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Death and bereavement are often poorly dealt with in emergency departments. Guidelines exist for optimal care of bereaved relatives. Establishing a limited bereavement program in a busy emergency department is quite feasible. Bereaved relatives appreciate a more "human" approach from hospital staff. Ultimately hospital staff also benefit from confronting issues surrounding death in the emergency department.

Objective: To determine the effect of establishing an emergency department observation ward (OW) on admission numbers, average length of stay (ALOS) for the entire hospital and overall bed days for conditions commonly treated in the OW., Setting: Sir Charles Gairdner Hospital (SCGH), Perth, a tertiary referral teaching hospital., Design: Retrospective analysis of routinely collected hospital data for the 10 most common diagnosis-related group (DRG) categories of patients discharged from the OW for the financial years 1995-96 to 1998-99. Comparison of these data with those for adult patients at the other Perth teaching hospitals over the same period., Main Outcome Measures: For patients in the 10 most common DRGs: numbers of admissions to the OW compared with other inpatient wards; total number of patients admitted to the hospital compared with total bed days; ALOS at SCGH compared with other Perth teaching hospitals., Results: Increased admissions to the OW were paralleled by a decrease in admissions for the same DRG codes to other inpatient wards. ALOS remained approximately the same from 1995-96 to 1998-99 for patients in the OW (one day) and other inpatient wards (4.38 to 4.20 days). However, overall ALOS for patients in these DRGs fell by over a third (from 3.97 to 2.59 days) over this time. The total number of patients in these DRGs treated by the hospital increased by 19% over the four years, but the total number of bed days fell by 23%. By contrast, the ALOS for patients in the same DRGs treated at the other Perth teaching hospitals rose 8% (from 2.12 to 2.28 days)., Conclusion: Establishment of a formal emergency department OW results in the more efficient management of certain groups of patients, with a decrease in overall hospital bed days and length of stay.

Objective: To describe the epidemiology and clinical features of children presenting to an emergency department with suspected snakebite., Design: A retrospective study of patient records., Setting: An emergency department of a children's teaching hospital (Princess Margaret Hospital) in Perth, Western Australia., Participants: All children attending the emergency department from 1984 to 1993 with suspected snakebite., Main Outcome Measure: Clinical and laboratory evidence of envenomation., Results: Over the decade studied, 156 children (mean age, six years and eight months) presented with suspected snakebite; over two-thirds (68%) were boys. In at least 31% of cases, no appropriate first aid had been applied. Only 14 children were envenomed according to clinical and laboratory criteria: 10 of these had coagulopathy; one of the 10 also had rhabdomyolysis. A Venom Detection Kit was used in 117 children. The test gave a positive result in 21 children (13%). Antivenom was given to 18 children, 14 of whom were definitely envenomed. Four of the envenomed children returned a negative result of Venom Detection Kit testing at all sites tested, and in five patients not clinically envenomed the urine specimen tested positive with the Venom Detection Kit (presumably a false positive result or subclinical envenomation). Of the 156 children, 130 were admitted to hospital, and 26 were discharged directly from the emergency department. All children recovered completely., Conclusions: (i) Many children did not receive appropriate first aid for snakebite; (ii) Most children with suspected snakebite presenting to the emergency department were not envenomed; (iii) Envenomation was best diagnosed by clinical features and laboratory investigations, with the Venom Detection Kit being used to determine the appropriate antivenom; (iv) Discharging children directly from the emergency department is not recommended.

The selection of appropriate non-inpatient casemix classification systems is pivotal to the overall success of casemix in Australia. Before implementation, an extensive review and evaluation of issues relating to non-inpatient casemix must be undertaken in conjunction with inpatient casemix to avoid adverse economic and clinical outcomes. Here, we review the background to and current status of non-inpatient casemix classification systems. The current Commonwealth/State research agenda is defined and possible options for both classification and funding of non-inpatient services are described.

Objective: To describe the epidemiology of snake bite in Perth, and the likelihood of envenomation., Design: Information from case notes was retrospectively analysed., Setting: Emergency medicine, teaching hospitals., Patients: All patients admitted to the three adult teaching hospitals in Perth for suspected snake bite from 1979 to 1988., Main Outcome Measure: Systemic envenomation, was accepted as present if there were definite symptoms, signs or laboratory evidence (vomiting, abdominal pain, ptosis, convulsions, difficulty with breathing or swallowing, coagulopathy, haemolysis, rhabdomyolysis or renal failure)., Results: Ninety-nine patients were definitely bitten, with 53 envenomed, including three snake handlers. Thirty others may have been envenomed. Nearly half (44%) of the 82 patients with witnessed snake bite were envenomed. The dugite (Pseudonaja affinis) caused most cases of envenomation, most often producing coagulopathy only. The remainder were probably due to bites by the tiger snake (Notechis after occidentalis) and gwardar (Pseudonaja nuchalis), with one by a sea snake. The Commonwealth Serum Laboratories Snake Venom Detection Kit (VDK) enabled identification of the genus in 36% of definite cases of snake bite, and in 51% of cases of envenomation. It may occasionally produce false-positive results. The VDK is of greatest value in establishing the genus of snake in envenomed patients., Conclusions: It is suggested that a mixture of brown and tiger snake antivenom be used to treat patients envenomed by an unidentified snake in the Perth metropolitan area. This does not apply to patients bitten elsewhere in Western Australia or transferred to Perth from country regions where other snakes are more prevalent.

Seventy-six patients (30% children) were admitted to Fremantle Hospital over 10 years with suspected snake bite. Twenty-nine patients were definitely bitten, with 26 bites being witnessed. Of the 13 patients definitely envenomated, 11 had a coagulopathy although seven were asymptomatic; four other patients may have been envenomated. The dugite (Pseudonaja affinis) was probably responsible for most envenomations. Eleven of the 13 envenomated patients received antivenom (six brown snake, four polyvalent and one tiger snake antivenom). The patient envenomated by the tiger snake (Notechis ater occidentalis), a 13-year-old girl, was initially incorrectly treated with brown snake antivenom at a country hospital, and did not receive appropriate antivenom until 50 hours after the bite. She developed profound paralysis, rhabdomyolysis and renal failure, and required prolonged ventilation during her 53-day hospital admission, but survived without disability. Snake bite wounds should not be washed, so that venom can be identified from the wound. Attempts to kill snakes are dangerous, often leading to bites on the fingers. First aid measures of a pressure bandage and immobilisation, used in 13 of the 29 cases (45%), should be more widely publicised.

Observation wards have not been discussed in the Australian literature. In the United Kingdom, the few published reports suggest that they are an essential part of the function of emergency departments. This paper presents the results of a survey of 44 major Australian hospitals regarding their use of observation wards. Half the hospitals that were surveyed had such wards but variations existed in the way that they functioned. Nearly half the remaining hospitals wanted to establish an observation ward. Our concept of observation wards is discussed.

The published literature in Australia on red-back spider-bites allows no means of determination of the incidence of this envenomation. This retrospective study describes the experience at Fremantle Hospital with red-back spider-bites over a six-year period from 1982-1987 inclusive. One hundred and fifty patients were admitted to hospital with a definite red-back spider-bite, of whom 32 (21%) patients received antivenom; 11 (34%) of these patients received more than one ampoule. In earlier series, only 3% of patients have received more than one ampoule. These results suggest that the WA red-back spider is particularly venomous, and that the annual number of definite red-back spider-bites in Australia lies between approximately 830 and 1950 cases.