Behavioural 'nudging' interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial.

Introduction: Opioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and two in three will receive an opioid. NUDG-ED aims to determine the effectiveness of two different behavioural 'nudge' interventions on low-value care for ED patients with low back pain.

A cluster of acute thebaine poisonings from non-food grade poppy seeds in the Australian food supply.

Introduction: Poppy seed tea is used for its opioid effects and contains multiple opium alkaloids, including morphine, codeine, papaverine, and thebaine. Animal studies indicate thebaine has strychnine-like properties, but there is limited literature describing human thebaine poisoning. We describe a cluster of acute thebaine poisoning in people ingesting tea made using poppy seeds with high thebaine content that entered the Australian food supply chain.

Toxicity and Adverse Effects in Clozapine-Related Presentations to a Medical Toxicology Service in Western Sydney.

Background: Clozapine is an anti-psychotic agent, reserved for treatment-resistant schizophrenia, with demonstrated efficacy in an otherwise therapeutically challenging patient population. We aimed to review the full spectrum casemix of clozapine presentations to our tertiary toxicology service.

Methods: In this retrospective study, we reviewed consecutive clozapine related toxicity presentations to a tertiary medical toxicology inpatient and consultation service-including deliberate self-poisoning (DSP), adverse drug reaction (ADR), recreational use, and therapeutic misadventure over a 10-year period from 2011 to 2021.

The Impact of an Electronic Medication Management System on Medication Deviations on Admission and Discharge from Hospital.

Medication errors at transition of care remain a concerning issue. In recent times, the use of integrated electronic medication management systems (EMMS) has caused a reduction in medication errors, but its effectiveness in reducing medication deviations at transition of care has not been studied in hospital-wide settings in Australia. The aim of this study is to assess medication deviations, such as omissions and mismatches, pre-EMMS and post-EMMS implementation at transition of care across a hospital.

Toxicology presentations to a tertiary unit in New South Wales during the COVID-19 pandemic first wave: A retrospective comparison study.

Objective: To compare presentation numbers, class of exposure, poison severity score (PSS) and drugs ingested by patients in a tertiary toxicology service during the first wave of the COVID-19 pandemic to the corresponding time periods in 2018 and 2019.

Methods: A retrospective cohort observational study of patients admitted or consulted to the Western Sydney Toxicology Service (WSTS) from ED during February to May in 2018-2020. Patient age, sex, triage category, time and date of arrival, mode of arrival, type of poisoning, discharge location, length of stay and PSS were collected from WSTS database and electronic medical records.

Implementation of an Electronic Medication Management System in a large tertiary hospital: a case of qualitative inquiry.

Background: Hospitals across Australia are implementing Clinical Information Systems, e.g. Electronic Medication Management Systems (EMMS) at a rapid pace to moderate health services.

Can existing electronic medical records be used to quantify cardiovascular risk at point of care?

Background: Using electronic data for cardiovascular risk stratification could help in prioritising healthcare access and optimise cardiovascular prevention.

Aims: To determine whether assessment of absolute cardiovascular risk (Australian absolute cardiovascular disease risk (ACVDR)) and short-term ischaemic risk (History, ECG, Age, Risk factors, and Troponin (HEART) score) is possible from available data in Electronic Medical Record (EMR) and My Health Record (MHR) of patients presenting with acute cardiac symptoms to a Rapid Access Cardiology Clinic (RACC).

Methods: Audit of EMR and MHR on 200 randomly selected adults who presented to RACC between 1 March 2017 and 4 February 2020.

Utility of non-contrast head computed tomography in poisoned patients.

Objective: To investigate the utility of non-contrast head computed tomography (CT) in poisoned patients.

Methods: A retrospective cohort study of patients referred to a toxicology unit between August 2010 and December 2017. Our database yielded patients who underwent head CT at presentation to the ED.

Evaluation of an augmented emergency department electronic medical record-based sepsis alert.

Objective: Electronic medical records-based alerts have shown mixed results in identifying ED sepsis. Augmenting clinical patient-flagging with automated alert systems may improve sepsis screening. We evaluate the performance of a hybrid alert to identify patients in ED with sepsis or in-hospital secondary outcomes from infection.

Efficacy of a two bag acetylcysteine regimen to treat paracetamol overdose (2NAC study).

Background: Previous studies of paracetamol overdose treatment show that a 2-bag, 20-h intravenous (IV) acetylcysteine regimen decreased the incidence of non-allergic anaphylactic reactions compared to the 3-bag, 21 h IV regimen, but have not examined efficacy of the 20-h 2 bag regimen.

Methods: This was a multi-centre observational study of paracetamol overdose presentations treated with a 2-bag IV acetylcysteine regimen (200 mg/kg over 4 h, 100 mg/kg over 16 h) compared to a 3-bag regimen, performed from 2009 to 2019. Patients were referred from the emergency department to the inpatient toxicology units for continued management.

Attitudes of health professionals to using routinely collected clinical data for performance feedback and personalised professional development.

Objectives: To learn the attitudes of health professionals, health informaticians and information communication technology professionals to using data in electronic health records (eHRs) for performance feedback and professional development.

Design: Qualitative research in a co-design framework. Health professionals' perceptions of the accessibility of data in eHRs, and barriers to and enablers of using these data in performance feedback and professional development were explored in co-design workshops.

Patient-centric implementation of an electronic medication management system at a tertiary hospital in Western Sydney.

Background: Traditional implementations of electronic medication management (EMM) systems have involved two common formats - a 'big bang' approach on the day of go-live, or a phased ward-by-ward approach over months.

Objective: To describe the patient-centric roll-out, a novel implementation model in converting from paper to EMM.

Method: This model iteratively converted a large tertiary teaching hospital to electronic from paper medication charts, commencing the roll-out in the emergency department (ED).

The NACSTOP Trial: A Multicenter, Cluster-Controlled Trial of Early Cessation of Acetylcysteine in Acetaminophen Overdose.

Historically, intravenous acetylcysteine has been delivered at a fixed dose and duration of 300 mg/kg over 20 to 21 hours to nearly every patient deemed to be at any risk for hepatotoxicity following acetaminophen overdose. We investigated a 12-hour treatment regimen for selected low-risk patients. This was a multicenter, open-label, cluster-controlled trial at six metropolitan emergency departments.

Fewer adverse effects with a modified two-bag acetylcysteine protocol in paracetamol overdose.

Objective: Acetylcysteine (NAC), an effective antidote for paracetamol poisoning, is commonly associated with adverse reactions. This has been postulated to be related to the rapid initial infusion rate (150 mg/kg over 1 h) of the traditional three-bag protocol. We hypothesized that a slower rate would result in fewer adverse reactions.

Analysis of an 8-hour acetylcysteine infusion protocol for repeated supratherapeutic ingestion (RSTI) of paracetamol.

Objectives: In Australia, the treatment guideline for patients with repeated supratherapeutic ingestion (RSTI) of paracetamol recommends an abbreviated acetylcysteine regimen if the paracetamol concentration is low (<10 mg/L) and alanine aminotransferase (ALT) is normal or static after 8 hours of infusion. There are currently no studies of this recommendation.

Method: A retrospective review of paracetamol overdose presentations from October 2009 to August 2016 in two hospital toxicology networks was performed.

Accuracy of the paracetamol-aminotransferase product to predict hepatotoxicity in paracetamol overdose treated with a 2-bag acetylcysteine regimen.

Introduction: Paracetamol concentration is a highly accurate risk predictor for hepatotoxicity following overdose with known time of ingestion. However, the paracetamol-aminotransferase multiplication product can be used as a risk predictor independent of timing or ingestion type. Validated in patients treated with the traditional, "three-bag" intravenous acetylcysteine regimen, we evaluated the accuracy of the multiplication product in paracetamol overdose treated with a two-bag acetylcysteine regimen.

The impact of Australian legislative changes on synthetic cannabinoid exposures reported to the New South Wales Poisons Information Centre.

Background: The emergence of new psychoactive substances (NPS), including synthetic cannabinoid receptor agonists (SCRAs) poses novel challenges for drug regulation and public health. Misconceptions of safety and legality, coupled with the fact that NPS are undetectable on routine drugs screens contributes to their popularity. Concerns over the unpredictable toxicity and abuse potential of NPS has led to a variety of legislative responses worldwide.

Chloroform ingestion causing severe gastrointestinal injury, hepatotoxicity and dermatitis confirmed with plasma chloroform concentrations.

Context: Poisoning due to chloroform ingestion is rare. The classic features of acute chloroform toxicity include central nervous system (CNS) and respiratory depression, and delayed hepatotoxicity.

Case Details: A 30-year-old female ingested 20-30 mL of 99% chloroform solution, which caused rapid loss of consciousness, transient hypotension and severe respiratory depression requiring endotracheal intubation and ventilation.

Chemical agents for the sedation of agitated patients in the ED: a systematic review.

Objective: Chemical agents commonly used to sedate agitated patients in the emergency department include benzodiazepines, antipsychotics, or a combination of the 2 classes. Our objective was to determine if a class or combination therapy is (1) more effective, as measured by the proportion sedated at 15-20 minutes and the need for repeat sedation, and (2) safer, as measured by the proportion of reported adverse events.

Methods: Systematic literature review and meta-analysis of studies comparing 2 or more chemical agents for sedation of agitated patients in the emergency department were carried out in PubMed, PsycINFO, Embase, and the Cochrane database.

A validated LC-MS-MS method for simultaneous identification and quantitation of rodenticides in blood.

A rapid, highly sensitive and specific analytical method for the extraction, identification and quantification of nine rodenticides from whole blood has been developed and validated. Commercially available rodenticides in Australia include coumatetralyl, warfarin, brodifacoum, bromadiolone, difenacoum, flocoumafen, difethialone, diphacinone and chlorophacinone. A Waters ACQUITY UPLC TQD system operating in multiple reaction monitoring mode was used to conduct the analysis.