AUD) of the patient's emergency presentation and hospital admission was calculated.

RESULTS

During the study period, 256 electric scooter related injuries were recorded, comprising 247 riders and nine pedestrians. The majority of patients were males (69%) with a median age of 29.5 (15-78). Alcohol use was reported by 34% and helmet use by 33%. Injuries most commonly affected the upper limb (53%) and head (50%), with abrasions (75%) and fractures (48%) being the most common type of injury sustained. The total hospital cost was $1 911 062, and the median cost was $1321.66 per patient (IQR: $479.37-$5096.65).

CONCLUSION

Electric scooter usage, as observed through patient presentations to the Royal Melbourne Hospital, is associated with a considerable number of injuries, primarily among young males, and an ensuing substantial economic burden. The findings underscore the urgent need for improved safety measures to minimize electric scooter-related injuries and their clinical and economic repercussions.

The impact of rapid diagnostic testing on hospital administrative coding accuracy for influenza

BACKGROUND

Hospital administrative coding may underestimate the true incidence of influenza-associated hospitalisation. Earlier availability of test results could lead to improved accuracy of administrative coding.

METHODS

In this study we evaluated International Classification of Diseases 10 (ICD-10) coding for influenza (with [J09-J10] or without [J11] virus identified) in adult inpatients who underwent testing in the year prior, compared to those in the 2.5 years after, the introduction of rapid PCR testing in 2017. Other factors associated with influenza coding were evaluated using logistic regression. Discharge summaries were audited to assess the impact of documentation and result availability on coding accuracy.

RESULTS

Influenza was confirmed by laboratory testing in 862 of 5755 (15%) patients tested after rapid PCR introduction compared with 170 of 926 (18%) prior. Following the introduction of rapid testing there was a significant increase in patients allocated J09 or J10 ICD-10 codes (768 of 860 [89%] vs 107 of 140 [79%], P = 0.001). On multivariable analysis, factors independently associated with correct coding were rapid PCR testing (aOR 4.36 95% CI [2.75-6.90]) and increasing length of stay (aOR 1.01, 95% CI [1.00-1.01]). Correctly coded patients were more likely to have documentation of influenza in their discharge summaries (95 of 101 [89%] vs 11 of 101 [10%], P < 0.001) and less likely to have pending results at discharge (8 of 101 [8%] vs 65 of 101 [61%], P < 0.001).

CONCLUSION

The introduction of rapid PCR testing for influenza was associated with more accurate hospital coding. One possible explanation is faster test turnaround leading to improvement in clinical documentation.

Reverse triage in COVID surge planning: a case study of an allied health supported clinical care pathway in an acute hospital setting

ObjectiveThis case study describes the development and outcomes of a new integrated and multidisciplinary care pathway. Spearheaded by allied health, the 'COVID community navigator team', applied established principles of reverse triage to create additional surge capacity.MethodsA retrospective cohort study examined workflow patterns using electronic medical records of patients who received navigator input at the Royal Melbourne Hospital between 20 September 2021 and 20 December 2021.ResultsThere were 437 eligible patient encounters identified. On average patients stayed 4.15 h in the emergency departments (ED) (s.d. = 4.31) and 9.5 h (s.d. = 10.9) in the short stay unit. Most patients were discharged into a 'low risk pathway' with community general practitioner follow up. Of discharged patients, only 38 re-presented to the ED with symptoms related to their initial COVID-19 diagnosis (34.9% of total re-admissions). Of these re-admissions, more than half did not require admission to a ward.ConclusionThe findings presented here provide support for the clinical utility of a multidisciplinary reverse triage approach in surge planning for anticipated presentation peaks.

Utility of SARS-CoV-2 rapid antigen testing for patient triage in the emergency department: A clinical implementation study in Melbourne, Australia

Background

Early, rapid detection of SARS-CoV-2 is essential in healthcare settings in order to implement appropriate infection control precautions and rapidly assign patients to care pathways. Rapid testing methods, such as SARS-CoV-2 rapid antigen testing (RAT) may improve patient care, despite a lower sensitivity than real-time PCR (RT-PCR) testing.

Methods

Patients presenting to an Emergency Department (ED) in Melbourne, Australia, were risk-stratified for their likelihood of active COVID-19 infection, and a non-randomised cohort of patients were tested by both Abbott Panbio™ COVID-19 Ag test (RAT) and SARS-CoV-2 RT-PCR. Patients with a positive RAT in the ‘At or High Risk’ COVID-19 group were moved immediately to a COVID-19 ward rather than waiting for a RT-PCR result. Clinical and laboratory data were assessed to determine test performance characteristics; and length of stay in the ED was compared for the different patient cohorts.

Findings

Analysis of 1762 paired RAT/RT-PCR samples demonstrated an overall sensitivity of 75.5% (206/273; 95% CI: 69·9-80·4) for the Abbott Panbio™ COVID-12 Ag test, with specificity of 100% (1489/1489; 95% CI: 99·8-100). Sensitivity improved with increasing risk for COVID-19 infection, from 72·4% (95% CI: 52·8-87·3) in the ‘No Risk’ cohort to 100% (95% CI: 29·2-100) in the ‘High Risk’ group. Time in the ED for the ‘At/High Risk’ group decreased from 421 minutes (IQR: 281, 525) for those with a positive RAT result to 274 minutes (IQR:140, 425) for those with a negative RAT result, p = 0.02.

Interpretation

The positive predictive value of a positive RAT in this setting was high, allowing more rapid instigation of COVID-19 care pathways and an improvement in patient flow within the ED.

Funding

Royal Melbourne Hospital, Melbourne, Australia.

Mental health symptoms in Australian general practitioners during the COVID-19 pandemic

BACKGROUND

General practitioners (GPs) play a central role during the COVID-19 pandemic, and yet awareness of their mental health is limited.

METHODS

A nationwide online survey of self-identified frontline healthcare workers was conducted between 27 August and 23 October 2020. Participants were recruited through health and professional organisations, colleges, universities, government contacts, and media. A subset of the findings on GPs and hospital medical staff (HMS) was used for this study.

RESULTS

Of 9518 responses, there were 389 (4%) GPs and 1966 (21%) HMS. Compared with HMS, GPs received significantly less training on personal protective equipment usage or care for COVID-19 patients, and less support or communication within their workplace. GPs were significantly more concerned about household income, disease transmission to family and being blamed by colleagues if they became infected, all of which were associated with worse psychological outcomes. Significantly more GPs reported burnout, and experienced moderate-to-severe emotional exhaustion than HMS. Both groups used similar coping strategies, except fewer GPs than HMS used digital health applications or increased alcohol consumption. Less than 25% of either group sought professional help.

CONCLUSIONS

GPs are vital in our healthcare systems, yet face unique workplace challenges and mental health stressors during the pandemic. Targeted workplace and psychological support is essential to protect wellbeing among the primary care workforce.

Remote COVID-19 patient monitoring system: a qualitative evaluation

BACKGROUND

Many COVID-19 patients are discharged home from hospital with instructions to self-isolate. This reduces the burden on potentially overwhelmed hospitals. The Royal Melbourne Hospital (RMH) Home Monitoring Programme (HMP) is a model of care for COVID-19 patients which chiefly tracks pulse oximetry and body temperature readings.

OBJECTIVE

To evaluate the feasibility and acceptability of the HMP from a patient perspective.

DESIGN, SETTINGS AND PARTICIPANTS

Of 46 COVID-19 patients who used the HMP through RMH during April to August 2020, 16 were invited to participate in this qualitative evaluation study; all accepted, including 6 healthcare workers. Attempts were made to recruit a gender-balanced sample across a range of COVID-19 severities and comorbidities. Participants completed a brief semistructured phone interview discussing their experience of using the HMP.

OUTCOME MEASURES AND ANALYSIS

A thematic analysis of interview data was conducted. Feasibility was defined as the HMP's reported ease of use. Acceptability was considered holistically by reviewing themes in the interview data.

RESULTS

The HMP allowed clinical deterioration to be recognised as it occurred enabling prompt intervention. All participants reported a positive opinion of the HMP, stating it was highly acceptable and easy to use. Almost all participants said they found using it reassuring. Patients frequently mentioned the importance of the monitoring clinicians as an information conduit. The most suggested improvement was to monitor a broader set of symptoms.

CONCLUSIONS

The HMP is highly feasible and acceptable to patients. This model of care could potentially be implemented on a mass-scale to reduce the burden of COVID-19 on hospitals. A key benefit of the HMP is the ability to reassure patients they will receive suitable intervention should they deteriorate while isolating outside of hospital settings.

High levels of psychosocial distress among Australian frontline healthcare workers during the COVID-19 pandemic: a cross-sectional survey

Background

The coronavirus disease 2019 (COVID-19) pandemic has had a profound and prolonged impact on healthcare services and healthcare workers.

Aims

The Australian COVID-19 Frontline Healthcare Workers Study aimed to investigate the severity and prevalence of mental health issues, as well as the social, workplace and financial disruptions experienced by Australian healthcare workers during the COVID-19 pandemic.

Methods

A nationwide, voluntary, anonymous, single timepoint, online survey was conducted between 27 August and 23 October 2020. Individuals self-identifying as frontline healthcare workers in secondary or primary care were invited to participate. Participants were recruited through health organisations, professional associations or colleges, universities, government contacts and national media. Demographics, home and work situation, health and psychological well-being data were collected.

Results

A total of 9518 survey responses were received; of the 9518 participants, 7846 (82.4%) participants reported complete data. With regard to age, 4110 (52.4%) participants were younger than 40 years; 6344 (80.9%) participants were women. Participants were nurses (n=3088, 39.4%), doctors (n=2436, 31.1%), allied health staff (n=1314, 16.7%) or in other roles (n=523, 6.7%). In addition, 1250 (15.9%) participants worked in primary care. Objectively measured mental health symptoms were common: mild to severe anxiety (n=4694, 59.8%), moderate to severe burnout (n=5458, 70.9%) and mild to severe depression (n=4495, 57.3%). Participants were highly resilient (mean (SD)=3.2 (0.66)). Predictors for worse outcomes on all scales included female gender; younger age; pre-existing psychiatric condition; experiencing relationship problems; nursing, allied health or other roles; frontline area; being worried about being blamed by colleagues and working with patients with COVID-19.

Conclusions

The COVID-19 pandemic is associated with significant mental health symptoms in frontline healthcare workers. Crisis preparedness together with policies and practices addressing psychological well-being are needed.

Longitudinal evaluation of laboratory-based serological assays for SARS-CoV-2 antibody detection

Serological assays for SARS-CoV-2 infection are now widely available for use in diagnostic laboratories. Limited data are available on the performance characteristics in different settings, and at time periods remote from the initial infection. Validation of the Abbott (Architect SARS-CoV-2 IgG), DiaSorin (Liaison SARS-CoV-2 S1/S2 IgG) and Roche (Cobas Elecsys Anti-SARS-CoV-2) assays was undertaken utilising 217 serum samples from 131 participants up to 7 months following COVID-19 infection. The Abbott and DiaSorin assays were implemented into routine laboratory workflow, with outcomes reported for 2764 clinical specimens. Sensitivity and specificity were concordant with the range reported by the manufacturers for all assays. Sensitivity across the convalescent period was highest for the Roche at 95.2-100% (95% CI 81.0-100%), then the DiaSorin at 88.1-100% (95% CI 76.0-100%), followed by the Abbott 68.2-100% (95% CI 53.4-100%). Sensitivity of the Abbott assay fell from approximately 5 months; on this assay paired serum samples for 45 participants showed a significant drop in the signal-to-cut-off ratio and 10 sero-reversion events. When used in clinical practice, all samples testing positive by both DiaSorin and Abbott assays were confirmed as true positive results. In this low prevalence setting, despite high laboratory specificity, the positive predictive value of a single positive assay was low. Comprehensive validation of serological assays is necessary to determine the optimal assay for each diagnostic setting. In this low prevalence setting we found implementation of two assays with different antibody targets maximised sensitivity and specificity, with confirmatory testing necessary for any sample which was positive in only one assay.

Threat of COVID-19 impacting on a quaternary healthcare service: a retrospective cohort study of administrative data

OBJECTIVES

The threat of a pandemic, over and above the disease itself, may have significant and broad effects on a healthcare system. We aimed to describe the impact of the SARS-CoV-2 pandemic (during a relatively low transmission period) and associated societal restrictions on presentations, admissions and outpatient visits.

DESIGN

We compared hospital activity in 2020 with the preceding 5 years, 2015-2019, using a retrospective cohort study design.

SETTING

Quaternary hospital in Melbourne, Australia.

PARTICIPANTS

Emergency department presentations, hospital admissions and outpatient visits from 1 January 2015 to 30 June 2020, n=896 934 episodes of care.

INTERVENTION

In Australia, the initial peak COVID-19 phase was March-April.

PRIMARY AND SECONDARY OUTCOME MEASURES

Separate linear regression models were fitted to estimate the impact of the pandemic on the number, type and severity of emergency presentations, hospital admissions and outpatient visits.

RESULTS

During the peak COVID-19 phase (March and April 2020), there were marked reductions in emergency presentations (10 389 observed vs 14 678 expected; 29% reduction; p<0.05) and hospital admissions (5972 observed vs 8368 expected; 28% reduction; p<0.05). Stroke (114 observed vs 177 expected; 35% reduction; p<0.05) and trauma (1336 observed vs 1764 expected; 24% reduction; p<0.05) presentations decreased; acute myocardial infarctions were unchanged. There was an increase in the proportion of hospital admissions requiring intensive care (7.0% observed vs 6.0% expected; p<0.05) or resulting in death (2.2% observed vs 1.5% expected; p<0.05). Outpatient attendances remained similar (30 267 observed vs 31 980 expected; 5% reduction; not significant) but telephone/telehealth consultations increased from 2.5% to 45% (p<0.05) of total consultations.

CONCLUSIONS

Although case numbers of COVID-19 were relatively low in Australia during the first 6 months of 2020, the impact on hospital activity was profound.

Multi-site assessment of rapid, point-of-care antigen testing for the diagnosis of SARS-CoV-2 infection in a low-prevalence setting: A validation and implementation study

Background

In Australia, COVID-19 diagnosis relies on RT-PCR testing which is relatively costly and time-consuming. To date, few studies have assessed the performance and implementation of rapid antigen-based SARS-CoV-2 testing in a setting with a low prevalence of COVID-19 infections, such as Australia.

Methods

This study recruited participants presenting for COVID-19 testing at three Melbourne metropolitan hospitals during a period of low COVID-19 prevalence. The Abbott PanBio^TM COVID-19 Ag point-of-care test was performed alongside RT-PCR. In addition, participants with COVID-19 notified to the Victorian Government were invited to provide additional swabs to aid validation. Implementation challenges were also documented.

Findings

The specificity of the Abbott PanBio^TM COVID-19 Ag test was 99.96% (95% CI 99.73 - 100%). Sensitivity amongst participants with RT-PCR-confirmed infection was dependent upon the duration of symptoms reported, ranging from 77.3% (duration 1 to 33 days) to 100% in those within seven days of symptom onset. A range of implementation challenges were identified which may inform future COVID-19 testing strategies in a low prevalence setting.

Interpretation

Given the high specificity, antigen-based tests may be most useful in rapidly triaging public health and hospital resources while expediting confirmatory RT-PCR testing. Considering the limitations in test sensitivity and the potential for rapid transmission in susceptible populations, particularly in hospital settings, careful consideration is required for implementation of antigen testing in a low prevalence setting.

Funding

This work was funded by the Victorian Department of Health and Human Services. The funder was not involved in data analysis or manuscript preparation.

Coping strategies adopted by Australian frontline health workers to address psychological distress during the COVID-19 pandemic

OBJECTIVES

The Australian COVID-19 Frontline Healthcare Workers Study investigated coping strategies and help-seeking behaviours, and their relationship to mental health symptoms experienced by Australian healthcare workers (HCWs) during the COVID-19 pandemic.

METHODS

Australian HCWs were invited to participate a nationwide, voluntary, anonymous, single time-point, online survey between 27th August and 23rd October 2020. Complete responses on demographics, home and work situation, and measures of health and psychological wellbeing were received from 7846 participants.

RESULTS

The most commonly reported adaptive coping strategies were maintaining exercise (44.9%) and social connections (31.7%). Over a quarter of HCWs (26.3%) reported increased alcohol use which was associated with a history of poor mental health and worse personal relationships. Few used psychological wellbeing apps or sought professional help; those who did were more likely to be suffering from moderate to severe symptoms of mental illness. People living in Victoria, in regional areas, and those with children at home were significantly less likely to report adaptive coping strategies.

CONCLUSIONS

Personal, social, and workplace predictors of coping strategies and help-seeking behaviour during the pandemic were identified. Use of maladaptive coping strategies and low rates of professional help-seeking indicate an urgent need to understand the effectiveness of, and the barriers and enablers of accessing, different coping strategies.

Variation in CT use for paediatric head injuries across different types of emergency departments in Australia and New Zealand

Objectives

CT of the brain (CTB) for paediatric head injury is used less frequently at tertiary paediatric emergency departments (EDs) in Australia and New Zealand than in North America. In preparation for release of a national head injury guideline and given the high variation in CTB use found in North America, we aimed to assess variation in CTB use for paediatric head injury across hospitals types.

Methods

Multicentre retrospective review of presentations to tertiary, urban/suburban and regional/rural EDs in Australia and New Zealand in 2016. Children aged <16 years, with a primary ED diagnosis of head injury were included and data extracted from 100 eligible cases per site. Primary outcome was CTB use adjusted for severity (Glasgow Coma Scale) with 95% CIs; secondary outcomes included hospital length of stay and admission rate.

Results

There were 3072 head injury presentations at 31 EDs: 9 tertiary (n=900), 11 urban/suburban (n=1072) and 11 regional/rural EDs (n=1100). The proportion of children with Glasgow Coma Score ≤13 was 1.3% in each type of hospital. Among all presentations, CTB was performed for 8.2% (95% CI 6.4 to 10.0) in tertiary hospitals, 6.6% (95% CI 5.1 to 8.1) in urban/suburban hospitals and 6.1% (95% CI 4.7 to 7.5) in regional/rural. Intragroup variation of CTB use ranged from 0% to 14%. The regional/rural hospitals admitted fewer patients (14.6%, 95% CI 12.6% to 16.9%, p<0.001) than tertiary and urban/suburban hospitals (28.1%, 95% CI 25.2% to 31.2%; 27.3%, 95% CI 24.7% to 30.1%).

Conclusions

In Australia and New Zealand, there was no difference in CTB use for paediatric patients with head injuries across tertiary, urban/suburban and regional/rural EDs with similar intragroup variation. This information can inform a binational head injury guideline.

Patients presenting for hospital-based screening for the coronavirus disease 2019: Risk of disease, and healthcare access preferences

Objective

Early during the coronavirus disease 2019 (COVID‐19) pandemic, Australian EDs experienced an unprecedented surge in patients seeking screening. Understanding what proportion of these patients require testing and who can be safely screened in community‐based models of care is critical for workforce and infrastructure planning across the healthcare system, as well as public messaging campaigns.

Methods

In this cross‐sectional survey, we screened patients presenting to a COVID‐19 screening clinic in a tertiary ED. We assessed the proportion of patients who met testing criteria; self‐reported symptom severity; reasons why they came to the ED for screening and views on community‐based care.

Results

We include findings from 1846 patients. Most patients (55.3%) did not meet contemporaneous criteria for testing and most (57.6%) had mild or no (13.4%) symptoms. The main reason for coming to the ED was being referred by a telephone health service (31.3%) and 136 (7.4%) said they tried to contact their general practitioner but could not get an appointment. Only 47 (2.6%) said they thought the disease was too specialised for their general practitioner to manage.

Conclusions

While capacity building in acute care facilities is an important part of pandemic planning, it is also important that patients not needing hospital level of care can be assessed and treated elsewhere. We have identified a significant proportion of people at this early stage in the pandemic who have sought healthcare at hospital but who might have been assisted in the community had services been available and public health messaging structured to guide them there.

Influenza With and Without Fever: Clinical Predictors and Impact on Outcomes in Patients Requiring Hospitalization

Background

The Infectious Diseases Society of America influenza guidelines no longer require fever as part of their influenza case definition in patients requiring hospitalization. However, the impact of fever or lack of fever on clinical decision-making and patient outcomes has not been studied.

Methods

We conducted a retrospective review of adult patients admitted to our tertiary health service between April 2016 and June 2019 with laboratory-confirmed influenza, with and without fever (≥37.8ºC). Patient demographics, presenting features, and outcomes were analyzed using Pearson's chi-square test, the Wilcoxon rank-sum test, and logistic regression.

Results

Of 578 influenza inpatients, 219 (37.9%) had no fever at presentation. Fever was less likely in individuals with a nonrespiratory syndrome (adjusted odds ratio [aOR], 0.44; 95% CI, 0.26-0.77), symptoms for ≥3 days (aOR, 0.53; 95% CI, 0.36-0.78), influenza B infection (aOR, 0.45; 95% CI, 0.29-0.70), chronic lung disease (aOR, 0.55; 95% CI, 0.37-0.81), age ≥65 (aOR, 0.36; 95% CI, 0.23-0.54), and female sex (aOR, 0.69; 95% CI, 0.48-0.99). Patients without fever had lower rates of testing for influenza in the emergency department (64.8% vs 77.2%; P = .002) and longer inpatient stays (median, 2.4 vs 1.9 days; P = .015). These patients were less likely to receive antiviral treatment (55.7% vs 65.6%; P = .024) and more likely die in the hospital (3.2% vs 0.6%; P = .031), and these differences persisted after adjustment for potential confounders.

Conclusions

Absence of fever in influenza is associated with delayed diagnosis, longer length of stay, and higher mortality.

Sex disparities in the assessment and outcomes of chest pain presentations in emergency departments

OBJECTIVE

To determine whether sex differences exist in the triage, management and outcomes associated with non-traumatic chest pain presentations in the emergency department (ED).

METHODS

All adults (≥18 years) with non-traumatic chest pain presentations to three EDs in Melbourne, Australia between 2009 and 2013 were retrospectively analysed. Data sources included routinely collected hospital databases. Triage scoring of the urgency of presentation, time to medical examination, cardiac troponin testing, admission to specialised care units, and in-ED and in-hospital mortality were each modelled using the generalised estimating equations approach.

RESULTS

Overall 54 138 patients (48.7% women) presented with chest pain, contributing to 76 216 presentations, of which 26 282 (34.5%) were cardiac. In multivariable analyses, compared with men, women were 18% less likely to be allocated an urgency of 'immediate review' or 'within 10 min review' (OR=0.82, 95% CI 0.79 to 0.85), 16% less likely to be examined within the first hour of arrival to the ED by an emergency physician (0.84, 0.81 to 0.87), 20% less likely to have a troponin test performed (0.80, 0.77 to 0.83), 36% less likely to be admitted to a specialised care unit (0.64, 0.61 to 0.68), and 35% (p=0.039) and 36% (p=0.002) more likely to die in the ED and in the hospital, respectively.

CONCLUSIONS

In the ED, systemic sex bias, to the detriment of women, exists in the early management and treatment of non-traumatic chest pain. Future studies that identify the drivers explaining why women presenting with chest pain are disadvantaged in terms of care, relative to men, are warranted.

Abstract WP303: Improving Treatment Within the Golden Hour in and Out of Hours With a Multi-Disciplinary Pre-Hospital, Within-Hospital Communication System

Delivery of time-critical stroke care requires rapid assessment, diagnosis and treatment, involving multiple clinicians. However, disparate communication systems exist between in-field paramedics and hospital clinicians, with variation for in and out of hours presentations. Repetition of patient information and fragmented systems may contribute to delayed processes.

Aim: To determine if smartphone communication technology can improve clinical care timelines for patients with suspected acute stroke in and out of hours.

Methods: A 12 month pre-post historical-control design was used. The Pulsara TM Stop Stroke/STEMI smartphone and tablet app (Pulsara) was implemented in 25 Ambulance Victoria branches and 2 hospitals in rural Victoria, Australia, during 2016/2017. Pulsara provides secure, simultaneous, two-way, real-time communication. Eligible patients had suspected acute stroke as assessed by paramedics or hospital clinicians. Analyses compare timelines (median minutes) for when Pulsara is (Pulsara+), or is not (Pulsara-), used by clinicians in hours (08:00-17:00; IH) and out of hours (17:01-07:59; OH).

Results: Pulsara was used in 80% (210/265) of cases. Using Pulsara, patients are off-ambulance stretcher 5 minutes faster (10 minutes Pulsara+ vs 15 minutes Pulsara- ; p=0.23), and depart hospital 4 minutes faster (11 minutes Pulsara+ vs 15 minutes Pulsara- ; p=0.02). The time to first medical review is similar IH (7 minutes), but 7 minutes faster OH (7 minutes Pulsara+ vs 14 minutes Pulsara-; p=.03). Time to CT scan is 40 minutes faster IH (27 minutes Pulsara+ vs 67 minutes Pulsara- ; p=.02), and 29 minutes faster OH (29 minutes Pulsara+ vs 58 minutes Pulsara- ; p=.0001). Pulsara was used on all cases receiving thrombolysis. Compared to the pre-Pulsara period, when Pulsara was used the proportion treated within 60 minutes increased from 9% (1/11) to 23% (3/13) during in hours, and from 13% (2/15) to 26% (7/27) out of hours.

Conclusion: The use of Pulsara improved hospital metrics and care timelines for treatment of patients with suspected stroke. There is a two-fold increase of patients treated within 60 minutes in hours, and also out of hours (when staffing levels are less). Pulsara has significantly improved stroke care in these two rural hospitals.

Impact of scribes on emergency medicine doctors' productivity and patient throughput: multicentre randomised trial

OBJECTIVES

To evaluate the changes in productivity when scribes were used by emergency physicians in emergency departments in Australia and assess the effect of scribes on throughput.

DESIGN

Randomised, multicentre clinical trial.

SETTING

Five emergency departments in Victoria used Australian trained scribes during their respective trial periods. Sites were broadly representative of Australian emergency departments: public (urban, tertiary, regional referral, paediatric) and private, not for profit.

PARTICIPANTS

88 physicians who were permanent, salaried employees working more than one shift a week and were either emergency consultants or senior registrars in their final year of training; 12 scribes trained at one site and rotated to each study site.

INTERVENTIONS

Physicians worked their routine shifts and were randomly allocated a scribe for the duration of their shift. Each site required a minimum of 100 scribed and non-scribed shifts, from November 2015 to January 2018.

MAIN OUTCOME MEASURES

Physicians' productivity (total patients, primary patients); patient throughput (door-to-doctor time, length of stay); physicians' productivity in emergency department regions. Self reported harms of scribes were analysed, and a cost-benefit analysis was done.

RESULTS

Data were collected from 589 scribed shifts (5098 patients) and 3296 non-scribed shifts (23 838 patients). Scribes increased physicians' productivity from 1.13 (95% confidence interval 1.11 to 1.17) to 1.31 (1.25 to 1.38) patients per hour per doctor, representing a 15.9% gain. Primary consultations increased from 0.83 (0.81 to 0.85) to 1.04 (0.98 to 1.11) patients per hour per doctor, representing a 25.6% gain. No change was seen in door-to-doctor time. Median length of stay reduced from 192 (interquartile range 108-311) minutes to 173 (96-208) minutes, representing a 19 minute reduction (P<0.001). The greatest gains were achieved by placing scribes with senior doctors at triage, the least by using them in sub-acute/fast track regions. No significant harm involving scribes was reported. The cost-benefit analysis based on productivity and throughput gains showed a favourable financial position with use of scribes.

CONCLUSIONS

Scribes improved emergency physicians' productivity, particularly during primary consultations, and decreased patients' length of stay. Further work should evaluate the role of the scribe in countries with health systems similar to Australia's.

TRIAL REGISTRATION

ACTRN12615000607572 (pilot site); ACTRN12616000618459.

Socioeconomic gradients in admission to coronary or intensive care units among Australians presenting with non-traumatic chest pain in emergency departments

BACKGROUND

Socioeconomic inequalities in cardiovascular morbidity have been previously reported showing direct associations between socioeconomic disadvantage and worse health outcomes. However, disagreement remains regarding the strength of the direct associations. The main objective of this panel design was to inspect socioeconomic gradients in admission to a coronary care unit (CCU) or an intensive care unit (ICU) among adult patients presenting with non-traumatic chest pain in three acute-care public hospitals in Victoria, Australia, during 2009-2013.

METHODS

Consecutive adults aged 18 or over presenting with chest pain in three emergency departments (ED) in Victoria, Australia during the five-year study period were eligible to participate. A relative index of inequality of socioeconomic status (SES) was estimated based on residential postcode socioeconomic index for areas (SEIFA) disadvantage scores. Admission to specialised care units over repeated presentations was modelled using a multivariable Generalized Estimating Equations approach that accounted for various socio-demographic and clinical variables.

RESULTS

Non-traumatic chest pain accounted for 10% of all presentations in the emergency departments (ED). A total of 53,177 individuals presented during the study period, with 22.5% presenting more than once. Of all patients, 17,579 (33.1%) were hospitalised over time, of whom 8584 (48.8%) were treated in a specialised care unit. Female sex was independently associated with fewer admissions to CCU / ICU, whereas, a dose-response effect of socioeconomic disadvantage and admission to CCU / ICU was found, with risk of admission increasing incrementally as SES declined. Patients coming from the lowest SES locations were 27% more likely to be admitted to these units compared with those coming from the least disadvantaged locations, p <  0.001. Men were significantly more likely to be admitted to such units than similarly affected and aged women among those diagnosed with angina pectoris, arrhythmia, myocardial infarction, heart failure, chest pain, and general signs and symptoms.

CONCLUSIONS

This study is the first to report socioeconomic gradients in admission to CCU / ICU in patients presenting with chest pain showing a dose-response effect. Our findings suggest increased cardiovascular morbidity as socioeconomic disadvantage increases.

Low major trauma confidence among emergency physicians working outside major trauma services: Inevitable result of a centralised trauma system or evidence for change?

OBJECTIVE

Regionalised civilian trauma systems improve patient outcomes, but may deskill clinicians outside major trauma services (MTSs). We aimed to characterise experience and confidence in trauma management among emergency physicians working in MTS to those working elsewhere.

METHODS

Emergency physicians working within the Victorian State Trauma System were surveyed about their pre- and post-fellowship training experience, their estimated hours per fortnight in different centres, the frequency of performance/supervision of critical emergency skills and their confidence in a range of trauma skills.

RESULTS

The 138 respondents analysed represented 33% of active Victorian FACEMs. The cohort were mostly males (69.6%), younger than 50 (75.4%) and were generally (69.6%) six or more years post-fellowship. FACEMs working in a MTS were more likely to have been a trauma registrar prior to fellowship (13.3% vs 3.7%, P = 0.046). MTS clinicians performed more, supervised more and were more confident in trauma team leading, traumatic airway management and rapid infusion catheter and multi-access catheters. Confidence in trauma team leading was only associated with exposure to performance or supervision of trauma team leading. Performance of trauma team leading was more common in clinicians at a MTS (odds ratio 3.19, 95% CI 1.00-10.20, P = 0.05).

CONCLUSION

Exposure to major trauma is associated with time spent working in a MTS and exposure is associated with confidence. A mature inclusive trauma system must ensure clinicians across the system gain the experience or training to provide trauma care that will result in similar outcomes for patients regardless of initial presenting hospital.

Adverse events associated with the use of intravenous epinephrine in emergency department patients presenting with severe asthma

STUDY OBJECTIVE

We determine the rate of adverse effects associated with the use of intravenous (IV) epinephrine by infusion for the treatment of severe asthma in the emergency department (ED).

METHODS

This retrospective, structured, medical record review included adult patients who presented to the ED of Western Hospital between 1998 and 2003 and who were triaged as category 1, 2, or 3, had a discharge diagnosis of asthma, and were administered IV epinephrine in the ED. Patients were excluded if they were older than 55 years or if a diagnosis of asthma was not confirmed. The primary outcome measures were occurrence of cardiac arrhythmia or ischemia, local tissue ischemia, hypotension or hypertension, neurologic injury, or death related to epinephrine infusion.

RESULTS

Two hundred twenty episodes of care met the inclusion criteria. Adverse events occurred in 67 episodes (30.5%; 95% confidence interval [CI] 24.5% to 37.1%); however, most were minor and self-limiting. There were no deaths. Major adverse events occurred in 3.6% of cases (8/220; 95% CI 1.7% to 7.3%), including 2 cases of supraventricular tachycardia, 1 case of chest pain with ECG changes, 1 case of incidental elevated troponin, and 4 cases of hypotension requiring intervention.

CONCLUSION

IV epinephrine is associated with a low rate of major and a moderate rate of minor adverse events in patients with severe asthma; however, a causal relationship has not been established. Further research investigating effectiveness, as well as safety, is warranted.

Histologic comparison of cultured epithelial autograft and meshed expanded split-thickness skin graft

Histologic appearance of cultured epithelial autograft (CEA) biopsies obtained up to 2100 days after application from patients with burn injuries differs from time-matched, meshed expanded autograft. The CEA interface with underlying bed remained flat for up to 3 years in three of four patients. CEA epidermal rete ridges, if formed subsequently, were fewer, thinner, and shorter, whereas expanded split-thickness skin grafts had well-defined rete ridges after 1 year. CEA basal layer remained separated from its bed up to 50 days after application, and late blister formation was seen on occasion for up to 3 years. The underlying bed was homogeneous up to 2 years; later some beds demonstrated differentiation with superficial, fine, filamentous collagen fibers and deeper, thick collagen fibers. Fine elastin filaments were initially identified in the superficial bed after 1 year in some specimens and in all after 3 years. Delay in rete ridge formation may explain poor adherence and poor stability.