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Objective: Early recognition and treatment for sepsis is critical in improving patient outcomes. The present study sought to examine whether triage location was associated with time to appropriate antibiotics in a cohort of ED patients with septic shock. Methods: Septic shock patients were identified from a database of ED patients admitted with infection. Demographic, clinical and outcome data were reported by triage location. Time to event analyses sought to identify the association between triage location and time to appropriate antibiotic. Secondary outcome variables included ED and hospital length of stay (LOS), 30-day mortality, and ICU admission. Results: Time to appropriate antibiotic administration was longer for those patients triaged to lower acuity (242 min) compared to higher acuity (98 min, P < 0.01) locations. After adjustment for severity of illness, hospital LOS, ED LOS and 30-day mortality were similar regardless of the triaged location. Admission to ICU was lower for patients triaged to lower (7.3%) compared to higher (47.3%) acuity treatment locations. Conclusions: We identified a sub-group of septic shock patients triaged to a lower acuity treatment location who received significant delays to antibiotics. This research area deserves closer examination to potentially recognise septic shock earlier in the continuum.

To gain greater understanding of what it means to care for older patients dying from traumatic injuries in the emergency department.A Heideggerian phenomenological design using the methods of Van Manen.In-depth, face-to-face interviews were conducted with five emergency nurses who worked in an emergency department in Australia. Interview data were interpreted using a Heideggerian hermeneutic approach and guided by Van Manen's lifeworld analysis focusing on the experiential aspects of lived time (temporality) and lived space (spatiality) in the phenomenon.The older patient reflects the passage of chronological time. This temporal aspect shaped the participant experience as there was a sudden awareness of the impact of the injuries sustained on the fragile physical condition of the patients. There was an unexpectedness and unpreparedness which was related to a precognitive assumption that the older patient would die from an age-related comorbid condition. Also of significance was the sacred liminal space in which the nurses worked to facilitate the dying patient transition from life to death.The existential dimensions of temporality and spatiality revealed new insights into what it means to care for elderly patients dying from traumatic injuries. Temporal aspects were shaped by the longevity of the lives of patients and spatiality explored the liminal space where participants were morally guided to deliver end of life care with dignity and respect for a long-lived life taken by trauma.The findings may contribute to further understanding of what shapes the experience for emergency nurses delivering EOL care in the ED, with specific relevance and focus on the older patient with traumatic injuries. Hermeneutic research may also encourage clinicians to explore phenomena to reveal new understandings that will inform further dialogue and future research.

Background The objective of this study was to explore factors associated with the triage category assigned by the triage nurse for patients ultimately diagnosed with acute myocardial infarction. Methods This was a retrospective analysis of 12 months of data, on adult emergency department patients ultimately diagnosed with acute myocardial infarction. Data were obtained from hospital databases and included patient demographics, patient clinical characteristics and nurses’ experience. Results Of the 153 patients, 20% (95% CI: 14–27%) were given a lower urgency triage category than recommended by international guidelines. Compared to patients who were triaged Australasian Triage Category 1 or 2, patients with an Australasian Triage Category 3–5 were older (mean age 76 versus 68 years), more likely to be female (63% versus 32%), more likely to present without chest pain (93% versus 35%) and less likely to have a cardiac history (3.3% versus 17.9%). A slightly higher proportion of patients Australasian Triage Category 3–5 were triaged by an experienced nurse (50%) compared to patients categorised Australasian Triage Category 1–2 (35.2%) but this finding did not reach statistical significance. Conclusions One in five presentations was given a lower urgency triage category than recommended by international guidelines, potentially leading to delays in medical treatment. The absence of chest pain was the defining characteristic in this group of patients, along with other factors identified by previous research such as being of female sex and elderly.

To examine the safety and efficacy of the Improved Assessment of Chest pain Trial (IMPACT) protocol, a strategy for accelerated assessment of patients presenting to emergency departments (EDs) with chest pain.IMPACT was an intervention trial at a single tertiary referral hospital (Royal Brisbane and Women's Hospital) during February 2011 - March 2014. 1366 prospectively recruited patients presenting to the ED with symptoms of suspected acute coronary syndrome (ACS) were stratified into groups at low, intermediate or high risk of an ACS.High risk patients were treated according to NHFA/CSANZ guidelines. Low and intermediate risk patients underwent troponin testing (sensitive assay) 0 and 2 hours after presentation. Intermediate risk patients underwent objective testing after the second troponin test; low risk patients were discharged without further objective testing.The primary outcome was an ACS within 30 days of presentation. Secondary outcomes were ED and hospital lengths of stay (LOS).The IMPACT protocol stratified 244 (17.9%) patients to low risk, 789 (57.7%) to intermediate risk, and 333 (24.4%) to high risk categories. The overall 30-day ACS rate was 6.6%, but there were no ACS events in the low risk group, and 14 (1.8%) in the intermediate risk group. The median hospital LOS was 5.1 hours (IQR, 4.2-5.6 h) for low risk and 7.7 hours (IQR, 6.1-21 h) for intermediate risk patients.The IMPACT protocol safely and efficiently allowed a large proportion of patients presenting to EDs with chest pain to undergo accelerated assessment for risk of an ACS.Australian New Zealand Clinical Trials Registry ACTRN12611000206921.

Objective To evaluate the incidence of major adverse cardiac events (MACE) at 1 year in emergency department (ED) patients with possible acute coronary syndromes, stratified by high sensitivity troponin (hs-cTnI) concentrations using sex-specific cut points compared with overall cut points. Methods In a multicentre observational study of 2841 patients, presentation hs-cTnI concentrations were categorised using sex-specific (women 16 ng/L; men 34 ng/L) and overall (26 ng/L) cut points. The primary outcome was MACE occurring within 1 year of presentation. Patients with hs-cTnI values concentrations within these categories were reported by sex and 1-year MACE. Net reclassification improvement (NRI) was computed to measure the change in prediction after altering the hs-cTnI cut points, and was calculated separately for events and non-events. Results Application of sex-specific 99th percentile cut points rather than the overall cut point of 26 ng/L, reclassified 25 females from having a non-elevated troponin to having an elevated troponin, and 29 males from having an elevated troponin value to having a non-elevated troponin value on presentation. Of these, 7 (28.0%) females and 12 (41.4%) males had a 1-year MACE. There was no reclassification improvement for those with or without 1-year MACE (NRI events =−1.5%, 95% CI −4.0% to 1.1%; NRI non-events −0.04%, 95% CI −0.5% to 0.4%). Conclusions Sex-specific cut points improve the identification of women but not men at risk for 1-year MACE. The net-effect across the whole ED population with possible cardiac chest pain is minimal. Lowering the clinical cut point for both sexes may be appropriate for prognostic purposes. Trial registration number ISRCTN No. 21109279, ACTRN12609000283279.

Objectives To compare the predictive ability of three risk stratification tools used to assess patients presenting to the ED with potential acute coronary syndrome. Design Pre-planned analysis of an observational study. Setting A single tertiary referral hospital. Participants 1495 patients presented with chest pain. 948 patients were screened and enrolled. Patients with at least 5min of chest pain suggestive of ACS were eligible. Interventions Subjects were risk categorised using the Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines (HFA/CSANZ), the TIMI score and the GRACE score. Three strata of the TIMI and GRACE score were used to compare to the HFA/CSANZ risk categories. Main outcome measurement 30-Day cardiac event rates including cardiac death, acute myocardial infarction and unstable angina. Results There were 152 events in 91 patients (9.6%). The discriminatory ability of the scores determined by the AUC was 0.83 (95% CI 0.79–0.87) for the GRACE score, 0.79 (95% CI 0.74–0.83) for TIMI score and 0.75 (95% CI 0.70–0.80) for HFA/CSANZ. The AUCs with three strata of the GRACE and TIMI scores were 0.76 (95% CI 0.72–0.81) and 0.68 (95% CI 0.62–0.73) respectively. Conclusions All three scores were similar in performance in quantifying risk in ED patients with possible ACS. The GRACE score identified a sizable low risk cohort with high sensitivity and NPV but complexity of this tool may limit its utility. Improved scores are needed to allow early identification of low- and high-risk patients to support improvements in patient flow and ED overcrowding.