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Ketamine is commonly used for procedural sedation anaesthesia in paediatric patients undergoing painful procedures in the ED. Ketamine's safety profile is excellent, but ketamine‐associated vomiting (KAV) is common. Routine ondansetron prophylaxis could reduce KAV incidence. This literature review evaluated the efficacy of prophylactic ondansetron in reducing KAV incidence. A systematic literature review was performed on databases and trial registries on 14 January 2023 to identify randomised controlled trials. The primary outcome was reduction in KAV incidence, for any route of prophylactic ondansetron, in ED and up to 24 h post‐discharge. ED length of stay, parental satisfaction and time to resumption of normal diet were secondary outcomes. Data analysis was performed using Revman 5.3. Meta‐analysis was performed using random effects modelling. Risk of bias was assessed using the Cochrane Risk‐of‐Bias 2 tool. Evidence quality was assessed using Grading of Recommendation, Assessment Development and Evaluation methodology. Five trials with 920 participants met the eligibility criteria. Prophylactic ondansetron resulted in a reduction in KAV incidence overall odds ratio of 0.51 (95% confidence interval: 0.36–0.73). Intravenous and intramuscular prophylactic ondansetron showed benefit whereas the effect of oral administration was unclear. There was no difference between groups for secondary outcomes overall. The quality of evidence was deemed to be low overall because of high risk of bias and imprecision in outcome measures. This review found low to moderate certainty evidence that prophylactic ondansetron reduces KAV incidence. Methodologically rigorous research, with appropriately timed prophylactic ondansetron based on the route of administration, would further elucidate prophylactic oral ondansetron's efficacy. [ABSTRACT FROM AUTHOR]

The article presents the discussion on navigating low-value care in regional, rural and remote Australia. Topics include identified that approximately a third of urine cultures, coagulation studies, blood cultures and cranial CT scans conducted within the TUH-ED setting; and accept the patient until testing and imaging have been done, citing the need for efficiency.

Objective: The objective of this study was to assess the impact of introduction of a new pulmonary embolism (PE) diagnostic guideline with a raised D‐dimer threshold. Methods: This is a single‐site, observational, cohort study with a historical comparison. The new guideline raised the D‐dimer threshold to 1000 ng/mL for most patients with a Wells' score of 4 or less. Patients investigated for PE with a D‐dimer level and/or definitive imaging in 6‐month periods before and after the introduction of the guideline were eligible. Patients with D‐dimers of 500–1000 ng/mL were prospectively followed up at 3 months for missed PE. Results: During the pre‐intervention period, 688 patients were investigated for PE, 366 (53.2%) received definitive imaging and 39 PE were diagnosed (5.7% overall, 10.7% of those imaged). For the 121 patients with D‐dimers ≥500 and <1000 ng/mL, 87 (71.9%) were imaged with 7 (5.8%) having a PE diagnosed. Post intervention there were 930 patients, of which 426 (45.8%) received definitive chest imaging and there were 50 patients with PE diagnosed (5.4% overall, 11.7% of those imaged). For the 185 patients with D‐dimers ≥500 and <1000 ng/mL, 60 (32.4%) were imaged with 5 (2.7%) having PE diagnosed. No cases of missed PE were identified at 3 months. Conclusion: The introduction of the new guideline was associated with a reduction in overall imaging rates without evidence of missed PE. Further evaluation in other settings is recommended. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was to describe the characteristics and outcomes of patients presenting to Australian EDs with suspected and confirmed COVID‐19 during 2020, and to determine the predictors of in‐hospital death for SARS‐CoV‐2 positive patients. Methods: This analysis from the COVED Project presents data from 12 sites across four Australian states for the period from 1 April to 30 November 2020. All adult patients who met local criteria for suspected COVID‐19 and underwent testing for SARS‐CoV‐2 in the ED were eligible for inclusion. Study outcomes were mechanical ventilation and in‐hospital mortality. Results: Among 24 405 eligible ED presentations over the whole study period, 423 tested positive for SARS‐CoV‐2. During the 'second wave' from 1 July to 30 September 2020, 26 (6%) of 406 SARS‐CoV‐2 patients received invasive mechanical ventilation, compared to 175 (2%) of the 9024 SARS‐CoV‐2 negative patients (odds ratio [OR] 3.5; 95% confidence interval [CI] 2.3–5.2, P < 0.001), and 41 (10%) SARS‐CoV‐2 positive patients died in hospital compared to 312 (3%) SARS‐CoV‐2 negative patients (OR 3.2; 95% CI 2.2–4.4, P = 0.001). For SARS‐CoV‐2 positive patients, the strongest independent predictors of hospital death were age (OR 1.1; 95% CI 1.1–1.1, P < 0.001), higher triage category (OR 3.5; 95% CI 1.3–9.4, P = 0.012), obesity (OR 4.2; 95% CI 1.2–14.3, P = 0.024) and receiving immunosuppressive treatment (OR 8.2; 95% CI 1.8–36.7, P = 0.006). Conclusions: ED patients who tested positive for SARS‐CoV‐2 had higher odds of mechanical ventilation and death in hospital. The strongest predictors of death were age, a higher triage category, obesity and receiving immunosuppressive treatment. [ABSTRACT FROM AUTHOR]

Time‐based targets (TBTs) for ED stays were introduced to improve quality of care but criticised as having harmful unintended consequences. The aim of the review was to determine whether implementation of TBTs influenced quality of care. Structured searches in medical databases were undertaken (2000–2019). Studies describing a state, regional or national TBTs that reported processes or outcomes of care related to the target were included. Harvest plots were used to summarise the evidence. Thirty‐three studies (n = 34 million) were included. In some settings, reductions in mortality were seen in ED, in hospital and at 30 days, while in other settings mortality was unchanged. Mortality reductions were seen in the face of increasing age and acuity of presentations, when short‐stay admissions were excluded, and when pre‐target temporal trends were accounted for. ED crowding, time to assessment and admission times reduced. Fewer patients left prior to completing their care and fewer patients re‐presented to EDs. Short‐stay admissions and re‐admissions to wards within 30 days increased. There was conflicting evidence regarding hospital occupancy and ward medical emergency calls, while times to treatment for individual conditions did not change. The evidence for associations was mostly low certainty and confidence in the findings is accordingly low. Quality of care generally improved after targets were introduced and when compliance with targets was high. This depended on how targets were implemented at individual sites or within jurisdictions, with important implications for policy makers, health managers and clinicians. [ABSTRACT FROM AUTHOR]

Time‐based targets for ED length of stay were introduced in England in 2000, followed by the rest of the UK, Canada, Ireland, New Zealand, and Australia after ED crowding was associated with poor quality of care and increased mortality. This systematic review evaluates qualitative literature to see if ED time‐based targets have influenced patient care quality. We included 13 studies from four countries, incorporating 617 interviews. We conclude that time‐based targets have impacted on the quality of emergency patient care, both positively and negatively. Successful implementation depends on whole hospital resourcing and engagement with targets. This is a qualitative review of literature evaluating how time‐based‐targets impacted on patient quality of care in emergency departments. Thirteen studies from four countries, with the views of 617 stakeholders are presented. The impact of time‐based‐targets is varied, can be both positive and negative and successful implementation depends on whole hospital resourcing and engagement with targets. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was to describe the epidemiology and clinical features of patients presenting to the ED with suspected and confirmed COVID‐19 during Australia's 'second wave'. Methods: The COVID‐19 ED (COVED) Project is an ongoing prospective cohort study in Australian EDs. This analysis presents data from 12 sites across four Australian states for the period from 1 July to 31 August 2020. All adult patients who met the criteria for 'suspected COVID‐19' and underwent testing for SARS‐CoV‐2 in the ED were eligible for inclusion. Study outcomes included a positive SARS‐CoV‐2 test result, mechanical ventilation and in‐hospital mortality. Results: There were 106 136 presentations to the participating EDs and 12 055 (11.4%; 95% confidence interval [CI] 11.2–11.6) underwent testing for SARS‐CoV‐2. Of these, 255 (2%) patients returned a positive result. Among positive cases, 13 (5%) received mechanical ventilation during their hospital admission compared to 122 (2%) of the SARS‐CoV‐2 negative patients (odds ratio 2.7; 95% CI 1.5–4.9, P = 0.001). Nineteen (7%) SARS‐CoV‐2 positive patients died in hospital compared to 212 (3%) of the SARS‐CoV‐2 negative patients (odds ratio 2.3; 95% CI 1.4–3.7, P = 0.001). Strong clinical predictors of the SARS‐CoV‐2 test result included self‐reported fever, sore throat, bilateral infiltrates on chest X‐ray, and absence of a leucocytosis on first ED blood tests (P < 0.05). Conclusions: In this prospective multi‐site study during Australia's 'second wave', a substantial proportion of ED presentations required SARS‐CoV‐2 testing and isolation. Presence of SARS‐CoV‐2 on nasopharyngeal swab was associated with an increase in the odds of death and mechanical ventilation in hospital. [ABSTRACT FROM AUTHOR]

Background: Decreased bone mineral density (BMD) is a concern in patients with congenital adrenal hyperplasia (CAH) due to lifelong glucocorticoid replacement. Studies till date have yielded conflicting results. We wanted to systematically evaluate the available evidence regarding BMD in adult patients with CAH. Methods: We searched Medline, Embase and Cochrane Central Register of Controlled Trials to identify eligible studies. Studies comparing BMD in CAH patients with age- and sex-matched controls were included. Age <16 years and absence of controls were exclusion criteria. Two authors independently reviewed abstracts, read full-text articles, extracted data, assessed risk of bias using Newcastle-Ottawa scale, and determined level of evidence using Grading of Recommendations Assessment, Development, and Evaluation methodology. Results: Nine case-control studies with a total sample of 598 (cases n = 254, controls n = 344) met eligibility criteria. Median age was 31 years (IQR 23.9–37) and 65.7% were female. Total body BMD (Mean Difference [MD]-0.06; 95%CI −0.07, −0.04), lumbar spine BMD (MD −0.05; 95%CI −0.07, −0.03) and femoral neck BMD (MD −0.07; 95%CI −0.10, −0.05) was lower in cases compared to controls. Lumbar spine T -scores (MD −0.86; 95%CI −1.16, −0.56) and Z -scores (MD −0.66; 95%CI −0.99, −0.32) and femoral neck T -scores (MD −0.75 95%CI −0.95, −0.56) and Z -scores (MD −0.27 95%CI −0.58, 0.04) were lower in cases. Conclusion: BMD in adult patients with CAH was lower compared to controls. Although insufficient data precludes a dose-response relationship between glucocorticoid dose and BMD, it would be prudent to avoid overtreatment with glucocorticoids. [ABSTRACT FROM AUTHOR]

The article presents questions and answers related to emergency transvenous cardiac pacing such as is transvenous cardiac pacing catheter placement (TCPCP) an emergency procedure, is TCPCP a difficult skill to acquire, and how to prepare for the procedure.

The article presents the Australasian College for Emergency Medicine has commissioned an expert working group to inform the College's advocacy position on whether time-based targets (TBT) should be used as a health system performance measure. Topics include the emergency physicians in the group were asked to use a critical appraisal tool, the important characteristics to be considered alongside evidence of improved outcomes, and the indicator have face validity for stakeholders.