Emergency medicine

Management of critical bleeding requires a multidisciplinary approach to haemorrhage control, correction and prevention of coagulopathy, and normalisation of physiological derangements

for the Clinical and Consumer Reference Group for the Update of Patient Blood Management Guidelines (Module 1: Critical Bleeding/Massive Transfusion)

A cardiac arrest system with integrated ECPR is a promising intervention for patients with refractory cardiac arrest

For the National ECPR Working Group

Despite the large national DFD burden, Australian regions implementing guideline-based care have demonstrated large reductions in their regional DFD burdens and costs

Peter A Lazzarini · Anita Raspovic · Jenny Prentice · Robert J Commons · Robert A Fitridge · James Charles · Jane Cheney · Nytasha Purcell · Stephen M Twigg

A 32-year-old woman presented with a painless but cosmetically bothersome chronic indolent lesion on her left knee

Ruby C Lee · Kennedy Wong · Yolanka Lobo · Heba Jibreal

More effective care strategies are required to reduce the burden of TBI, particularly among younger men

Gerard M O'Reilly · Kate Curtis · Biswadev Mitra · Yesul Kim · Afsana Afroz · Kate Hunter · Courtney Ryder · Delia V Hendrie · Nick Rushworth · Jin Tee · Shane D'Angelo · Emma Solly · Oashe Bhattacharya · Mark C Fitzgerald · Gerard M O'Reilly · Kate Curtis · Biswadev Mitra · Yesul Kim · Afsana Afroz · Kate Hunter · Courtney Ryder · Delia V Hendrie · Nick Rushworth · Jin Tee · Shane D'Angelo · Emma Solly · Oashe Bhattacharya · Mark C Fitzgerald

Many ED presentations deemed suitable for GP care based on the AIHW defintion of lower urgency care may be unsuitable

Haomin S Wu · James L Mallows

To survive a sudden cardiac arrest, you need to be in the “right place at the right time”; but should someone’s chance of surviving a sudden cardiac arrest really come down to a roll of the dice?

Elizabeth Paratz · Gregory J Page · Garry LR Jennings

Further research is needed to determine the reasons for poorer outcomes during the COVID-19 pandemic

Lucy E Kirk · Imogen Mitchell

We must continue to review and document the safety and outcomes of transfers, despite their apparent safety

Peter T Morley

Most children with COVID-19 can be cared for adequately in primary care, relieving the demand for emergency department services

Laila Ibrahim · Catherine Wilson · Doris Tham · Mark Corden · Shefali Jani · Michael Zhang · Amit Kochar · Ker Fern Tan · Shane George · Natalie T Phillips · Paul Buntine · Karen Robins‐Browne · Vimuthi Chong · Thomas Georgeson · Anna Lithgow · Sarah Davidson · Sharon O'Brien · Viet Tran · Franz E Babl

Increased in-hospital mortality may reflect changes in care across the Australian health system that need to be rectified

Sing Chee Tan · Tess Evans · Matthew L Durie · Paul J Secombe · David Pilcher

The case for a market mechanism to improve health system flow and patient care

Benedict Rogers · Juan Paolo Legaspi · Tarun Bastiampillai

To the Editor: Over 26000 Australians experience out‐of‐hospital cardiac arrest (OHCA) each year, with almost nine in ten of these patients not surviving to hospital discharge or 30 days.1 Although it is known that swift defibrillation increases the possibility of patient survival in these situations, and that initial defibrillation by first responders (regardless of training) is associated with greater survival than initial defibrillation by emergency medical services,2 in Australia, less than 2% of OHCA cases receive defibrillation by a bystander.1 It is likely that this is driven by the limits to publicly accessible automated external defibrillators (AEDs) in Australian communities.3 On 30 November 2022, South Australia took a major step to deal with this problem and reduce death from OHCA. The SA Parliament passed the Automated External Defibrillators (Public Access) Bill 2022,4 making SA the first state or territory in Australia, and one of few in the world, to mandate the public provision of AEDs. The legislation, introduced by Member of the Legislative Council, the Hon Frank Pangallo of the SA‐BEST party, had bipartisan political support and backing from various organisations, and follows a recent public health campaign to install AEDs in Adelaide. The Bill will come into effect for government and public buildings in 2025 and a variety of private buildings in 2026, with awareness campaigns, grant programs, and communication with organisations being the focus of the interim period. The expected cost to the SA government of $7.2 million across four years is weighed against the $2 billion gross domestic product loss that Australia incurs annually as a result of sudden cardiac arrest.5 The health and economic benefits of public access defibrillation to Australian society are large. For the benefit of all Australians, other states and territories should follow the example set by SA and move to implement similar laws mandating the public availability of AEDs in their communities.

Joshua G Kovoor · Gregory J Page · Pramesh Kovoor

Recent advances in critical care relevant to a broad range of clinicians

Yasmine Ali Abdelhamid · Adam Deane · Rinaldo Bellomo

Careful clinical assessment is indicated in migraineurs to differentiate between migraine and more serious neurological pathologies

Alanna Rottler · Yew Li Dang · Wai Foong Hooi · David Burrows · Hong Kuan Kok · Douglas Crompton

Health system leaders should integrate alternative models of emergency care that proved useful during the pandemic into care pathways

Amith Shetty · Jean‐Frederic Levesque

To the Editor: We applaud the authors for comparing ambulance offload times with mortality and re‐presentation rates for patients presenting with chest pain.1 However, the model employed by the authors fails to account for the independent impacts of access block and emergency department (ED) overcrowding on poor outcomes and thus risks overemphasising the influence of ramping. There is clear evidence that ED overcrowding and access block are associated with worse patient outcomes, including increased mortality, re‐presentation rates and ambulance offload times.2,3,4,5 This could explain many of the study's findings: ramping is the symptom, ED overcrowding and access block are the disease. Secondly, there are fundamental differences between tertiles 1 and 3 that have not been addressed. The patients in tertile 1 are more likely to have been offloaded straight into the waiting room, a common procedure in most EDs, whereas patients in tertile 3 would not, potentially due to poor mobility, dementia, or being assessed as requiring significant cardiorespiratory monitoring. For this reason, patients in tertile 1 would be expected to have better outcomes than those in tertile 3. The article adjusts for the presence of eight comorbid conditions but not their severity. Furthermore, the incidence of each individual comorbid condition was marginally higher in tertile 3, and although individually not statistically significant, the cumulative impact of multiple comorbid conditions would be higher in tertile 3, which could confound the results. The study's use of the Charlson index is limited, as it only uses the identified eight comorbid conditions. The Charlson index also includes dementia, hemiplegia, heart failure, liver disease, and cancer; these are not measured in the study and would all contribute to offload delays and worsened outcomes. Lastly, without including patients presenting via private transport with chest pain, and in the absence of any measures of ED overcrowding and access block, the analysis of patients presenting with chest pain remains incomplete. That ED overcrowding and access block, evidenced by ambulance offload delays, is associated with worsened outcomes is well known. Unfortunately, focusing on the symptom of ambulance ramping, rather than the disease of ED overcrowding and access block, risks leading to ill‐informed policy decisions and ineffective solutions.

James L Mallows · Bridget Honan · Sierra Beck

Restrictions should be accompanied by advice about appropriate locations for seeking medical care, by condition severity and type

Amy L Sweeny · Gerben Keijzers · Andrea Marshall · Emma J Hall · Jamie Ranse · Ping Zhang · Gary Grant · Ya‐Ling Huang · Dinesh Palipana · Yang D Teng · Benjamin Gerhardy · Jaimi H Greenslade · Philip Jones · Julia L Crilly

After adjusting for age and other factors, survival outcomes are poorer for Indigenous than non-Indigenous people admitted to ICUs

Paul J Secombe · Alex Brown · Michael J Bailey · Sue Huckson · Shaila Chavan · Edward Litton · David Pilcher

To the Editor: We read with interest the article by Drewett and colleagues,1 on anaphylaxis presentations to emergency departments in Victoria, and the linked editorial by Lucas and Vale,2 which proposes a comprehensive adverse drug reaction registry to improve patient safety and care. Re‐exposure of a patient to a medicine to which they have had a previously documented allergy or adverse drug reaction (ADR) is a preventable clinical incident. The Australian sentinel events list includes “medication error resulting in serious harm or death” to ensure public accountability and transparency and drive national improvements in patient safety.3 The availability of accurate and up to date allergy/ADR information for prescribers is vital to support the decision on appropriate treatment and to prescribe a medicine. It is also critical that health professionals who administer medicines and pharmacists who dispense medicines have access to accurate allergy/ADR information, as they provide redundancy within the medication management system to prevent unintentional re‐exposure. We recently undertook an audit to assess the accuracy of medication history documentation performed by pharmacists. Our methodology has been published elsewhere.4 As part of this work, we assessed the quality of pharmacist‐documented allergy/ADR information. Allergy/ADR documentation best practice suggests documentation of the medication name, reaction details and reaction date.5 New findings from our audit identified a total of 108 allergies/ADRs across 99 patients. Of the 52 patients with a previous history of allergy/ADR, only 31% (n = 16) had complete and correct allergy/ADR information documented. These results highlight that the current systems do not adequately support clinicians to provide safe and high quality care. Moreover, these systems risk patient harm through inadvertent re‐exposure to a medicine where there is a previously documented allergy/ADR, given that, at the point of prescribing, administration or dispensing, data are not available, disparate, incorrect or incomplete. We believe the national allergy/ADR registry proposed by Lucas and Vale2 should go one step further, and legislation should mandate interoperability between all electronic prescribing, administration and dispensing systems in Australia. A further challenge will be populating accurate historical allergy/ADR information into the registry. It would require high quality documentation to assist informed clinical decision making. An additional challenge is the complex, hybrid paper and electronic prescribing and documentation systems used across health care settings. Even though these may be challenges to overcome, there are potential opportunities through patient engagement, incentive schemes and machine learning. There needs to be a national consumer‐focused education campaign so the public can be active participants in their own care to support optimal medicine choice based on their allergy/ADR history. We believe a national allergy/ADR registry is of key importance to further enhance patient safety and will be a true system change to overcome the barriers we face in day‐to‐day clinical practice.

Martin L Canning · Andrew Munns · Bonnie Tai

Our efforts to prepare and respond to the challenges posed by climate change must focus on community support and recovery, providing sustainable financial security and social connectedness

George Braitberg