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OBJECTIVE: To identify behavioural drivers and barriers that may have contributed to changes in ED attendance during the first 10 months of the coronavirus disease 2019 (COVID-19) pandemic in Victoria. METHODS: We conducted a mixed methods analysis of patients who attended one of eight participating EDs between 1 November 2019 and 31 December 2020. A random sample of patients were chosen after their visit and invited to participate in an online survey assessing behavioural drivers and barriers to attendance. The study timespan was divided into four periods based on local and world events to assess changes in attitudes and behaviours over this period. RESULTS: A total of 5600 patients were invited to complete the survey and 606 (11%) submitted sufficient information for analysis. There were significant differences in participants' attitudes towards healthcare and EDs, levels of concern about contracting and spreading COVID-19 and the influence of mask wearing. Patients expressed more concern about the safety of an ED during the largest outbreak of COVID-19 infections than they did pre-COVID, but this difference was not sustained once community infection numbers dropped. General concerns about hospital attendance were higher after COVID than they were pre-COVID. A total of 27% of patients specifically stated that they had delayed their ED attendance. CONCLUSION: Patients expressed increased concerns around attending ED during the first 10 months of the 2020 COVID-19 pandemic and frequently cited COVID-19 as a reason for delaying their presentation. These factors would be amenable to mitigation via focussed public health messaging.

Endothelial glycocalyx (EG) shedding is associated with septic shock and described following intravenous (IV) fluid administration. To investigate the possible impact of IV fluids on the pathobiology of septic shock we investigated associations between biomarkers of EG shedding and endothelial cell activation, and relationships with IV fluid volume. Serum samples were obtained on admission (T0) and at 24 h (T24) in patients undergoing haemodynamic resuscitation for suspected septic shock in the emergency department. Biomarkers of EG shedding—Syndecan-1 (Syn-1), Syndecan-4 (Syn-4), Hyaluronan, endothelial activation—Endothelin-1 (ET-1), Angiopoeitin-2 (Ang-2), Vascular Endothelial Growth Factor Receptor-1(VEGF-1) and leucocyte activation/inflammation—Resistin, Neutrophil Gelatinase Associated Lipocalin (NGAL) and a marker of cardiac stretch—Pro-Atrial Natriuretic Peptide (Pro-ANP) were compared to the total IV fluid volume administered using Tobit regression. Data on 86 patients (52 male) with a mean age of 60 (SD 18) years were included. The mean fluid volume administered to T24 was 4038 ml (SD 2507 ml). No significant association between fluid volume and Pro-ANP or any of the biomarkers were observed. Syn-1 and Syn-4 were significantly correlated with each other (Spearman Rho 0.43, p < 0.001) but not with Hyaluronan. Syn-1 and Syn-4 both correlated with VEGFR-1 (Rho 0.56 and 0.57 respectively, p < 0.001) whereas Hyaluronan correlated with ET-1 (Rho 0.43, p < 0.001) and Ang-2 (Rho 0.43, p < 0.001). There was no correlation between Pro-ANP and any of the EG biomarkers. Distinct patterns of association between biomarkers of EG shedding and endothelial cell activation were observed among patients undergoing resuscitation for sepsis. No relationship between IV fluid volume and Pro-ANP or any of the other biomarkers was observed.

Aims To describe neurological and functional outcomes among out-of-hospital cardiac arrest (OHCA) patients who survived to hospital discharge; to determine the association between neurological outcome at hospital discharge and 12-month survival. Methods Our cohort comprised adult OHCA patients (≥18 years) attended by St John WA (SJWA) paramedics in Perth, Western Australia (WA), who survived to hospital discharge, between 1st January 2004 and 31st December 2019. Neurological and functional status at hospital discharge (and before the arrest) was determined by medical record review using the five-point ‘Cerebral Performance Category (CPC)’ and ‘Overall Performance Category (OPC)’ scores. Adjusted multivariable logistic regression analysis was used to estimate the association of CPC score at hospital discharge with 12-month survival, adjusted for prognostic variables. Results Over the study period, SJWA attended 23,712 OHCAs. Resuscitation was attempted in 43.4% of cases (n = 10,299) with 2171 subsequent admissions, 99.4% (n = 2158) of these were admitted to a study hospital. Of the 1062 hospital survivors, 71.3% (n = 757) were CPC1 (highest category of neurological performance), 21.4% (n = 227) CPC2, 6.3% (n = 67) CPC3 and 1.0% (n = 11) CPC4. OPC scores followed a similar distribution. Of the 1,011 WA residents who survived to hospital discharge, 92.3% (n = 933) survived to 12-months. A CPC1-2 at hospital discharge was significantly associated with 12-month survival (adjusted odds ratio 3.28, 95% confidence interval 1.69–6.39). Conclusion Whilst overall survival is low, most survivors of OHCA have a good neurological outcome at hospital discharge and are alive at 12-months.

Introduction Mild traumatic brain injury (mTBI) is a complex injury with heterogeneous physical, cognitive, emotional and functional outcomes. Many who sustain mTBI recover within 2 weeks of injury; however, approximately 10%–20% of individuals experience mTBI symptoms beyond this ‘typical’ recovery timeframe, known as persistent post-concussion symptoms (PPCS). Despite increasing interest in PPCS, uncertainty remains regarding its prevalence in community-based populations and the extent to which poor recovery may be identified using early predictive markers. Objective (1) Establish a research dataset of people who have experienced mTBI and document their recovery trajectories; (2) Evaluate a broad range of novel and established prognostic factors for inclusion in a predictive model for PPCS. Methods and analysis The Concussion Recovery Study (CREST) is a prospective, longitudinal observational cohort study conducted in Perth, Western Australia. CREST is recruiting adults aged 18–65 from medical and community-based settings with acute diagnosis of mTBI. CREST will create a state-wide research dataset of mTBI cases, with data being collected in two phases. Phase I collates data on demographics, medical background, lifestyle habits, nature of injury and acute mTBI symptomatology. In Phase II, participants undergo neuropsychological evaluation, exercise tolerance and vestibular/ocular motor screening, MRI, quantitative electroencephalography and blood-based biomarker assessment. Follow-up is conducted via telephone interview at 1, 3, 6 and 12 months after injury. Primary outcome measures are presence of PPCS and quality of life, as measured by the Post-Concussion Symptom Scale and the Quality of Life after Brain Injury questionnaires, respectively. Multivariate modelling will examine the prognostic value of promising factors. Ethics and dissemination Human Research Ethics Committees of Royal Perth Hospital (#RGS0000003024), Curtin University (HRE2019-0209), Ramsay Heal

Purpose International guidelines recommend targeting normocapnia in mechanically ventilated out-of-hospital cardiac arrest (OHCA) survivors, but the optimal arterial carbon dioxide (PaCO2) target remains controversial. We hypothesised that the relationship between PaCO2 and survival is non-linear, and targeting an intermediate level of PaCO2 compared to a low or high PaCO2 in the first 24-h of ICU admission is associated with an improved survival to hospital discharge (STHD) and at 12-months. Methods We conducted a retrospective multi-centre cohort study of adults with non-traumatic OHCA requiring admission to one of four tertiary hospital intensive care units for mechanical ventilation. A four-knot restricted cubic spline function was used to allow non-linearity between the mean PaCO2 within the first 24 h of ICU admission after OHCA and survival, and optimal PaCO2 cut-points were identified from the spline curve to generate corresponding odds ratios. Results We analysed 3769 PaCO2 results within the first 24-h of ICU admission, from 493 patients. PaCO2 and survival had an inverted U-shape association; normocapnia was associated with significantly improved STHD compared to either hypocapnia (<35 mmHg) (adjusted odds ratio [aOR] 0.45, 95% confidence interval [CI] 0.24−0.83) or hypercapnia (>45 mmHg) (aOR 0.45, 95% CI 0.24−0.84). Of the twelve predictors assessed, PaCO2 was the third most important predictor, and explained >11% of the variability in survival. The survival benefits of normocapnia extended to 12-months. Conclusions Normocapnia within the first 24-h of intensive care admission after OHCA was associated with an improved survival compared to patients with hypocapnia or hypercapnia.

Objective: There is uncertainty about the optimal i.v. fluid volume and timing of vasopressor commencement in the resuscitation of patients with sepsis and hypotension. We aim to study current resuscitation practices in EDs in Australia and New Zealand (the Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In Emergency Department Sepsis [ARISE FLUIDS] observational study). Method(s): ARISE FLUIDS is a prospective, multicentre observational study in 71 hospitals in Australia and New Zealand. It will include adult patients presenting to the ED during a 30 day period with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation. We will obtain data on baseline demographics, clinical and laboratory variables, all i.v. fluid given in the first 24 h, vasopressor use, time to antimicrobial administration, admission to intensive care, organ failure and in-hospital mortality. We will specifically describe (i) the volume of fluid administered at the following time points: when meeting eligibility criteria, in the first 6 h, at 24 h and prior to vasopressor commencement and (ii) the frequency and timing of vasopressor use in the first 6 h and at 24 h. Screening logs will provide reliable estimates of the proportion of ED patients meeting eligibility criteria for a subsequent randomised controlled trial. Discussion(s): This multicentre, observational study will provide insight into current haemodynamic resuscitation practices in patients with sepsis and hypotension as well as estimates of practice variation and patient outcomes. The results will inform the design and feasibility of a multicentre phase III trial of early haemodynamic resuscitation in patients presenting to ED with sepsis and hypotension.Copyright © 2019 Australasian College for Emergency Medicine

Purpose: International guidelines recommend targeting normocapnia in mechanically ventilated out-of-hospital cardiac arrest (OHCA) survivors, but the optimal arterial carbon dioxide (PaCO2) target remains controversial. We hypothesised that the relationship between PaCO2 and survival is non-linear, and targeting an intermediate level of PaCO2 compared to a low or high PaCO2 in the first 24-h of ICU admission is associated with an improved survival to hospital discharge (STHD) and at 12-months. Methods: We conducted a retrospective multi-centre cohort study of adults with non-traumatic OHCA requiring admission to one of four tertiary hospital intensive care units for mechanical ventilation. A four-knot restricted cubic spline function was used to allow non-linearity between the mean PaCO2 within the first 24 h of ICU admission after OHCA and survival, and optimal PaCO2 cut-points were identified from the spline curve to generate corresponding odds ratios. Results: We analysed 3769 PaCO2 results within the first 24-h of ICU admission, from 493 patients. PaCO2 and survival had an inverted U-shape association; normocapnia was associated with significantly improved STHD compared to either hypocapnia (<35 mmHg) (adjusted odds ratio [aOR] 0.45, 95% confidence interval [CI] 0.24−0.83) or hypercapnia (>45 mmHg) (aOR 0.45, 95% CI 0.24−0.84). Of the twelve predictors assessed, PaCO2 was the third most important predictor, and explained >11% of the variability in survival. The survival benefits of normocapnia extended to 12-months. Conclusions: Normocapnia within the first 24-h of intensive care admission after OHCA was associated with an improved survival compared to patients with hypocapnia or hypercapnia.

Background: Studies to identify safe oxygenation targets after out-of-hospital cardiac arrest (OHCA) have often assumed a linear relationship between arterial oxygen tension (PaO2) and survival, or have dichotomised PaO2 at a supra-physiological level. We hypothesised that abnormalities in mean PaO2 (both high and low) would be associated with decreased survival after OHCA. Methods: We conducted a retrospective multicentre cohort study of adult OHCA patients who received mechanical ventilation on admission to the intensive care unit (ICU). The potential non-linear relationship between the mean PaO2 within the first 24 -hs of ICU admission and survival to hospital discharge (STHD) was assessed by a four-knot restricted cubic spline function with adjustment for potential confounders. Results: 3764 arterial blood gas results were available for 491 patients in the first 24-hs of ICU admission. The relationship between mean PaO2 over the first 24-hs and STHD was an inverted U-shape, with highest survival for those with a mean PaO2 between 100 and 180 mmHg (reference category) compared to a mean PaO2 of <100 mmHg (adjusted odds ratio [aOR] 0.50 95% confidence interval [CI] 0.30, 0.84), or >180 mmHg (aOR 0.41, 95% CI 0.18, 0.92). Mean PaO2 within 24 -hs was the third most important predictor and explained 9.1% of the variability in STHD. Conclusion: The mean PaO2 within the first 24-hs after admission for OHCA has a non-linear association with the highest STHD seen between 100 and 180 mmHg. Randomised controlled trials are now needed to validate the optimal oxygenation targets in mechanically ventilated OHCA patients.

Background Studies to identify safe oxygenation targets after out-of-hospital cardiac arrest (OHCA) have often assumed a linear relationship between arterial oxygen tension (PaO2) and survival, or have dichotomised PaO2 at a supra-physiological level. We hypothesised that abnormalities in mean PaO2 (both high and low) would be associated with decreased survival after OHCA. Methods We conducted a retrospective multicentre cohort study of adult OHCA patients who received mechanical ventilation on admission to the intensive care unit (ICU). The potential non-linear relationship between the mean PaO2 within the first 24 -hs of ICU admission and survival to hospital discharge (STHD) was assessed by a four-knot restricted cubic spline function with adjustment for potential confounders. Results 3764 arterial blood gas results were available for 491 patients in the first 24 -hs of ICU admission. The relationship between mean PaO2 over the first 24 -hs and STHD was an inverted U-shape, with highest survival for those with a mean PaO2 between 100 and 180 mmHg (reference category) compared to a mean PaO2 of <100 mmHg (adjusted odds ratio [aOR] 0.50 95% confidence interval [CI] 0.30, 0.84), or >180 mmHg (aOR 0.41, 95% CI 0.18, 0.92). Mean PaO2 within 24 -hs was the third most important predictor and explained 9.1% of the variability in STHD. Conclusion The mean PaO2 within the first 24-hs after admission for OHCA has a non-linear association with the highest STHD seen between 100 and 180 mmHg. Randomised controlled trials are now needed to validate the optimal oxygenation targets in mechanically ventilated OHCA patients.

Background:Themajority of older people who fall and present to EmergencyDepartments (EDs) are reported not to receive guideline level care to reduce future risk of falls. The aim of this randomized controlled trial was to evaluate whether RESPOND, a 6-month telephone-based patient-centred program had an effect on falls and fall injuries in older people presenting to ED after a fall. Method(s): 541 older fallers who presented to a WA or Victorian ED were recruited (inclusion criteria: discharged home <72 hours, could walk without hands-on assistance, use a telephone, and no cognitive impairment (MMSE>23). Intervention participants (n=263, mean age=73) received the RESPOND intervention, comprising (1) home-based risk assessment; (2) six months telephone-based education, coaching, goal setting and support for evidence-based risk factor management; and (3) linkages to existing services; while controls (n=260, mean age=73) received usual care. 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. Result(s): Falls rate was significantly lower in the RESPOND group (incidence rate ratio 0.65 [95%CI 0.43-0.99]; p=0.042). Although there was no significant difference in fall injuries (p=0.374), the rate of fractures was significantly lower in the RESPOND group (p=0.03).There were no significant group differences in other secondary outcomes. Conclusion(s): The RESPOND falls prevention program reduced falls and fractures, in older people presenting to the ED with a fall. Key learnings for translation include: potential scalability and sustainability of a patient-centred and predominantly telephonebased program.

OBJECTIVE: To determine whether multifactorial falls prevention interventions are effective in preventing falls, fall injuries, emergency department (ED) re-presentations and hospital admissions in older adults presenting to the ED with a fall. DESIGN: Systematic review and meta-analyses of randomised controlled trials (RCTs). DATA SOURCES: Four health-related electronic databases (Ovid MEDLINE, CINAHL, EMBASE, PEDro and The Cochrane Central Register of Controlled Trials) were searched (inception to June 2018). STUDY SELECTION: RCTs of multifactorial falls prevention interventions targeting community-dwelling older adults ( >= 60 years) presenting to the ED with a fall with quantitative data on at least one review outcome. DATA EXTRACTION: Two independent reviewers determined inclusion, assessed study quality and undertook data extraction, discrepancies resolved by a third. DATA SYNTHESIS: 12 studies involving 3986 participants, from six countries, were eligible for inclusion. Studies were of variable methodological quality. Multifactorial interventions were heterogeneous, though the majority included education, referral to healthcare services, home modifications, exercise and medication changes. Meta-analyses demonstrated no reduction in falls (rate ratio = 0.78; 95% CI: 0.58 to 1.05), number of fallers (risk ratio = 1.02; 95% CI: 0.88 to 1.18), rate of fractured neck of femur (risk ratio = 0.82; 95% CI: 0.53 to 1.25), fall-related ED presentations (rate ratio = 0.99; 95% CI: 0.84 to 1.16) or hospitalisations (rate ratio = 1.14; 95% CI: 0.69 to 1.89) with multifactorial falls prevention programmes. CONCLUSION(S): There is insufficient evidence to support the use of multifactorial interventions to prevent falls or hospital utilisation in older people presenting to ED following a fall. Further research targeting this population group is required.Copyright © Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.

Objectives: To describe haemodynamic resuscitation practices in ED patients with suspected sepsis and hypotension. Method(s): This was a prospective, multicentre, observational study conducted in 70 hospitals in Australia and New Zealand between September 2018 and January 2019. Consecutive adults presenting to the ED during a 30-day period at each site, with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation, were eligible. Data included baseline demographics, clinical and laboratory variables and intravenous fluid volume administered, vasopressor administration at baseline and 6- and 24-h post-enrolment, time to antimicrobial administration, intensive care admission, organ support and in-hospital mortality. Result(s): A total of 4477 patients were screened and 591 were included with a mean (standard deviation) age of 62 (19) years, Acute Physiology and Chronic Health Evaluation II score 15.2 (6.6) and a median (interquartile range) systolic blood pressure of 94 mmHg (87-100). Median time to first intravenous antimicrobials was 77 min (42-148). A vasopressor infusion was commenced within 24 h in 177 (30.2%) patients, with noradrenaline the most frequently used (n = 138, 78%). A median of 2000 mL (1500-3000) of intravenous fluids was administered prior to commencing vasopressors. The total volume of fluid administered from pre-enrolment to 24 h was 4200 mL (3000-5661), with a range from 1000 to 12 200 mL. Two hundred and eighteen patients (37.1%) were admitted to an intensive care unit. Overall in-hospital mortality was 6.2% (95% confidence interval 4.4-8.5%). Conclusion(s): Current resuscitation practice in patients with sepsis and hypotension varies widely and occupies the spectrum between a restricted volume/earlier vasopressor and liberal fluid/later vasopressor strategy.Copyright © 2020 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian

OBJECTIVES: To describe haemodynamic resuscitation practices in ED patients with suspected sepsis and hypotension. METHODS: This was a prospective, multicentre, observational study conducted in 70 hospitals in Australia and New Zealand between September 2018 and January 2019. Consecutive adults presenting to the ED during a 30-day period at each site, with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation, were eligible. Data included baseline demographics, clinical and laboratory variables and intravenous fluid volume administered, vasopressor administration at baseline and 6- and 24-h post-enrolment, time to antimicrobial administration, intensive care admission, organ support and in-hospital mortality. RESULTS: A total of 4477 patients were screened and 591 were included with a mean (standard deviation) age of 62 (19) years, Acute Physiology and Chronic Health Evaluation II score 15.2 (6.6) and a median (interquartile range) systolic blood pressure of 94 mmHg (87-100). Median time to first intravenous antimicrobials was 77 min (42-148). A vasopressor infusion was commenced within 24 h in 177 (30.2%) patients, with noradrenaline the most frequently used (n = 138, 78%). A median of 2000 mL (1500-3000) of intravenous fluids was administered prior to commencing vasopressors. The total volume of fluid administered from pre-enrolment to 24 h was 4200 mL (3000-5661), with a range from 1000 to 12 200 mL. Two hundred and eighteen patients (37.1%) were admitted to an intensive care unit. Overall in-hospital mortality was 6.2% (95% confidence interval 4.4-8.5%). CONCLUSION: Current resuscitation practice in patients with sepsis and hypotension varies widely and occupies the spectrum between a restricted volume/earlier vasopressor and liberal fluid/later vasopressor strategy.

Ceftriaxone is widely used for respiratory and urinary infections in elderly and frail patients, but there are few pharmacokinetic studies. A prospective population pharmacokinetic study of ceftriaxone in adults over 65 years old was undertaken. Dried blood spots collected at baseline (predose) and 0.5, 1, 4, 8, and 24 h after administration of 1 g of ceftriaxone were assayed using a validated liquid chromatography-mass spectroscopy analytical method. Frailty was classified using the Edmonton frailty scale and grip strength via a hand dynamometer. Estimates of glomerular filtration rate were determined using creatinine-based and cystatin C-based equations. Of 26 patients recruited, 23 (88%) were vulnerable or very frail. Estimates of drug clearance improved significantly with a cystatin C-based estimate of renal function that accounted for frailty. Simulations indicate that the combined effects of ranges of size and renal function resulted in a 6-fold range in peak ceftriaxone concentrations and 9-fold range in total exposure (area under the concentration-time curve [AUC]). For elderly patients with moderate or severe renal impairment, 48-h dosing results in greater trough concentrations and total exposure than the trough concentrations and total exposure in patients with normal renal function receiving 24-h dosing. Cystatin C-based measures of renal function improved predictions of ceftriaxone clearance in elderly patients.

© 2020 by the authors. Licensee MDPI, Basel, Switzerland. Background: Persisting post-concussion symptoms (PPCS) is a complex, multifaceted condition in which individuals continue to experience the symptoms of mild traumatic brain injury (mTBI; concussion) beyond the timeframe that it typically takes to recover. Currently, there is no way of knowing which individuals may develop this condition. Method: Patients presenting to a hospital emergency department (ED) within 48 h of sustaining a mTBI underwent neuropsychological assessment and demographic, injury-related information and blood samples were collected. Concentrations of blood-based biomarkers neuron specific enolase, neurofilament protein-light, and glial fibrillary acidic protein were assessed, and a subset of patients also underwent diffusion tensor–magnetic resonance imaging; both relative to healthy controls. Individuals were classified as having PPCS if they reported a score of 25 or higher on the Rivermead Postconcussion Symptoms Questionnaire at ~28 days post-injury. Univariate exact logistic regression was performed to identify measures that may be predictive of PPCS. Neuroimaging data were examined for differences in fractional anisotropy (FA) and mean diffusivity in regions of interest. Results: Of n = 36 individuals, three (8.33%) were classified as having PPCS. Increased performance on the Repeatable Battery for the Assessment of Neuropsychological Status Update Total Score (OR = 0.81, 95% CI: 0.61–0.95, p = 0.004), Immediate Memory (OR = 0.79, 95% CI: 0.56–0.94, p = 0.001), and Attention (OR = 0.86, 95% CI: 0.71–0.97, p = 0.007) indices, as well as faster completion of the Trails Making Test B (OR = 1.06, 95% CI: 1.00–1.12, p = 0.032) at ED presentation were associated with a statistically significant decreased odds of an individual being classified as having PPCS. There was no significant association between blood-based biomarkers and PPCS in this small sample, although glial fibrillary acidic p

Objective and design Hypertonic saline administered during fluid resuscitation may mitigate endothelial glycocalyx (EG) shedding and inflammation. The objective of this pilot randomised controlled trial was to measure the effect of hypertonic saline, compared to isotonic saline on biomarkers of EG shedding and inflammation in emergency department patients with suspected sepsis. Methods Patients received either 5 mL/kg of 3% saline (hypertonic group, n = 34) or 10 mL/kg of 0.9% saline (isotonic group, n = 31). Serum biomarker concentrations of syndecan-1, hyaluronan, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, interleukin-6, -8, -10, interferon-γ, neutrophil gelatinase-associated lipocalin and resistin were compared at baseline (T0), after fluid (T1), 3 h (T3) and 12–24 h (T24) later, as was serum osmolality, using linear mixed effects models. Results The hypertonic group had significantly increased mean serum osmolality compared to the isotonic group at T1 (P < .001) and T3 (P = .004). Minor differences were found in some biomarker outcomes, including a decreased fold-change in syndecan-1 at T1 (P = .012) and in interleukin-10 at T24 (P = .006) in the isotonic group, compared to the hypertonic group. Conclusions Although a single bolus of hypertonic saline increased serum osmolality, it did not reduce biomarkers of EG shedding or inflammation, compared to patients that received isotonic saline.

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

BACKGROUND: RESPOND is a telephone-based falls prevention program for older people who present to a hospital emergency department (ED) with a fall. A randomised controlled trial (RCT) found RESPOND to be effective at reducing the rate of falls and fractures, compared with usual care, but not fall injuries or hospitalisations. This process evaluation aimed to determine whether RESPOND was implemented as planned, and identify implementation barriers and facilitators. METHODS: A mixed-methods evaluation was conducted alongside the RCT. Evaluation participants were the RESPOND intervention group (n = 263) and the clinicians delivering RESPOND (n = 7). Evaluation data were collected from participant recruitment and intervention records, hospital administrative records, audio-recordings of intervention sessions, and participant questionnaires. The Rochester Participatory Decision-Making Scale (RPAD) was used to evaluate person-centredness (score range 0 (worst) - 9 (best)). Process factors were compared with pre-specified criteria to determine implementation fidelity. Six focus groups were held with participants (n = 41), and interviews were conducted with RESPOND clinicians (n = 6). Quantitative data were analysed descriptively and qualitative data thematically. Barriers and facilitators to implementation were mapped to the 'Capability, Opportunity, Motivation - Behaviour' (COM-B) behaviour change framework. RESULTS: RESPOND was implemented at a lower dose than the planned 10 h over 6 months, with a median (IQR) of 2.9 h (2.1, 4). The majority (76%) of participants received their first intervention session within 1 month of hospital discharge with a median (IQR) of 18 (12, 30) days. Clinicians delivered the program in a person-centred manner with a median (IQR) RPAD score of 7 (6.5, 7.5) and 87% of questionnaire respondents were satisfied with the program. The reports from participants and clinicians suggested that implementation was facilitated by the use of positive an

OBJECTIVE: There is uncertainty about the optimal i.v. fluid volume and timing of vasopressor commencement in the resuscitation of patients with sepsis and hypotension. We aim to study current resuscitation practices in EDs in Australia and New Zealand (the Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In Emergency Department Sepsis [ARISE FLUIDS] observational study). METHODS: ARISE FLUIDS is a prospective, multicentre observational study in 71 hospitals in Australia and New Zealand. It will include adult patients presenting to the ED during a 30 day period with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation. We will obtain data on baseline demographics, clinical and laboratory variables, all i.v. fluid given in the first 24 h, vasopressor use, time to antimicrobial administration, admission to intensive care, organ failure and in-hospital mortality. We will specifically describe (i) the volume of fluid administered at the following time points: when meeting eligibility criteria, in the first 6 h, at 24 h and prior to vasopressor commencement and (ii) the frequency and timing of vasopressor use in the first 6 h and at 24 h. Screening logs will provide reliable estimates of the proportion of ED patients meeting eligibility criteria for a subsequent randomised controlled trial. DISCUSSION: This multicentre, observational study will provide insight into current haemodynamic resuscitation practices in patients with sepsis and hypotension as well as estimates of practice variation and patient outcomes. The results will inform the design and feasibility of a multicentre phase III trial of early haemodynamic resuscitation in patients presenting to ED with sepsis and hypotension.

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

Background: In older people, quantification of risk of reattendance after emergency department (ED) discharge is important to provide adequate post ED discharge care in the community to appropriately targeted patients at risk. Methods: We reanalysed data from a prospective observational study, previously used for derivation of a nomogram for stratifying people aged 65 and older at risk for ED reattendance. We investigated the potential effect of comorbidity load and frailty by adding the Charlson or Elixhauser comorbidity index and a ten-item frailty measure from our data to develop four new nomograms. Model I and model F built on the original nomogram by including the frailty measure with and without the addition of the Charlson comorbidity score; model E adapted for efficiency in the time-constrained environment of ED was without the frailty measure; and model P manually constructed in a purposeful stepwise manner and including only statistically significant variables. Areas under the ROC curve of models were compared. The primary outcome was any ED reattendance within 28 days of discharge. Results: Data from 1357 patients were used. The point estimate of the respective areas under ROC were 0.63 (O), 0.63 (I), 0.68 (E), 0.71 (P) and 0.63 (F). Conclusion: Addition of a comorbidity index to our previous model improves stratifying elderly at risk of ED reattendance. Our frailty measure did not demonstrate any additional predictive benefit.

Objective The primary objective of the study was to measure the impact of an observational pain assessment dementia tool on time from ED arrival to first dose of analgesic medicine. Methods A multisite cluster randomised controlled trial was conducted to test the Pain Assessment in Advanced Dementia (PAINAD) tool. Patients aged 65 years or older suspected of a long bone fracture were screened for cognitive impairment using the Six-Item Screening (SIS) tool. Patients scoring 4 or less on SIS (intervention sites) were assessed for pain using PAINAD. Control sites, assessed pain using standard methods. The primary outcome was time to first dose of analgesia and was analysed on an intention-to-treat basis with a sensitivity analysis. Results We enrolled 602 patients, of which 323 (54%) were at intervention sites (n=4). The median time to analgesia was 82 min (IQR 45-151 min). There was no statistically significant difference in median time to analgesia for intervention 83 (IQR 48-158 min) and nonintervention 82 min (IQR 41-147 min) sites (p=0.414). After adjusting for age, fracture type, arrival mode and triage category, there remained no significant difference in time to analgesia (HR 0.97, 95% CI 0.80 to 1.17, p=0.74). Of the 602 patients enrolled, 273 actually had cognitive impairment. A sensitivity analysis demonstrated patients at intervention sites received analgesia 13 min sooner (90 vs 103 min, p=0.91). Conclusion Use of the PAINAD was not associated with a shorter time to analgesia, although there was a clinically important but non-significant improvement in the cognitively impaired patient group. Further research is needed to address this clinically important and complex issue.

BACKGROUND: Falls remain common for community-dwelling older people and impose a substantial economic burden to the healthcare system. RESPOND is a novel falls prevention programme that aims to reduce secondary falls and fall injuries among older people who present to a hospital emergency department (ED) with a fall. The present protocol describes a prospective economic evaluation examining the incremental cost-effectiveness of the RESPOND programme, compared with usual care practice, from the Australian health system perspective. METHODS AND DESIGN: This economic evaluation will recruit 528 participants from two major tertiary hospital EDs in Australia and will be undertaken alongside a multisite randomised controlled trial. Outcome and costing data will be collected for all participants over the 12-month trial. It will compare the RESPOND falls prevention programme with usual care practice (current community-based falls prevention practices) to determine its incremental cost-effectiveness according to three intermediate clinical outcomes: (1) falls prevented, (2) fall injuries prevented and (3) injurious falls prevented. In addition, utilities will be derived from a generic quality-of-life measure (EQ-5D-5L) and used to calculate the 'incremental cost per quality-adjusted life years gained'. DISCUSSION: The results of this study will provide healthcare decision makers with evidence to assist with setting spending thresholds for preventive health programmes and inform selection of emergency and community service models of care. TRIAL REGISTRATION NUMBER: The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000336684); Pre-results.Copyright Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Purpose Endocan, a component of the endothelial glycocalyx (EG), has been linked with respiratory failure in sepsis. This study explored the temporal patterns of three EG biomarkers, including endocan, and their relationships with inflammation and respiratory failure. Materials and methods Plasma endocan, syndecan-1, and hyaluronan concentrations were measured in Emergency Department (ED) patients with sepsis due to pneumonia (n = 44) on ED arrival (T0), 1 h (T1), 3 h (T3) and 12–24 h (T24) later, with change over time tested using mixed regression models. Biomarker associations with inflammatory cytokine concentrations and with respiratory failure on days 1, 2 or 3, need for mechanical ventilation and 30-day mortality were also tested. Results Endocan concentration significantly decreased over time (T0–T24, P = 0.003) whereas both syndecan-1 (T0–T3, P = 0.010; T0–T24, P < 0.001) and hyaluronan (T0–T1, P = 0.010; T0–T3, P < 0.001; T0–T24, P = 0.003) significantly increased over time. Increased syndecan-1 was significantly correlated with neutrophil activation biomarkers and significantly increased the odds of respiratory failure (OR 1.18, 95% CI 1.05–1.33, P = 0.004), need for mechanical ventilation (OR 1.24, 95% CI 1.04–1.48, P = 0.014) and 30-day mortality (OR 1.29, 95% CI 1.07–1.55, P = 0.008). Conclusion Syndecan-1, but not endocan, was associated with neutrophil activation and was the best EG biomarker predictor of adverse clinical outcomes.

Study Objectives To identify and summarize the pooled diagnostic test characteristics for dementia screening instruments in the emergency department (ED). Methods This was a systematic review and meta-analysis adherent to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis of Diagnostic Test Accuracy guidelines of prospective observational ED studies comparing appropriately brief dementia screening instruments against an acceptable criterion standard with sufficient detail to reconstruct 2x2 contingency tables. Two investigators independently assessed risk of bias using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2). When ≥1 study evaluated the same dementia screening instrument with the same criterion standard, pooled estimates of diagnostic accuracy were computed using a random-effects model and Meta-DiSc Version 1.4. Results From 1604 unique citations, 9 met inclusion criteria. QUADAS-2 assessment indicated moderate quality studies. The criterion standard for dementia was solely the Mini Mental Status Exam (MMSE) in 7 studies. The criterion standard for one of the other studies was a combination of the MMSE and a delirium screen, while the remaining study used a geriatrician’s assessment of Diagnostic Statistical Manual of Mental Disorders criteria as the gold standard. The weighted mean prevalence of dementia was 31% and ranged from 12% to 43% across studies. Eight instruments were described of which the Abbreviated Mental Test-4 (AMT-4) demonstrated the highest positive likelihood ratio [pooled LR+ 7.7, 95% CI 3.5-17.1] and the Brief Alzheimer’s Screen (BAS) demonstrated the lowest negative likelihood ratio [LR- = 0.10, 95% CI 0.02-0.28]. The Six Item Screener test time was reported as under 1 minute compared with 1.5 minutes for the Mini-Cog and 4.7 minutes for the AMT-4. Conclusions Existing research is limited by inadequate criterion standards juxtaposed wi

Objective: People with schizophrenia face an increased risk of premature death from chronic diseases and injury. This study describes the trajectory of acute care health service use in the last year of life for people with schizophrenia and how this varied with receipt of community-based specialist palliative care and morbidity burden. Method: A population-based retrospective matched cohort study of people who died from 01/01/ 2009 to 31/12/2013 with and without schizophrenia in Western Australia. Hospital inpatient, emergency department, death and community-based care data collections were linked at the person level. Rates of emergency department presentations and hospital admissions over the last year of life were estimated. Results: Of the 63508 decedents, 1196 (1.9%) had a lifetime history of schizophrenia. After adjusting for confounders and averaging over the last year of life there was no difference in the overall rate of ED presentation between decedents with schizophrenia and the matched cohort (HR 1.09; 95%CI 0.99–1.19). However, amongst the subset of decedents with cancer, choking or intentional self-harm recorded on their death certificate, those with schizophrenia presented to ED more often. Males with schizophrenia had the highest rates of emergency department use in the last year of life. Rates of hospital admission for decedents with schizophrenia were on average half (HR 0.53, 95%CI 0.44–0.65) that of the matched cohort although this varied by cause of death. Of all decedents with cancer, 27.5% of people with schizophrenia accessed community-based specialist palliative care compared to 40.4% of the matched cohort (p<0.001). Rates of hospital admissions for decedents with schizophrenia increased 50% (95% CI: 10%-110%) when enrolled in specialist palliative care. Conclusion: In the last year of life, people with schizophrenia were less likely to be admitted to hospital and access community-based speciality palliative care, but more likely to attend

An 84 year old functionally independent man, presents with right‐sided chest pain. His general practitioner prescribed rivaroxaban 9 months ago following a deep venous thrombosis. He was cleaning his garage and slipped from a small stool, falling backwards onto his bottom and then chest. He reports three other falls over the last year, but none of them were injurious and he has not sought medical care before today. His only other past medical history is hypertension for which his general practitioner recently added a third antihypertensive agent. He has blood pressure 105/73, heart rate 96, oxygen saturation 92% on room air and Glasgow Coma Scale 15. His chest wall is tender on the right without crepitus or palpable deformity. No traumatic injuries were found on imaging. The patient is eager to return home, as you contemplate an opportunity to prevent future injurious falls. Should emergency medicine's role include intervening in this sentinel event?

BACKGROUND: Guidelines recommend an initial intravenous (IV) fluid bolus of 30 ml/kg isotonic crystalloid for patients with sepsis and hypotension. However, there is a lack of evidence from clinical trials to support this. Accumulating observational data suggest harm associated with the injudicious use of fluids in sepsis. There is currently equipoise regarding liberal or restricted fluid-volume resuscitation as first-line treatment for sepsis-related hypotension. A randomised trial comparing these two approaches is, therefore, justified. METHODS/DESIGN: The REstricted Fluid REsuscitation in Sepsis-associated Hypotension trial (REFRESH) is a multicentre, open-label, randomised, phase II clinical feasibility trial. Participants will be patients presenting to the emergency departments of Australian metropolitan hospitals with suspected sepsis and a systolic blood pressure of < 100 mmHg, persisting after a 1000-ml fluid bolus with isotonic crystalloid. Participants will be randomised to either a second 1000-ml fluid bolus (standard care) or maintenance rate fluid only, with the early commencement of a vasopressor infusion to maintain a mean arterial pressure of > 65 mmHg, if required (restricted fluid). All will receive further protocolised fluid boluses (500 ml or 250 ml, respectively), if required during the 6-h study period. The primary outcome measure is total volume administered in the first 6 h. Secondary outcomes include fluid volume at 24 h, organ support 'free days' to day 28, 90-day mortality, and a range of feasibility and process-of-care measures. Participants will also undergo serial measurement, over the first 24 h, of biomarkers of inflammation, endothelial cell activation and glycocalyx degradation for comparison between the groups. DISCUSSION: This is the first randomised trial examining fluid volume for initial resuscitation in septic shock in an industrialised country. A pragmatic, open-label design will establish the feasibility of undertaking a lar

© 2016 John Wiley & Sons Ltd Aims and objectives: To explore emergency nurses’ perceptions of the feasibility and utility of Pain Assessment in Advanced Dementia tool in people over 65 with cognitive impairment. The Pain Assessment in Advanced Dementia tool was then compared with The Abbey Pain Scale, Doloplus-2 and PACSLAC. The objective was to determine which observational pain assessment tool was the most appropriate for the emergency department context and the cognitively impaired older person. Background: The number of older people with cognitive impairment conditions, such as dementia, presenting to the emergency department is increasing. Approximately 28% of people over 65 years who present will have cognitive impairment. Older people with cognitive impairment often receive suboptimal pain management in the ED. There is limited evidence of the use and/or appropriateness of dementia-specific pain observation assessment tools in the ED. Design: This was a multicentre exploratory qualitative study, which was conducted within a constructivist paradigm. Methods: Focus group interviews were conducted with nurses across three hospital emergency departments. Data were subject to thematic analysis. Results: Six focus groups were conducted with 36 nurses over a 12-week period. Four themes emerged from the analysis: 1) cognitive impairment is a barrier to pain management; 2) PAINAD gives structure to pain assessment; 3) PAINAD assists to convey pain intensity; and 4) selection of an appropriate observational pain assessment tool. Conclusions: This study identified that emergency nurses find it challenging to detect, assess and manage pain in cognitively impaired people. While the use of the PAINAD helped to address these challenges compared to other tools, nurses also identified the important role that family and carers can play in pain assessment and management for older people with cognitive impairment. Relevance to clinical practice: This study has generated new know

Objective: Community-based palliative care is known to be associated with reduced acute care health service use. Our objective was to investigate how reduced acute care hospital use in the last year of life varied temporally and by patient factors. Methods: A retrospective cohort study of the last year of life of 12,763 Western Australians who died from cancer or one of seven non-cancer conditions. Outcome measures were rates of hospital admissions and mean length of hospital stays. Multivariate analyses involved time-to-event and population averaged log-link gamma models. Results: There were 28,939 acute care overnight hospital admissions recorded in the last year of life, an average of 2.3 (SD 2.2) per decedent and a mean length of stay of 9.2 (SD 10.3) days. Overall, the rate of hospital admissions was reduced 34% (95%CI 1–66) and the mean length of stay reduced 6% (95%CI 2–10) during periods of time decedents received community-based palliative care compared to periods of time not receiving this care. Decedents aged < 70 years receiving community-based palliative care showed a reduced rate of hospital admission around five months before death, whereas for older decedents the reduction in hospital admissions was apparent a year before death. All decedents who were receiving community-based palliative care tended towards shorter hospital stays in the last month of life. Decedents with neoplasms had a mean length of stay three weeks prior to death while not receiving community-based palliative care of 9.6 (95%CI 9.3–9.9) days compared to 8.2 (95% CI 7.9–8.7) days when receiving community-based palliative care. Conclusion: Rates of hospital admission during periods of receiving community-based palliative care were reduced with benefits evident five months before death and even earlier for older decedents. The mean length of hospital stay was also reduced while receiving community-based palliative care, mostly in the last month of life. © 2017 Spilsbury et al.

Traumatic brain injury (TBI) encompasses a broad range of injury mechanisms and severity. A detailed determination of TBI severity can be a complex challenge, with current clinical tools sometimes insufficient to tailor a clinical response to a spectrum of patient needs. Blood biomarkers of TBI may supplement clinical assessments but currently available biomarkers have limited sensitivity and specificity. While oxidative stress is known to feature in damage mechanisms following TBI, investigation of blood biomarkers of oxidative stress has been limited. This exploratory pilot study of a subset of 18 trauma patients with TBI of varying severity, quantifies circulating concentrations of the structural damage indicators S100b, and myelin basic protein (MBP), and the biomarkers of oxidative stress hydroxynonenal (HNE), malondialdehyde (MDA), carboxy-methyl-lysine (CML), and 8-hydroxy-2'-deoxy-guanosine (8-OHDG). Significant increases in circulating S100b, MBP, and HNE were observed in TBI patient samples compared to 8 uninjured controls, and there was a significant decrease in CML. This small exploratory study supports the current literature on S100b and MBP elevation in TBI, and reveals potential for the use of peripheral oxidative stress markers to assist in determination of TBI severity. Further investigation is required to validate results and confirm trends.

Background: Health literacy is an important concept associated with participation in preventive health initiatives, such as falls prevention programs. A comprehensive health literacy measurement tool, appropriate for this population, is required. The aim of this study was to evaluate the measurement properties of the Health Literacy Questionnaire (HLQ) in a cohort of older adults who presented to a hospital emergency department (ED) after a fall. Methods: Older adults who presented to an ED after a fall had their health literacy assessed using the HLQ (n = 433). Data were collected as part of a multi-centre randomised controlled trial of a falls prevention program. Measurement properties of the HLQ were assessed using Rasch analysis. Results: All nine scales of the HLQ were unidimensional, with good internal consistency reliability. No item bias was found for most items (43 of 44). A degree of overall misfit to the Rasch model was evident for six of the nine HLQ scales. The majority of misfit indicated content overlap between some items and does not compromise measurement. A measurement gap was identified for this cohort at mid to high HLQ score. Conclusions: The HLQ demonstrated good measurement properties in a cohort of older adults who presented to an ED after a fall. The summation of the HLQ items within each scale, providing unbiased information on nine separate areas of health literacy, is supported. Clinicians, researchers and policy makers may have confidence using the HLQ scale scores to gain information about health literacy in older people presenting to the ED after a fall. Trial registration: This study was registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12614000336684 (27 March 2014).

Background: Guidelines recommend an initial intravenous (IV) fluid bolus of 30 ml/kg isotonic crystalloid for patients with sepsis and hypotension. However, there is a lack of evidence from clinical trials to support this. Accumulating observational data suggest harm associated with the injudicious use of fluids in sepsis. There is currently equipoise regarding liberal or restricted fluid-volume resuscitation as first-line treatment for sepsis-related hypotension. A randomised trial comparing these two approaches is, therefore, justified. Methods/design: The REstricted Fluid REsuscitation in Sepsis-associated Hypotension trial (REFRESH) is a multicentre, open-label, randomised, phase II clinical feasibility trial. Participants will be patients presenting to the emergency departments of Australian metropolitan hospitals with suspected sepsis and a systolic blood pressure of < 100 mmHg, persisting after a 1000-ml fluid bolus with isotonic crystalloid. Participants will be randomised to either a second 1000-ml fluid bolus (standard care) or maintenance rate fluid only, with the early commencement of a vasopressor infusion to maintain a mean arterial pressure of > 65 mmHg, if required (restricted fluid). All will receive further protocolised fluid boluses (500 ml or 250 ml, respectively), if required during the 6-h study period. The primary outcome measure is total volume administered in the first 6 h. Secondary outcomes include fluid volume at 24 h, organ support 'free days' to day 28, 90-day mortality, and a range of feasibility and process-of-care measures. Participants will also undergo serial measurement, over the first 24 h, of biomarkers of inflammation, endothelial cell activation and glycocalyx degradation for comparison between the groups. Discussion: This is the first randomised trial examining fluid volume for initial resuscitation in septic shock in an industrialised country. A pragmatic, open-label design will establish the feasibility of undertaking

© 2015 Elsevier Ltd. Introduction: Older Australians experience health disparities in pain management compared to other groups. This article is focused on understanding the emergency nurses' perceptions of pain and pain management for older persons with cognitive impairment and presenting with a long bone fracture. This article is part of a larger study focusing on emergency nurses' pain management practices for older Australians with cognitive impairment. Aim: The aim of the study was to understand emergency nurses' perceptions of the management of pain for older persons with cognitive impairment and presenting with a long bone fracture. Method: This is part of a larger multicentre programme of research exploring pain management in older persons with cognitive impairment and who are experiencing pain from a long bone fracture. This study had a qualitative research design, with data collected through focus group interviews and a thematic method of analysis. The study is framed by a constructivist's paradigm, which enabled multiple realities to surface and be interpreted. Results: Eighty emergency nurses participated, with 67 (84%) females and 13 (16%) males, in 16 focus groups across four emergency departments. Nurses had an average of 12.5 years as a Registered Nurse (SD ± 10.06) and 8.6 years (SD ± 8.64) emergency experience. Five themes emerged from data analysis and included: 1) Belief in championing pain management; 2) Pain management and the ageing processes; 3) Lack of pain assessment tools for the cognitively impaired older person; 4) Delivering analgesia - a balancing act; and 5) Policy barriers to nurse initiated pain management. Conclusion: This study makes clear the challenges clinicians' face in managing pain in older patients presenting to emergency departments. More specifically, older persons with cognitive impairment face substantially greater obstacles in receiving effective pain relief given the lack of any standardised pain assessment screening t

Objective: To examine the ability of paramedics to identify patients who could be managed in the community and to identify predictors that could be used to accurately identify patients who should be transported to EDs. Methods: Lower acuity patients who were assessed by paramedics in the Perth metropolitan area in 2013 were studied. Paramedics prospectively indicated on the patient care record if they considered that the patient could be treated in the community. The paramedic decisions were compared with actual disposition from the ED (discharge and admission), and the occurrence of subsequent events (ambulance request, ED visit, admission and death) for discharged patients at the scene was investigated. Decision tree analysis was used to identify predictors that were associated with hospital admission. Results: In total, 57183 patients were transported to the ED, and 10204 patients were discharged at the scene by paramedics. Paramedics identified 2717 patients who could potentially be treated in the community among those who were transported to the ED. Of these, 1455 patients (53.6%) were admitted to hospital. For patients discharged at the scene, those who were indicated as suitable for community care were more likely to experience subsequent events than those who were not. The decision tree found that two predictors (age and aetiology) were associated with hospital admission. Overall discriminative power of the decision tree was poor; the area under the receiver operating characteristic curve was 0.686. Conclusion: Lower acuity patients who could be treated in the community were not accurately identified by paramedics. This process requires further evaluation. © 2016 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

BACKGROUND: Outcomes of patients who are discharged at the scene by paramedics are not fully understood. OBJECTIVE: We aimed to describe the risk of re-presentation and/or death in prehospital patients discharged at the scene. METHODS: We conducted a retrospective cohort study using linked ambulance, emergency department (ED), and death data. We compared outcomes in patients who were discharged at the scene by paramedics with those who were transported to ED by paramedics and then discharged from ED between January 1 and December 31, 2013 in metropolitan Perth, Western Australia. Occurrences of subsequent ambulance requests, ED attendance, hospital admission and death were compared between those discharged at the scene and those discharged from ED. RESULTS: There were 47,330 patients during the study period, of whom 19,732 and 27,598 patients were discharged at the scene and from ED, respectively. Compared to those discharged from ED, those discharged at the scene were more likely to subsequently: request an ambulance (6.1% vs. 1.8%, adjusted odds ratio [adj OR] 3.4; 95% confidence interval [CI] 3.0-3.9), attend ED (4.6% vs. 1.4%, adj OR 3.3; 95% CI 2.8-3.8), be admitted to hospital (3.3% vs. 0.8%, adj OR 4.2; 95% CI 3.4-5.1). Those discharged at the scene tended towards an increased likelihood of death (0.2% vs. 0.1%, adj OR 1.8; 95% CI 0.99-3.2) within 24 hours of discharge compared to those discharged from ED. CONCLUSION: Patients attended by paramedics who were discharged at the scene had more subsequent events than those who were transported to and discharged from ED. Further consideration needs to be given to who is suitable to be discharged at the scene by paramedics.

Study objective: Palliative care has been shown to reduce end-of-life emergency department (ED) use. Our objective was to determine how the association of community-based palliative care with reduced ED visits in the last year of life varied by patient factors. Methods: This was a retrospective cohort study of 11,875 decedents who died with neoplasms, heart failure, renal failure, chronic obstructive pulmonary disease, or liver failure in Western Australia in 2009 to 2010. Outcome measures were adjusted hazard ratios (HRs) and daily (hazard) rates of ED visits. Results: The adjusted average rate of ED visits for the cohort was reduced 50% (HR 0.50; 95% confidence interval [CI] 0.47 to 0.53) during periods of receipt of community-based palliative care. This relative reduction in ED visits varied by patient factors, ranging from 43% (HR 0.57; 95% CI 0.45 to 0.74) for decedents aged 60 years and younger up to 71% (HR 0.29; 95% CI 0.18 to 0.46) for people aged 90 years and older. Decedents living in the most disadvantaged areas had a 44% (HR 0.56; 95% CI 0.44 to 0.72) reduction in ED visits when receiving community-based palliative care compared with a 60% (HR 0.40; 95% CI 0.31 to 0.53) reduction for decedents who lived in the least disadvantaged areas and received this care. The ED visit rates while patients were receiving palliative care also varied by ED visit history, partner status, and region of residence. Conclusion: Receipt of community-based palliative care in the last year of life was associated with a reduced rate of ED visits. The magnitude of this association was modified by patient health, as well as social and demographic factors. © 2016 American College of Emergency Physicians.

Objectives: The objective of this study was to assess the accuracy and safety of two pre-defined checklists to identify prehospital post-ictal or hypoglycemic patients who could be discharged at the scene. Methods: A retrospective cohort study of lower acuity, adult patients attended by paramedics in 2013, and who were either post-ictal or hypoglycemic, was conducted. Two self-care pathway assessment checklists (one each for post-ictal and hypoglycemia) designed as clinical decision tools for paramedics to identify patients suitable for discharge at the scene were used. The intention of the checklists was to provide paramedics with justification to not transport a patient if all checklist criteria were met. Actual patient destination (emergency department [ED] or discharge at the scene) and subsequent events (eg, ambulance requests) were compared between patients who did and did not fulfill the checklists. The performance of the checklists against the destination determined by paramedics was also assessed. Results: Totals of 629 post-ictal and 609 hypoglycemic patients were identified. Of these, 91 (14.5%) and 37 (6.1%) patients fulfilled the respective checklist. Among those who fulfilled the checklist, 25 (27.5%) post-ictal and 18 (48.6%) hypoglycemic patients were discharged at the scene, and 21 (23.1%) and seven (18.9%) were admitted to hospital after ED assessment. Amongst post-ictal patients, those fulfilling the checklist had more subsequent ambulance requests (P=.01) and ED attendances with seizure-related conditions (P=.04) within three days than those who did not.Amongst hypoglycemic patients, there were no significant differences in subsequent events between those who did and did not meet the criteria. Paramedics discharged five times more hypoglycemic patients at the scene than the checklist predicted with no significant differences in the rate of subsequent events. Four deaths (0.66%) occurred within seven days in the hypoglycemic cohort, and none of th