Patient care on the ramp: Who is legally responsible?

Ambulance ramping, the delay to transfer of a patient arriving at an ED by ambulance into an ED treatment space and handover of care to ED clinicians, is a problem in all Australian states and territories and New Zealand. It is a symptom of ED overcrowding and access block and has been associated with adverse health outcomes for some patient groups. The questions arise, who might be legally responsible for the care of patients who are ramped and does their physical location matter? The short answers are 'everyone' and 'no', however, whether there will be a breach of duty depends on the reasonableness of responses and resource allocation considerations.

UnTWISTing the BALS: A study of predictive accuracy of clinical scoring tools for testicular torsion identification in adults.

Objective: Testicular torsion is an uncommon but time-critical condition in EDs. If the diagnosis is missed or delayed, there are significant medicolegal and patient fertility implications. Scoring tools are advocated for use in children but have limited validation in adults.

Review article: Patients who leave before care is completed: What does the legal duty to warn mean for emergency department clinicians?

Patients leave ED for a variety of reasons and at all stages of care. In Australian law, clinicians and health services owe a duty of care to people presenting to the ED for care, even if they have not yet entered a treatment space. There is also a positive duty to warn patients of material risks associated with their condition, proposed treatment(s), reasonable alternative treatment options and the likely effect of their healthcare decisions, including refusing treatment.

Who should provide expert opinion in emergency medicine-related medical litigation?

Expert evidence plays a central role in establishing the relevant standard of care in medical litigation. In Australia, little is known about the expert witnesses who provide evidence about the standard of care provided in ED. A sample of recent published case law suggests that a proportion of expert evidence about breach of the standard of reasonable care in ED is provided by medical practitioners who are not emergency physicians and/or have no recent practice experience in an ED.

Thunderclap headache syndrome presenting to the emergency department: an international multicentre observational cohort study.

Background: Most headache presentations to emergency departments (ED) have benign causes; however, approximately 10% will have serious pathology. International guidelines recommend that patients describing the onset of headache as 'thunderclap' undergo neuroimaging and further investigation. The association of this feature with serious headache cause is unclear.

Does the evidence justify routine transfer of residents of aged care facilities for CT scan after minor head trauma?

Background: In 2014, the South Australian coroner recommended that residents of residential aged care facilities (RACF) who had sustained a head injury should be transported to emergency departments (ED) for assessment and a head CT scan, with the view to preventing mortality. The evidence base for the recommendation is unclear.

Aims: To determine the rate of emergent intervention (neurosurgery, transfusion of blood products or reversal of anti-coagulation) in residents transferred to ED with minor head trauma who had their usual cognitive function on ED assessment.

Epidemiology of Headache in Children in a Community Emergency Department: A Scoping Study.

Objective: This study aimed to describe the epidemiology of headache in children attending a community mixed adult-pediatric emergency department (ED) in Australia with a view to providing scoping data for future headache-related projects for the pediatric ED research networks.

Methods: This is a retrospective cohort study by medical record review. Participants were children aged 2 to 16 years who presented to the ED between January 1, 2016, and December 31, 2016, with a major symptom of headache.

Anatomy of a demand shock: Quantitative analysis of crowding in hospital emergency departments in Victoria, Australia during the 2009 influenza pandemic.

Objective: An infectious disease outbreak such as the 2009 influenza pandemic is an unexpected demand shock to hospital emergency departments (EDs). We analysed changes in key performance metrics in (EDs) in Victoria during this pandemic to assess the impact of this demand shock.

Design And Setting: Descriptive time-series analysis and longitudinal regression analysis of data from the Victorian Emergency Minimum Dataset (VEMD) using data from the 38 EDs that submit data to the state's Department of Health and Human Services.

Epidemiology of patients presenting with dyspnea to emergency departments in Europe and the Asia-Pacific region.

Objective: The primary objective of this study was to describe the epidemiology and management of dyspneic patients presenting to emergency departments (EDs) in an international patient population. Our secondary objective was to compare the EURODEM and AANZDEM patient populations.

Patients And Methods: An observational prospective cohort study was carried out in Europe and the Asia-Pacific region.

Diagnostic utility of an age-specific cut-off for d-dimer for pulmonary embolism assessment when used with various pulmonary embolism risk scores.

This retrospective cohort study compared the diagnostic utility (sensitivity, specificity and negative predictive value (NPV)) of the age-times-10 adjusted d-dimer cut-off used in combination with the original and simplified Well's pulmonary embolism (PE) scores and the original and simplified revised Geneva scores to identify patients in whom PE is classified as unlikely according to each score. The PE risk scores performed similarly with high sensitivity (97.6, 97.

Asthma among adult patients presenting with dyspnea to the emergency department: An observational study.

Introduction: Shortness of breath is a common presenting symptom to the emergency department (ED) that can arise from a myriad of possible diagnoses. Asthma is one of the major causes.

Objective: The aim of this study was to describe the demographic features, clinical characteristics, management and outcomes of adults with an ED diagnosis of asthma who presented to an ED in the Asia Pacific region with a principal symptom of dyspnea.

Long Term Prognostic Value of a Negative Work-Up for Acute Coronary Disease in Emergency Department Chest Pain Patients Without Known Coronary Artery Disease: A Cohort Study.

Background: To determine the rate of all cause and cardiac death, new myocardial infarction (MI) or coronary revascularisation at over three years from index visit in emergency department chest pain patients without known coronary artery disease (CAD) at index presentation who had a negative electrocardiogram (ECG) and biomarker workup for acute coronary syndrome (ACS).

Methods: An unplanned sub-study of a prospective observational study of consecutive adult patients presenting to the ED with atraumatic chest pain (or equivalents). The primary outcome of interest was the predictive performance of a negative ECG and biomarker work-up for ACS for all cause and cardiac mortality over more than three years' follow-up in patients not known to have pre-existing CAD presenting to the ED with chest pain.

Presentation patterns and outcomes of patients with cancer accessing care in emergency departments in Victoria, Australia.

Purpose: People with cancer attend emergency departments (EDs) for many reasons. Improved understanding of the specific needs of these patients may assist in optimizing health service delivery. ED presentation and hospital utilization characteristics were explored for people with cancer and compared with those patients without cancer.

What is the Yield of Testing for Coronary Artery Disease after an Emergency Department Attendance with Chest Pain?

Background: Guidelines recommend testing for coronary artery disease (CAD) for emergency department (ED) patients with a negative workup for acute coronary syndrome (ACS). The rationale is that, although myocardial infarction has been ruled out, the presentation could still indicate cardiac ischaemia. Evidence supporting this recommendation is weak.

Prospective external validation of an accelerated (2-h) acute coronary syndrome rule-out process using a contemporary troponin assay.

Background: Recently there have been efforts to derive safe, efficient processes to rule out acute coronary syndrome (ACS) in emergency department (ED) chest pain patients. We aimed to prospectively validate an ACS assessment pathway (the 2-Hour Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker (ADAPT) pathway) under pragmatic ED working conditions.

Methods: This prospective cohort study included patients with atraumatic chest pain in whom ACS was suspected but who did not have clear evidence of ischaemia on ECG.

Characteristics and outcome of patients brought to an emergency department by police under the provisions (Section 10) of the Mental Health Act in Victoria, Australia.

Objective: The aim of this study is to describe the characteristics and outcome of patients brought to an emergency department by police under Section 10 of Mental Health Act (Victoria, Australia).

Methods: Retrospective medical record review. Patients referred under Section 10 provisions treated in calendar year 2009 were identified from ED database.

Agreement between mathematically arterialised venous versus arterial blood gas values in patients undergoing non-invasive ventilation: a cohort study.

Background: Blood gas analysis is important for assessment of ventilatory function. Traditionally, arterial analysis has been used. A method for mathematically arterialising venous blood gas values has been developed.

Taking blood cultures from a newly established intravenous catheter in the emergency department does not increase the rate of contaminated blood cultures.

Objective: It has been suggested that blood cultures drawn from vascular catheters have a higher false positive rate than those drawn by venepuncture. In the face of institutionally imposed practice change prohibiting obtaining blood cultures from intravenous (i.v.

Agreement between arterial and venous pH and pCO2 in patients undergoing non-invasive ventilation in the emergency department.

Background: Blood gas analysis is an important part of the assessment of ventilatory function in patients with respiratory distress. Traditionally, analysis of arterial blood has been used, but recently, there has been a move towards venous blood gas analysis for selected conditions. Arteriovenous agreement for pH and pCO2 in adult patients undergoing non-invasive ventilation (NIV) has not been explored to date.

How useful are the Heart Foundation risk criteria for assessment of emergency department patients with chest pain?

Objective: To investigate the prognostic utility of Heart Foundation (Australia) risk stratification table in an ED chest pain population.

Methods: A planned sub-study of a prospective observational study of adult patients with potentially cardiac chest pain who underwent evaluation for acute coronary syndrome (ACS) was conducted. Data collected included demographical, clinical, ECG, biomarker and outcome data.

Is elevated troponin associated with in-hospital mortality in emergency department patients admitted with chronic obstructive pulmonary disease?

The aim of this study was to determine the prevalence and prognostic value of troponin elevation at emergency department (ED) presentation in patients admitted with an exacerbation of chronic obstructive pulmonary disease (COPD). A retrospective cohort study of ED patients with acute exacerbations of COPD who were admitted to hospital and in whom troponin was assayed at ED presentation. Other data collected included demographics, clinical characteristics, test results, and outcome.

What is the incidence of major adverse cardiac events in emergency department chest pain patients with a normal ECG, thrombolysis in myocardial infarction score of zero and initial troponin <=99th centile: an observational study?

Objective: To determine the rate of major adverse cardiac events (MACE) in patients assessed in an emergency department (ED) for chest pain with a non-ischaemic ECG, Thrombolysis in Myocardial Infarction (TIMI) score of 0 and initial troponin I (TnI) ≤99th centile.

Methods: This was a sub-study of a prospective observational study of adult patients with potentially cardiac chest pain who underwent evaluation for acute coronary syndrome in an urban teaching hospital. Adult patients with non-traumatic chest pain were eligible for inclusion.