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Objective: An observational study on the current diagnostic and procedural utility, as well as impact of point-of-care ultrasound (POCUS) in the emergency department (ED). Background(s): Point-of-care ultrasound (POCUS) has been recognised as a useful non-invasive bedside tool in providing valuable information, as well as its utility in procedural guidance for clinicians. However, its current prevalence and utility in ED remain unknown. Method(s): In October 2016, a 31-day prospective observational study was performed in three Monash Health Emergency Departments in Melbourne, Australia. Data regarding patients' presenting complaints, frequency, operators' qualifications and POCUS module were collected and analysed. Factors associated with diagnostic impacts were identified. Result(s): A total of 390 (2.1%) POCUS examinations were performed among 18,355 presentations in the three Monash Health EDs during the study period. POCUS was performed as a diagnostic tool in 344 (88.2%) and procedural guidance in 46 (11.8%) cases. eFAST/AAA and bedside echocardiography were the two most frequently utilised diagnostic modules. Overall, the majority of diagnostic POCUS cases were indicated for abdominal pain (35.3%), chest pain (14.0%) and trauma mainly traffic accidents (5.8%). Procedural POCUS was most commonly used for vascular access (71.7%), where dyspnoea (21.6%) was the most common presenting complaint. The majority of the cases were performed by FACEMs (Fellows of Australasian College of Emergency Medicine) (66.4%). Conclusion(s): Despite known diagnostic and procedural values, the prevalence of POCUS in ED was found to be lower than what was expected. The prevalence was shown to be proportional to the level of clinical expertise among the operators. Training and utility of POCUS among physicians and trainees should be further advocated and supported.Copyright © 2019 Australasian Society for Ultrasound in Medicine

Bronchiolitis is the most common reason for infants to be hospitalised. Over the past decade, the use of high-flow nasal cannulae (HFNC) therapy has increased markedly and it is now utilised not only in the intensive care unit setting but in general paediatric wards and emergency departments. The aim of this systematic review was to summarise and critique the current evidence-base for the use of HFNC in infants with bronchiolitis. We searched Ovid Medline, OvidEmbase, PubMed, Cinahl, Cochrane Library, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials for systematic reviews and randomised controlled trials of HFNC therapy in infants with bronchiolitis from 1 January 2000 to 27 June 2018. We identified four randomised controlled trials (n = 1891) of HFNC in infants with bronchiolitis: three of these studies involved infants treated in emergency departments and inpatient paediatric wards in Spain, Australia and New Zealand, and one study involved infants treated in paediatric intensive care units in France. The findings of this review suggest that HFNC should be used as a rescue treatment for hypoxaemic infants who have not responded to standard sub nasal oxygen therapy. The use of HFNC for work of breathing in the absence of hypoxaemia, and severe disease, is not currently supported by the evidence, and should only be considered in the context of an appropriate research trial.Copyright © 2019 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)

Objective: Asthma exacerbations are common presentations to ED. Key guideline recommendations for management include administration of inhaled bronchodilators, systemic corticosteroids and titrated oxygen therapy. Our aim was to compare management and outcomes between patients treated for asthma in Europe (EUR) and South East Asia/Australasia (SEA) and compliance with international guidelines. Method(s): In each region, prospective, interrupted time series studies were performed including adult (age >18 years) patients presenting to ED with the main complaint of dyspnoea during three 72 h periods. This was a planned sub-study that included those with an ED primary diagnosis of asthma. Data was collected on demographics, clinical features, treatment in ED, diagnosis, disposition and in-hospital outcome. The results of interest were differences in treatment and outcome between EUR and SEA cohorts. Result(s): Five hundred and eighty-four patients were identified from 112 EDs (66 EUR and 46 SEA). The cohorts had similar demographics and co-morbidity patterns, with 89% of the cohort having a previous diagnosis of asthma. There were no significant differences in treatment between EUR and SEA patients - inhaled beta-agonists were administered in 86% of cases, systemic corticosteroids in 66%, oxygen therapy in 44% and antibiotics in 20%. Two thirds of patients were discharged home from the ED. Conclusion(s): The data suggests that compliance with guideline-recommended therapy in both regions, particularly corticosteroid administration, is sub-optimal. It also suggests over-use of antibiotics.Copyright © 2019 Australasian College for Emergency Medicine

Objective To determine the variability of primary and secondary outcomes used in trials of intravenous bronchodilators in children with acute severe paediatric asthma. Methods Systematic search of MEDLINE, EMBASE, Cochrane CENTRAL and the WHO International Clinical Trials Registry Platform for randomised trials in children (less than18 years) with acute severe paediatric asthma comparing intravenous bronchodilator therapy to another treatment. Initial search was performed on 7 January 2016 with an updated search performed on 6 September 2018. Primary and secondary outcomes were collated. Results We identified 35 published papers and four registered study protocols. 56 primary outcomes were found, the most common being a clinical asthma score (23/56; 41%). Other identified primary outcomes included bedside tests of respiratory function (11/56; 20%) and measures of length of stay (9/56; 16%). There were a total of 60 different secondary outcomes, the most common were various length of stay measures (24/60; 40%) and adverse events (11/60; 18%). Conclusion Studies comparing intravenous treatment modalities for children with acute severe paediatric asthma exhibit great variation in the type, number and timing of outcome measures used. There are no patient or family-specific outcomes reported. There is a need to develop international consensus.Copyright © 2019 Author(s) (or their employer(s)).

Background: Hospital, emergency presentation and death databases are frequently used to research outcomes after stroke. The reliability of diagnostic coding for cardiovascular disease (CVD) in these administrative data remains uncertain. We aimed to determine the reliability of these data in Australia using an existing clinical trial cohort. Method(s): Patients with stroke/TIA who participated in the Shared Team Approach between Nurses and Doctors For Improved Risk factor Management (STAND FIRM) trial (n = 563, recruited from 4 hospitals within Victoria). We used diagnostic ICD-10-AM coded data from hospital, emergency department and death databases within 2 years after stroke/TIA. Medical records for these potential CVD-related events were reviewed by two independent stroke specialists and adjudicated according to strict criteria. We then estimated sensitivity and specificity of using either primary or both primary and secondary diagnoses fields (obtained for all adjudicated records), against the events adjudicated by the specialists (gold standard). False positives were CVD-events defined by ICD-10-AM diagnostic codes that were adjudicated as not being a CVD-event. False negatives were true CVD-events that were misclassified as not being CVD-related when using ICD-10-AM codes. Result(s): We identified 261 events for medical review. After adjudication, 65 were classified as CVD-events (cases) and 196 were not CVD-events. Using both primary and secondary diagnoses, 55 true positives were correctly identified among the cases (sensitivity = 84.6%) and 129 true negatives among the non-cases (specificity = 65.8%). Using only primary diagnoses, 48 true positives were identified (sensitivity = 73.9%) and 171 true negatives (specificity = 87.2%). Using both primary and secondary diagnoses had an increased sensitivity, but decreased specificity (area under the Receiver Operating Characteristic curve (AUC) = 0.75; 95% CI, 0.70, 0.81) when compared with using only primary dia

Introduction: Human factors engineering multimodal interventions (MMI) are known to be effective in reducing the rate of unused peripheral intravenous cannulas (PIVCs). However, there has been no research on the long-term effects of these interventions. Our primary aim was to examine the long-term effect of multimodal interventions on PIVC use in the emergency department (ED). Method(s): A single-centre retrospective cohort study of adult patients presenting to the ED was conducted in April 2018, approximately 5 years since the original MMI. This data (termed "Delayed Post-MMI") was compared to previously published data before the MMI ("pre-MMI") and 3 months after the MMI ("Immediately Post-MMI"). The incidence and appropriateness (based on its use, or intentions of use) of PIVCs inserted in a random sample of 380 patients was assessed using a structured electronic medical record review. The rate of PIVC insertion since the original MMI was also investigated. Result(s): A PIVC was inserted in 925 out of 4573 adult patients (20.2%) in the ED during our study period and were included in the delayed post-MMI group. Compared to the previous Pre-MMI cohort, an absolute reduction of 13.7% in idle PIVCs were observed with a relative risk (RR) of 0.6. Out of the random sample of 380 patients, 101 PIVCs were unused (101/373, 27.1%). 23 unused PIVCs were appropriately inserted (23/101, 22.8%) and 78 were idle (78/101. 77.2%). Between the Pre-MMI and Delayed Post-MMI sample of 380 patients, a 9.9% overall absolute reduction of PIVC insertion was observed (RR = 0.733). PIVC insertion rates remained low since theMMI. Conclusion(s): A human factor engineering multimodal intervention is shown to sustain a reduction in overall PIVC insertion rates and idle PIVCs in the ED. Unused but appropriately inserted PIVCs remain unaffected by the intervention.

Background Falls are a leading reason for older people presenting to the emergency department (ED), and many experience further falls. Little evidence exists to guide secondary prevention in this population. This randomised controlled trial (RCT) investigated whether a 6-month telephone-based patient-centred program-RESPOND-had an effect on falls and fall injuries in older people presenting to the ED after a fall. Methods and findings Community-dwelling people aged 60-90 years presenting to the ED with a fall and planned for discharge home within 72 hours were recruited from two EDs in Australia. Participants were enrolled if they could walk without hands-on assistance, use a telephone, and were free of cognitive impairment (Mini-Mental State Examination > 23). Recruitment occurred between 1 April 2014 and 29 June 2015. Participants were randomised to receive either RESPOND (intervention) or usual care (control). RESPOND comprised (1) home-based risk assessment; (2) 6 months telephone-based education, coaching, goal setting, and support for evidence-based risk factor management; and (3) linkages to existing services. Primary outcomes were falls and fall injuries in the 12-month follow-up. Secondary outcomes included ED presentations, hospital admissions, fractures, death, falls risk, falls efficacy, and quality of life. Assessors blind to group allocation collected outcome data via postal calendars, telephone follow-up, and hospital records. There were 430 people in the primary outcome analysis-217 randomised to RESPOND and 213 to control. The mean age of participants was 73 years; 55% were female. Falls per person-year were 1.15 in the RESPOND group and 1.83 in the control (incidence rate ratio [IRR] 0.65 [95% CI 0.43- 0.99]; P = 0.042). There was no significant difference in fall injuries (IRR 0.81 [0.51-1.29]; P = 0.374). The rate of fractures was significantly lower in the RESPOND group compared with the control (0.05 versus 0.12; IRR 0.37 [95% CI 0.15-0.91]; P

Objective: To assess the efficacy and safety of a virtual reality distraction for needle pain in 2 common hospital settings: the emergency department (ED) and outpatient pathology (ie, outpatient laboratory). The control was standard of care (SOC) practice. Study design: In 2 clinical trials, we randomized children aged 4-11 years undergoing venous needle procedures to virtual reality or SOC at 2 tertiary Australian hospitals. In the first study, we enrolled children in the ED requiring intravenous cannulation or venipuncture. In the second, we enrolled children in outpatient pathology requiring venipuncture. In the ED, 64 children were assigned to virtual reality and 59 to SOC. In pathology, 63 children were assigned to virtual reality and 68 to SOC; 2 children withdrew assent in the SOC arm, leaving 66. The primary endpoint was change from baseline pain between virtual reality and SOC on child-rated Faces Pain Scale-Revised. Result(s): In the ED, there was no change in pain from baseline with SOC, whereas virtual reality produced a significant reduction in pain (between-group difference, -1.78; 95% CI, -3.24 to -0.317; P = .018). In pathology, both groups experienced an increase in pain from baseline, but this was significantly less in the virtual reality group (between-group difference, -1.39; 95% CI, -2.68 to -0.11; P = .034). Across both studies, 10 participants experienced minor adverse events, equally distributed between virtual reality/SOC; none required pharmacotherapy. Conclusion(s): In children aged 4-11 years of age undergoing intravenous cannulation or venipuncture, virtual reality was efficacious in decreasing pain and was safe. Trial registration: Australia and New Zealand Clinical Trial Registry: ACTRN12617000285358pCopyright © 2019 Elsevier Inc.

Objectives: To present the first comprehensive epidemiological profile of hospital-treated injuries sustained by female cricketers from 2002-2003 to 2013-2014 in Victoria, Australia. Design(s): Analysis of routinely collected hospital data (detailed case-series). Method(s): A retrospective analysis of hospital-treatment data associated with cricket injuries sustained by women between 1 July 2002 and 30 June 2014, inclusive were extracted from databases held by the Victorian Injury Surveillance Unit in Australia. Result(s): Over the 12-year period, 668 cases were treated in Victoria. Of these, 547 were emergency department (ED)-presentations. There were 121 hospital-admissions, of which, the length of stay was <2 days for 78.5% cases. All cases were treated and released, and no fatalities were reported. The 10-14 year age group most frequently presented to ED (19.9%) and were most commonly admitted to hospital (16.5% of the total admissions). Fractures were the most common cause of hospital-admissions (47.1%) but only accounted for 17.2% of the ED-presentations. Dislocations, sprains and strains, were the most common (36.4%) cause of ED-presentations. The head was the most commonly injured anatomical location (27.8% of ED-presentations and 28.1% of hospital-admissions), followed by the wrist and hand (27.8% ED-presentations and 17.4% hospital-admissions). Conclusion(s): These findings provide the first overview of the nature of injuries requiring hospital attendance in female cricketers, and a foundation to inform the development of targeted injury prevention programs for female cricketers.Copyright © 2019 Sports Medicine Australia

AIM: To determine the efficacy of a ray sum image derived from computed tomography of the kidneys, ureters and bladder (CT KUB) in detecting renal tract calculi and whether this can replace the baseline abdominal radiograph (AXR). MATERIALS AND METHODS: This is a retrospective study performed at a tertiary referral centre examining adult patients referred for urolithiasis who had undergone AXR within 24 hours of the diagnostic CT KUB. AXR and ray sum image for calculus visibility were reviewed blindly by two readers. Anteroposterior thickness of the patient, presence of excess gas/faecal material, calculus size, location, and mean attenuation were analysed to determine effect on the AXR and ray sum sensitivity. RESULT(S): One hundred and fifty-two calculi were examined with ray sum image sensitivity of 44% (95% confidence interval [CI]: 36-52) and AXR 30% (95% CI: 22-38). Calculus size and mean attenuation significantly affected sensitivities of both ray sum and AXR. There was substantial agreement between the two techniques with kappa(Kappa)=0.70 (95% CI: 0.58-0.81, p<0.001). CONCLUSION(S): Ray sum image as a post-processed image derived from CT KUB dataset may be a viable alternative to the baseline AXR in patients with CT proven urolithiasis. This would reduce patient radiation dose and streamline workflow in busy radiology and emergency departments.Copyright © 2019

Objectives: CASE: A previously well 62-year-old female presented to the emergency department with central chest pain. Initial electrocardiogram demonstrated sinus rhythm with ST-elevation in V1-V2 and she underwent emergent coronary angiography which demonstrated no obstructive coronary artery stenosis, however left ventriculography demonstrated focal dyskinesis / aneurysm of the mid anterior left ventricular (LV) wall. Contrast enhanced transthoracic echocardiography (TTE) confirmed the appearance and demonstrated a pericardial effusion, raising the suspicion of a contained LV rupture. Cardiacmagnetic resonance (CMR) imaging confirmed the presence of an anterior wall aneurysm with associated oedema on T2 weighted images (Fig 1) however there was no evidence of associated late gadolinium enhancement (LGE) in the region (Fig 1). The patient had been involved in an argument before presenting to hospital and the findings were thought to be most consistent with an atypical Takotsubo cardiomyopathy (TC), and repeat transthoracic echocardiography 1 month later demonstrated complete normalisation of LV contraction. DISCUSSION: TC is a rare syndrome characterized by transient regional systolic dysfunction of the LV, mimickingmyocardial infarction, but in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. Focal involvement of the myocardium is its rarest form. A large multi-centre study in this population found CMR can accurately identify TC through a typical pattern of LV dysfunction and demonstrates myocardial edema in 81% patients, and no significant LGE in 91%. These findings were consistent with our patient. Interestingly in this study 40% of this patient population also had a pericardial effusion. (Figure Presented).

Background: ED-based trials have repeatedly failed to demonstrate superiority for antiemetic drugs over placebo,1 but the clinical significance of reported between-group differences in mean visual analogue scale (VAS) change is obscure.2 Recent research suggests that a VAS change cut-off level can reliably identify improved patients.3 This would allow more clinically meaningful between-group comparisons to be made. Objective(s): To compare intravenous (IV) droperidol 1.25 mg and ondansetron 8 mg IV with 0.9% saline placebo for adult ED patients with nausea. A VAS change cut-off level was used as the primary outcome measure. Method(s): A randomised controlled trial was conducted at Monash Health, designed to demonstrate superiority of the active drugs over placebo. The primary outcome measure of symptom improvement was defined as a VAS change of >= -8 mm from baseline at 30-minute posttreatment. Mean VAS changes per group, and percentages experiencing the desired treatment effect were also compared. Result(s): Of 215 patients, 73 (34%), 71 (33%) and 71 (33%) received droperidol, ondansetron and placebo. Symptom improvement occurred in 75%, 80% and 76% respectively; between-group differences are shown in Table 1. Mean VAS changes were -29 mm (95% CI: -36 to -23), -34 mm (95% CI: -41 to -28), and -24 mm (95% CI: -29 to -19), respectively. Desired treatment effect was experienced by 77%, 73% and 59% respectively; between-group differences are shown in Table 2. Conclusion(s): Superiority was not demonstrated for droperidol or ondansetron over placebo. The new primary outcome measure provided results which were clinically meaningful and easily understandable. (Table Presented).

Objectives To evaluate the changes in productivity when scribes were used by emergency physicians in emergency departments in Australia and assess the effect of scribes on throughput. Design Randomised, multicentre clinical trial. Setting Five emergency departments in Victoria used Australian trained scribes during their respective trial periods. Sites were broadly representative of Australian emergency departments: public (urban, tertiary, regional referral, paediatric) and private, not for profit. Participants 88 physicians who were permanent, salaried employees working more than one shift a week and were either emergency consultants or senior registrars in their final year of training; 12 scribes trained at one site and rotated to each study site. Interventions Physicians worked their routine shifts and were randomly allocated a scribe for the duration of their shift. Each site required a minimum of 100 scribed and non-scribed shifts, from November 2015 to January 2018. Main outcome measures Physicians' productivity (total patients, primary patients); patient throughput (door-to-doctor time, length of stay); physicians' productivity in emergency department regions. Self reported harms of scribes were analysed, and a cost-benefit analysis was done. Results Data were collected from 589 scribed shifts (5098 patients) and 3296 non-scribed shifts (23 838 patients). Scribes increased physicians' productivity from 1.13 (95% confidence interval 1.11 to 1.17) to 1.31 (1.25 to 1.38) patients per hour per doctor, representing a 15.9% gain. Primary consultations increased from 0.83 (0.81 to 0.85) to 1.04 (0.98 to 1.11) patients per hour per doctor, representing a 25.6% gain. No change was seen in door-to-doctor time. Median length of stay reduced from 192 (interquartile range 108-311) minutes to 173 (96-208) minutes, representing a 19 minute reduction (P<0.001). The greatest gains were achieved by placing scribes with senior doctors at triage, the least by using them in sub

Objective: To describe and model a decade of ED presentations in metropolitan Melbourne, Australia, from July 2000 to June 2010 and to validate the model of ED presentations by testing the model's performance in forecasting the subsequent 2 year period of daily presentations, from July 2010 to June 2012. Method(s): Retrospective analyses of prospectively collected data sourced from the Victorian Emergency Minimum Dataset were performed and included 13 public hospitals. Time series modelling involved unobserved components modelling and forward selection of variables using incidence rate ratios. Forecasting with the model and validation were performed using the 2 year period up to June 2012. Model performance was calculated using the mean average percentage error. Result(s): A total of 7 031 242 patient presentations occurred to the sample metropolitan EDs in the 12 year study period. An absolute increase in mean daily ED presentations of 81.3% was observed. Presentations increased on Sunday and Monday incidence rate ratio of 1.10 (95% CI 1.08-1.11, P < 0.05). No monthly or seasonal pattern was evident. Public holidays were associated with increased presentations, incidence rate ratio of 1.11 (95% CI 1.08-1.15, P < 0.05). The model with the best goodness-of-fit and Wald chi2 value included Sunday-Monday (vs Tuesday-Saturday), public holidays, the trend of gradual increase over time and a stochastic (random white noise) cycle. The mean average percentage error for the 2 year forecast period was 3.6%. Conclusion(s): We have produced and validated a model for predicting daily ED presentations across a major city. Even though ED presentations are multifactorial, city-wide daily presentations are predictable and explained by a small number of variables. The model will have implications for future health planning.Copyright © 2019 Australasian College for Emergency Medicine

Introduction: Systemic sclerosis (SSc) is an incurable multi-organ autoimmune disease with substantial morbidity and mortality. Due to varied clinical manifestations, patients with SSc are usually on multiple medications and require frequent hospitalization and consultation with specialists and allied health from a broad range of disciplines. We hypothesize that the cost of healthcare in SSc is substantial, and sought to quantify this health service utilization and associated cost among Australian SSc patients. Material(s) and Method(s): Health service use was captured by means of data linkage. Data for all Victorian SSc patients enrolled in the Australian Scleroderma Cohort Study (ASCS) (n=531) between 2011-2015 were linked with the Victorian hospital admissions and emergency presentations data sets and the Medicare Benefits Schedule (MBS), which contains all government subsidized ambulatory care services. Hospitalization cost was calculated based on the financial year of admission, admission diagnosis, length of stay and the corresponding value of each admission unit for that financial year. Ambulatory care cost was based on the MBS fee payable by the Australian government for each service, and medication cost was estimated from the Pharmaceutical Benefits Scheme (PBS). Cost was extrapolated to all Australian SSc patients based on SSc prevalence (21.1 per 100,000) and population data (Australian population 24,304,682 in 2015). Result(s): Total health service utilization cost to the Australian government extrapolated to all Australian SSc patients between 2011-2015 amounted to AUD$298,065,737.15 (USD$219,376,382.55), which is an average annual cost of AUD$59,613,147.43 (USD$43,875,276.51) and annual cost per patient of AUD$11,622.76 (USD$8,554.35). Hospital costs, including inpatient hospitalization and emergency department presentations, accounted for the majority (44.5%) of these costs, followed by medication cost (31.1%) and ambulatory care cost (24.4%). Determi

Purpose: To validate the use of selected International Classification of Disease Codes 10th revision (ICD-10) to predict (positive predictive value) anaphylaxis due to vaccination using emergency department (ED) data. Method(s): We conducted a retrospective study using ED encounter data from a large tertiary-care teaching hospital, Monash Medical Centre, Melbourne, Australia. We searched all ED encounters potentially due to anaphylaxis after vaccination, between 1 January 2010 and 31 December 2018, using ICD-10-CM codes T80.5, T80.6, T88.1, T88.6, and T78.2. Health records of potential cases were examined to determine if they met the Brighton Collaboration (BC) criteria for anaphylaxis. We calculated the PPV to evaluate the accuracy of the selected ICD-10-CM codes in predicting anaphylaxis due to vaccination. Result(s): Of the 69 health records identified and reviewed, 29 (42.2%) met the criteria for anaphylaxis regardless of the cause, and 24.6% (17/69) of records were confirmed as anaphylaxis triggered by vaccination (low positive predictive value). However, of the 23 records identified using ICD-10-CM code T80.5, 22 were classified as anaphylaxis cases regardless of the cause, and 12 were anaphylaxis due to vaccination cases giving PPV of 95.7% and 52.2%, respectively. Conclusion(s): Given that there is no specific ICD-10-CM code for anaphylaxis due to vaccination, ICD-10-CM code T80.5 may be suitable to monitor anaphylaxis due to vaccination in the ED setting. The current study was conducted at a single centre and needs to be confirmed by future multicentre studies.Copyright © 2019 John Wiley & Sons, Ltd.

Background: This Australian partnership project uses anonymised emergency department (ED) data sharing to reduce alcohol-related injury, violence, and assaults, and is frequently referred to as the 'Cardiff' model in the UK with demonstrable harm-reduction efficacy.1 Objectives: This paper summarises preliminary data trends and interventions reports from the first six months of the intervention phase of the project. Method(s): a 5-year multi-site stepped-wedge cluster design trial. Nine hospitals are participating in the 36-month data collection period which commenced in July 2017. "Last-drinks" data regarding alcohol use in the preceding 12 hours, typical consumption, and location of alcohol purchase and consumption is prospectively collected by ED triage nurses and clinicians at all EDs as part of clinical process for all attendees aged 18 years or over. Data is used to inform public health interventions identifying problematic licensed venues and sources of alcohol harm in surrounding communities. Result(s): All nine ED's are collecting data successfully (n = 137,207 records with 61-100% compliance rate for screening items). During high-alcohol hours (8pm Friday -6am Saturday and 8pm Saturday - 6am Sunday) between 8.8-35.3% of patients reported consuming alcohol in the past 12 hours. The predominance of packaged liquor consumption overshadows on-premise consumption by a ratio of 4:1. Interventions have commenced in Warrnambool, Geelong and Eastern Melbourne, with remaining sites to enter intervention phase following the stepped model. Conclusion(s): Project data has given accurate and actionable profiles of the alcohol related harm coming into ED's in the cities Melbourne, Geelong and Warrnambool. Intervention results, content and delivery are summarised.

Introduction Australian Aboriginal and/or Torres Strait Islander (hereafter referred to as 'Aboriginal') adolescents (10-24 years) experience multiple challenges to their health and well-being. However, limited evidence is available on factors influencing their health trajectories. Given the needs of this group, the young age profile of the Aboriginal population and the long-term implications of issues during adolescence, reliable longitudinal data are needed. Methods and analysis The 'Next Generation: Youth Well-being Study' is a mixed-methods cohort study aiming to recruit 2250 Aboriginal adolescents aged 10-24 years from rural, remote and urban communities in Central Australia, Western Australia and New South Wales. The study assesses overall health and well-being and consists of two phases. During phase 1, we qualitatively explored the meaning of health and well-being for adolescents and accessibility of health services. During phase 2, participants are being recruited into a longitudinal cohort. Recruitment is occurring mainly through community networks and connections. At baseline, participants complete a comprehensive survey and undertake an extensive age relevant clinical assessment. Survey and clinical data will be linked to various databases including those relating to health services; medication; immunisation; hospitalisations and emergency department presentations; death registrations; education; child protection and corrective services. Participants will receive follow-up surveys approximately 2 years after their baseline visit. The 'Next Generation' study will fill important evidence gaps by providing longitudinal data on the health and social well-being of Aboriginal adolescents supplemented with narratives from participants to provide context. Ethics and dissemination Ethics approvals have been sought and granted. Along with peer-reviewed publications and policy briefs, research findings will be disseminated via reports, booklets and other formats th

BACKGROUND: Undifferentiated abdominal pain is a common pediatric presentation to the emergency department (ED). OBJECTIVE(S): The objective of this study was to describe the prevalence of clinically significant abdominal pathology (CSAP) including appendicitis, patterns of imaging and pathology tests, and management and outcomes of children with abdominal pain in ED. METHOD(S): A prospective multicenter observational cohort pilot study of children under the age of 16 years presenting to 4 Australian EDs with abdominal pain was performed for a 1-month period at each site. The primary outcome was to describe the prevalence of CSAP and appendicitis. Age, sex, length of stay, surgery or interventional procedure, investigations, and analgesia use were recorded. RESULT(S): There were 555 presentations with abdominal pain during the study period with a median age of 9 years (interquartile range, 6-12 years). Eighty-two patients (14.8%; 95% confidence interval, 11.8-17.7) had CSAP, of which 41 (7.4%, 5.2-9.6) had appendicitis. Three hundred forty-eight (62.7%, 58.7-66.7) were discharged directly from ED, and 207 (37.3%, 33.2-41.3) were admitted. Two hundred fifty-five (45.9%, 41.8-50.1) had pathology tests, and 173 (31.2%, 27.3-35.1) had imaging tests in ED. Of those contacted for telephone follow-up, 100 (50.5%, 43.5-57.5) of 198 reported ongoing pain after discharge, and 13.1% (8.4-17.8) had missed over a week of school due to abdominal pain. CONCLUSION(S): The prevalence of CSAP and appendicitis in our study was 14.8% (11.8-17.7) and 7.4% (5.2-9.6), respectively. Fewer than half of patients received blood tests, and a third received imaging during their ED attendance. The presentation of abdominal pain conveys a significant health burden on families with time off school and ongoing symptoms of pain.

Background. Invasive group A Streptococcus (GAS) disease has an incidence in high-income countries of 3 to 5 per 100 000 per annum and a case-fatality ratio of 10% to 15%. Although these rates are comparable to those of invasive meningococcal disease in Australia before vaccine introduction, invasive GAS disease currently requires reporting in only 2 jurisdictions. Methods. Data were collected prospectively through active surveillance at the Royal Children's Hospital, Melbourne (October 2014 to September 2016). Isolation of GAS from a sterile site was required for inclusion. Comprehensive demographic and clinical data were collected, and emm typing was performed on all isolates. Disease was considered severe if the patient required inotropic support or mechanical ventilation. Results. We recruited 28 patients. The median age of the patients was 3.5 years (range, 4 days to 11 years). Ten (36%) patients had severe disease. Fifteen (54%) children had presented to a medical practitioner for review in the 48 hours before their eventual admission, including 7 of the 10 patients with severe GAS infection. Complications 6 months after discharge persisted in 21% of the patients. emm1 was the most common emm type (29%). Conclusion. We found considerable short- and longer-term morbidity associated with pediatric invasive GAS disease in our study. Disease manifestations were frequently severe, and more than one-third of the patients required cardiorespiratory support. More than one-half of the patients attended a medical practitioner for assessment but were discharged in the 48-hour period before admission, which suggests that there might have been a window for earlier diagnosis. Our methodology was easy to implement as a surveillance system.Copyright © The Author(s) 2017. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society. All rights reserved.

In this series we address important topics for emergency clinicians who either participate in research as part of their work, or use the knowledge generated by research studies. Emergency clinicians are routinely in the position of applying new evidence in clinical practice. With an ever-increasing volume of evidence generated, this can be problematic when studies are conducted in different settings, and include different patient groups, different interventions and different outcomes. This is made even more difficult when the results of primary research studies do not agree. Systematic reviews are becoming increasingly valuable as they appraise and synthesise research findings using a clear methodology, and summarise the results of primary studies. As such, systematic reviews help translate research findings into clinical practice. This paper provides a practical starting point for understanding the steps involved in conducting a systematic review in emergency medicine and will help readers appraise the findings of systematic reviews.Copyright © 2019 Australasian College for Emergency Medicine

Background: To quantify the financial cost of pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc). Method(s): Healthcare use was captured through data linkage, wherein clinical data for SSc patients enrolled in the Australian Scleroderma Cohort Study were linked with hospital, emergency department (ED) and ambulatory care databases (MBS) for the period 2008-2015. PAH was diagnosed on right heart catheter according to international criteria. Determinants of healthcare cost were estimated using logistic regression. Result(s): Total median (25th-75th) healthcare cost per patient (including hospital, ED and MBS cost but excluding medication cost) for our cohort during 2008-2015 was AUD$37,685 (18,144-78,811) with an annual per patient healthcare cost of AUD$7506 (5273-10,654). Total healthcare cost was higher for SSc-PAH patients compared with those without PAH with a total cost per patient of AUD$70,034 (37,222-110,814) vs AUD$34,325 (16,093 - 69,957), p < 0.001 respectively with an annual excess healthcare cost per PAH patient of AUD$2463 (1973-1885), p < 0.001. The cost of SSc-PAH occurs early post PAH diagnosis with 89.4% utilizing a healthcare service within the first 12 months post PAH diagnosis with an associated cost per patient of AUD$4125 (0-15,666). PAH severity was the main significant determinant of increased healthcare cost (OR 2.5, p = 0.03) in our PAH cohort. Conclusion(s): Despite SSc-PAH being a low prevalence disease, it is associated with significant healthcare resource utilization and associated economic burden, predominantly driven by the severity of PAH.Copyright © 2019 The Author(s).

Objective: Our objective was to examine the impact of a human factor-designed multimodal intervention on the proportion of unused peripheral i.v. cannula (PIVC) insertion in our ED. Method(s): A pre- and post-multimodal intervention retrospective cohort study was conducted using a structured electronic medical record review within a single adult tertiary ED in Australia. Pre-intervention data was collected 30 days prior to the multimodal intervention, with 30 day post-intervention data collected 3 months after the intervention commenced. The rates of PIVC inserted, the unused rate and the unused but appropriately inserted cannulas were the main outcome measures. Result(s): Intravenous cannula insertion rates decreased by 12.9% (95% confidence interval [CI] 12.19-13.61) between the pre-intervention (1413/4167 [33.9%]; 95% CI 32.5-35.4) and post-intervention cohort (928/4421 [21.0%]; 95% CI 19.8-22.2). An analysis of 754 cases (376 pre-intervention and 378 post-intervention) showed that 139 of 376 (37.0%; 95% CI 32.1-42.1) i.v. cannulas were unused pre-intervention, while 73 of 378 (19.3%; 95% CI 15.4-23.7) was unused post-intervention; an absolute reduction of 17.7% (95% CI 14.98-20.42). The relative risk of an unused i.v. cannula was 0.52 (95% CI 0.41-0.67). The proportion of unused but appropriately inserted i.v. cannulas remained unchanged in both cohorts, with a relative risk of 0.91 (95% CI 0.58-1.42). Conclusion(s): Our multimodal intervention successfully reduced the number of unused PIVCs inserted in the ED, with a reduction in overall and unused PIVC insertions without any change in appropriate insertions.Copyright © 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Background: Sharing anonymised ED data with community agencies to reduce alcohol-related injury and assaults has been found effective in the UK. This protocol document outlines the design of an Australian multi-site trial using shared, anonymised ED data to reduce alcohol-related harm. Design and Method: Nine hospitals will participate in a 36 month stepped-wedge cluster randomised trial. After a 9 month baseline period, EDs will be randomised in five groups, clustered on geographic proximity, to commence the intervention at 3 monthly intervals. 'Last-drinks' data regarding alcohol use in the preceding 12 h, typical alcohol consumption amount, and location of alcohol purchase and consumption, are to be prospectively collected by ED triage nurses and clinicians at all nine EDs as a part of standard clinical process. Brief information flyers will be delivered to all ED patients who self-report risky alcohol consumption. Public Health Interventions to be conducted are: (i) information sharing with venues (via letter), and (ii) with police and other community agencies, and (iii) the option for public release of 'Top 5' venue lists. Outcome(s): Primary outcomes will be: (i) the number and proportion of ED attendances among patients reporting recent alcohol use; and (ii) the number and proportion of ED attendances during high-alcohol hours (Friday and Saturday nights, 20.00-06.00 hours) assigned an injury diagnosis. Process measures will assess logistical and feasibility concerns, and clinical impacts of implementing this systems-change model in an Australian context. An economic cost-benefit analysis will evaluate the economic impact, or return on investment.Copyright © 2019 Australasian College for Emergency Medicine

Objective: Abdominal pain is a common paediatric presentation to the ED. Accurate diagnosis of acute appendicitis is challenging, with the best-performing clinical scoring systems having sensitivities between 72% and 100%. The aim of this study is to assess the diagnostic accuracy of clinician gestalt according to seniority in diagnosing paediatric acute appendicitis in ED. Method(s): This is a prospective multi-centre observational study of clinician's prediction of appendicitis in children under the age of 16 years presenting to four EDs with abdominal pain over a 1 month period at each site. Clinician-estimated likelihood of acute appendicitis was compared with the final diagnosis determined by histopathology or operative findings and supplemented by telephone follow up for those without an operation. The primary outcome was diagnostic accuracy of clinician gestalt according to clinician seniority in diagnosing appendicitis. Result(s): There were 381 children enrolled with completed clinician questionnaires, and 224 children had complete follow up or underwent appendicectomy. The median age was 9 years (interquartile range 6-12) and the incidence of appendicitis was 31/224 (13.8%, 95% confidence interval 9.3-18.4). The area under the curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value of clinician gestalt were 0.84 (0.76-0.91), 81% (63-93%), 76% (69-82%), 35% (28-42%) and 96% (92-98%), respectively, giving an overall diagnostic accuracy of 76% (70-82%). AUC stratified by clinician seniority (junior, intermediate and senior) were 0.89 (0.80-0.98), 0.82 (0.69-0.95) and 0.76 (0.56-0.96), respectively. Conclusion(s): The diagnostic accuracy of ED clinician gestalt in paediatric appendicitis is comparable to current clinical scoring systems irrespective of seniority.Copyright © 2019 Australasian College for Emergency Medicine

Background: Phenytoin is the current standard of care for second-line treatment of paediatric convulsive status epilepticus after failure of first-line benzodiazepines, but is only effective in 60% of cases and is associated with considerable adverse effects. A newer anticonvulsant, levetiracetam, can be given more quickly, is potentially more efficacious, and has a more tolerable adverse effect profile. We aimed to determine whether phenytoin or levetiracetam is the superior second-line treatment for paediatric convulsive status epilepticus. Method(s): ConSEPT was an open-label, multicentre, randomised controlled trial conducted in 13 emergency departments in Australia and New Zealand. Children aged between 3 months and 16 years, with convulsive status epilepticus that failed first-line benzodiazepine treatment, were randomly assigned (1:1) using a computer-generated permuted block (block sizes 2 and 4) randomisation sequence, stratified by site and age (<=5 years, >5 years), to receive 20 mg/kg phenytoin (intravenous or intraosseous infusion over 20 min) or 40 mg/kg levetiracetam (intravenous or intraosseous infusion over 5 min). The primary outcome was clinical cessation of seizure activity 5 min after the completion of infusion of the study drug. Analysis was by intention to treat. This trial is registered with the Australian and New Zealand Clinical Trials Registry, number ACTRN12615000129583. Finding(s): Between March 19, 2015, and Nov 29, 2017, 639 children presented to participating emergency departments with convulsive status epilepticus; 127 were missed, and 278 did not meet eligibility criteria. The parents of one child declined to give consent, leaving 233 children (114 assigned to phenytoin and 119 assigned to levetiracetam) in the intention-to-treat population. Clinical cessation of seizure activity 5 min after completion of infusion of study drug occurred in 68 (60%) patients in the phenytoin group and 60 (50%) patients in the levetiracetam group (ris

Background: Hospital admissions for patients with back pain are increasing. Despite their significant contribution to the healthcare burden, they remain largely unstudied. Aim(s): To investigate the management and clinical outcomes of patients with acute back pain admitted to hospital under general medicine units when compared to a rheumatology unit. Method(s): A 36-month retrospective, observational study on patients presenting to the emergency department with back pain who were subsequently admitted to one of three general medicine units (GM) or a rheumatology unit (RU). Differences in patient demographics, management and clinical outcomes were assessed using Chi-squared tests for categorical variables and Kruskall-Wallis tests for continuous variables. Multivariate associations of two primary outcomes, length of stay (LOS) and complications were examined using generalised estimating equations. Result(s): Data from 712 admissions from 594 patients across the four inpatient units were used for this study. Common discharge diagnoses were musculoskeletal/non-specific back pain (41%), disc-related illness (22%), vertebral fracture (14%) and sciatica (14%). Non-English speaking background (NESB), age >= 80 years, disc-related disease, vertebral fracture and sciatica were statistically significantly associated with both increased LOS and complications. The presence of comorbidities was associated with more complications. GM admission was associated with a longer LOS and more complications than RU admission. Conclusion(s): Multiple factors associated with an increased LOS and complications were identified, including older patients and patients of NESB. Given the observed variations in back pain management between general and specialty units, strategies to standardise care should be considered.Copyright © 2018 Royal Australasian College of Physicians

Purpose of review: Knowledge of cerebrovascular anatomical variants is vital for clinicians working with patients presenting with signs and symptoms of cerebral infarction, particularly in the era of endovascular clot retrieval. Recent findings: We provide an overview of a cerebrovascular anatomical variation and detail a patient presenting with cerebral infarction secondary to occlusion of their anomalous vessel who underwent successful endovascular clot retrieval with excellent functional outcome. We also include technical descriptions. Summary: Given the clinical importance of the areas supplied by the accessory middle cerebral artery, knowledge of this vessel is not only important for diagnosis but also for neurosurgical or endovascular management of patients with this variant.Copyright © 2019 American Academy of Neurology.

Objective: An observational study on the current diagnostic and procedural utility and impact of point of care ultrasound (POCUS) in Emergency Departments. Background(s): POCUS has been recognised as a readily available, non-invasive imaging tool; providing prompt clinical information at the bedside, as well as a useful guiding tool during procedural interventions. However, its current use and clinical impact in ED remain unknown. Method(s): In October 2016, a 31-day prospective observational study was performed in three Monash Health Emergency Departments in Melbourne, Australia. Data regarding patients' presenting complaints, frequency, operators' qualifications and POCUS module were archived and analysed. Factors associated with diagnostic impacts were identified. Result(s): A total of 390 (2.82%) POCUS examinations were performed among 18,355 (13,822 adults) presentationsin the three Monash Health EDs during the 31-day study period. 292 (74.9%) cases were retrieved from electronic medical records (Symphony), recorded as Clinician-Performed Ultrasound (CPU);and 98 (25.1%) cases from written records which were collected by research assistants. The POCUS was performed as a diagnostic tool in 344 (88.2%) and procedural in 46 (11.8%) cases. eFAST/AAA and BELS were the two most frequently utilised diagnostic modalities. Overall, the majority of diagnostic POCUS cases were in patients presented with abdominal pain (35.3%), chest pain (14.0%) and trauma mainly motor vehicle accidents (5.8%). Procedural POCUS was most commonly used for vascular access (71.7%), where dyspnoea (21.6%) was the most common presenting complaint. Most of the cases were performed by Senior Medical Staffs (66.4%). DiagnosticPOCUS overall sensitivity and specificity were 94.1% (95% CI 85.6 - 98.4%) and 99.6% (97.5 - 100%); positive and negative predictive values were 98.5% (95% CI 90.1 - 99.8%) and 98.2% (95% CI 95.6 - 99.3%), respectively. Conclusion(s): Despite known diagnostic and procedural p

Background: Nasogastric tube insertion is a common but distressing procedure in young children. We aimed to compare the efficacy of topical local anaesthetic and vasoconstrictor nasal spray with placebo for distress related to nasogastric tube insertion. Method(s): We did a prospective, randomised, controlled, double-blind, superiority trial in a single tertiary paediatric emergency department in Australia. Eligible participants were children aged 6 months to 5 years who were planned to have a nasogastric tube inserted as part of their emergency department treatment. Patients were assigned using computer-generated block randomisation to receive lidocaine and phenylephrine nasal spray (10 mg lidocaine and 1 mg phenylephrine for children weighing 6-12 kg; 20 mg lidocaine and 2 mg phenylephrine for children weighing >12 kg), or 0.9% sodium chloride placebo nasal spray, before nasogastric insertion. Guardians, observers, and proceduralists were all masked to the intervention. The primary outcome was procedure-related distress, measured using the Face, Legs, Activity, Cry, and Consolability (FLACC)scale during the final attempt at nasogastric tube insertion. All patients were included in the primary analysis (intention-to-treat). FLACC scores were compared using the Wilcoxon rank-sum test, and categorical outcomes were compared using chi2 or Fisher's exact tests as appropriate. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12614000092695. Finding(s): Between July 30, 2014, and Aug 17, 2017, 107 children in a convenience sample were randomly assigned to receive lidocaine and phenylephrine nasal spray (n=54)or placebo (n=53). Seven children did not receive study medication (six no longer required nasogastric tube insertion and one withdrew consent). 50 children received each intervention; all were included in the analysis. There was no difference in median FLACC score at time of nasogastric tube insertion (9 [IQR 7-10]for li

Objective: Although there is a large body of research on head injury (HI) inflicted by caregivers in young children, little is known about intentional HI in older children and inflicted HI by perpetrators other than carers. Therefore, we set out to describe epidemiology, demographics and severity of intentional HIs in childhood. Method(s): A planned secondary analysis of a prospective multicentre cohort study was conducted in 10 EDs in Australia and New Zealand, including children aged <18 years with HIs. Epidemiology codes were used to prospectively code the injuries. Demographic and clinical information including the rate of clinically important traumatic brain injury (ciTBI: HI leading to death, neurosurgery, intubation >1 day or admission >=2 days with abnormal computed tomography [CT]) was descriptively analysed. Result(s): Intentional injuries were identified in 372 of 20 137 (1.8%) head-injured children. Injuries were caused by caregivers (103, 27.7%), by peers (97, 26.1%), by siblings (47, 12.6%), by strangers (35, 9.4%), by persons with unknown relation to the patient (21, 5.6%), other intentional injuries (8, 2.2%) or undetermined intent (61, 16.4%). About 75.7% of victims of assault by caregivers were <2 years, whereas in other categories, only 4.9% were <2 years. Overall, 66.9% of victims were male. Rates of CT performance and abnormal CT varied: assault by caregivers 68.9%/47.6%, by peers 18.6%/27.8%, by strangers 37.1%/5.7%. ciTBI rate was 22.3% in assault by caregivers, 3.1% when caused by peers and 0.0% with other perpetrators. Conclusion(s): Intentional HI is infrequent in children. The most frequently identified perpetrators are caregivers and peers. Caregiver injuries are particularly severe.Copyright © 2018 Australasian College for Emergency Medicine

Background: Detailed understanding of Australasian Emergency Department (ED) restraint practices is lacking. Objective(s): To describe restrictive interventions that occur in Victorian EDs. Method(s): A multicentre retrospective study involving five EDs collated data on all patients who attended in 2016 including the rate of security calls for threats to self, patients or staff, and any restrictive interventions used. From each site, 100 patients who had a restrictive intervention were randomly identified and data extracted from the medical record. Result(s): In 2016, 327 454 patients presented to the five EDs; 3871 had at least one security code (1.5%). Within the population that had a security code, 942 had at least one restrictive intervention (22.7%). Details were extracted on 494 patients. The majority (62.8%) were restrained under a Duty of Care and not the Mental Health Act. Physical restraint was used for 165 (33.4%) patients, 296 were mechanically restrained (59.9%, median restraint time 180 minutes IQR: 75-360), and 388 chemically restrained (78.5%). Approximately half the patients were discharged home or to an ED observation ward, only 81 (16.4%) were admitted to a mental health facility. Conclusion(s): Restrictive interventions in the ED are largely occurring under a Duty of Care and only a minority of patients will be admitted to a mental health ward. Care for patients managed under legislation that covers assessment and treatment of mental illness has a strong clinical governance framework, however this will not be the case for the majority of patients who experience restraint in Victorian EDs.

Introduction: Adults with intellectual disability have poor health outcomes and morbidity and premature mortality is often preventable. Many general practitioners feel inadequately trained and supported when managing the complex needs of this cohort, and individuals often present to hospital in crisis. The aim of this project was to better understand their healthcare needs and hospital service usage. Method(s): Study design included file reviews of patients attending a specialist clinic. Hospital usage data was extracted for demographic analysis. Result(s): Of 806 specialist clinic patients: 95% required support to communicate their health history. There were high percentages of comorbidities including obesity-overweight (38%), epilepsy (33%), Vitamin D deficiency (21%), and vision impairment (20%). Of 194 hospital patients, usage data highlighted: average age of admission 36 years, 69% presented via Emergency Department, average length of stay 5.4 days. Intellectual disability was coded in 2% of 998 Emergency Department presentations, and 14% of 1409 inpatient admissions. Implications: Results suggest patients with intellectual disabilities have multiple health needs and communication difficulty. Limited coding of intellectual disability in hospital patients limits understanding of service usage, health outcomes and patient experience. Consumer experience requires further investigation to help begin informing future service development.

BACKGROUND: Acute scrotal pain is a common paediatric surgical presentation. Delays in treatment can result in testicular loss from torsion. It is unclear where delays occur. We aimed to investigate presentations with an acute scrotum to identify any potential areas of delay. METHOD(S): We conducted a prospective study (April 2017-November 2018) of paediatric patients (<18years) presenting with acute scrotal pain. Data collected included: patient demographics, history/examination findings, mode of presentation, clinical timeline details and outcomes. RESULT(S): A total of 107 acute scrotum presentations were identified: 58 (54.2%) testicular appendage torsion, 23 (21.5%) testicular torsion, 6 (5.6%) epididymo-orchidits and 20 (18.7%) other diagnoses. Median age at presentation was 11years (4 months-16years). Fifty-seven (53.3%) underwent emergency surgery, of whom 23 (40.4%) had testicular torsion, with 2 requiring orchidectomy. Median time from onset of symptoms to seeking medical opinion was 5.5 (0-135) h. Once assessed by a medical professional, the route to paediatric surgical review via general practitioner (GP) and local emergency department (ED) to paediatric ED was 4.84 (1.67-24.5) h; via GP to paediatric ED was 2.58 (0.75-25.5) h; via local ED to paediatric ED was 2.25 (1-7.75) h; and directly to paediatric ED was 0.45 (0-1.42) h. CONCLUSION(S): Delays in assessment and treatment of acute scrotal pain occur from the time parents are aware of symptoms to seeking medical opinion. Education to increase awareness may reduce time delays. GPs should refer patients directly to a paediatric ED. Local EDs should manage paediatric cases as per the local surgeons' skill base.Copyright © 2019 Royal Australasian College of Surgeons.

Objective: To evaluate the appropriateness of plain abdominal X-ray (AXR) requests in adult patients presenting to a Victorian regional emergency department (ED). Method(s): A retrospective chart review was performed of all adult patients with a plain AXR requested by ED medical staff in a regional healthcare centre in Victoria, Australia in 2016. Patient demographics, ED disposition and any further imaging results were extracted from the medical record. Indications for x-ray and clinician seniority were determined from the radiology request slips signed by the treating emergency doctor. Appropriateness of imaging was determined by comparing the indication for abdominal radiograph to local evidencebased guidelines. Result(s): 109 episodes of plain AXR requests met the inclusion criteria. Of these, 40 were considered inappropriate according to clinical guidelines. Overall, 36% (39/109) had normal or non-specific findings and 42% (46/109) demonstrated faecal loading, while 22% (24/109) identified pathology. 33 patients had further imaging, mostly with computed tomography (CT). Junior staff were responsible for most of the AXR requests. Conclusion(s): In our regional hospital ED, over one third of AXRs requested for adult patients were inappropriate according to clinical guidelines. AXRs have a low diagnostic yield and frequently do not reduce the need for further imaging. The use of a clinical practice guideline and junior staff education may increase the appropriate use of plain AXRs in the regional ED setting.