Emergency medicine

Neil T Matthews Dean, Joint Faculty of Intensive Care Medicine, Australian and New Zealand College of Anaesthetists and Royal Australasian College of Physicians, 630 St Kilda Road, Melbourne, VIC 3004. jficmATanzca.edu.au To the Editor: The article by Hore et al1 raises many important issues for acute-care medicine in rural settings, including the need for specialists to be multiskilled and collaborate across disciplines, the lack of professional support for rural training programs and rural specialists, and the difficulty of overseeing multidisciplinary credentialling. These issues are not unique to acute-care medicine or to the Joint Faculty of Intensive Care Medicine (JFICM). They are problems for other faculties and colleges, rural healthcare facilities and governments. Many rural specialist services in Australia and New Zealand have the benefit of considerable expertise provided by medical practitioners who are not necessarily Fellows of the relevant specialist colleges. They should be supported by collaborative efforts of the relevant colleges, which should develop initiatives to increase the numbers of specialist medical practitioners working in rural settings. The JFICM, representing some 464 Fellows and 391 trainees, has been developing frameworks to support rural intensive care. JFICM’s goals are to develop a more flexible training program to encourage rural training; to establish a rural officer on the JFICM Board; to support a rural focus group, working through rural structures with the Committee of Presidents of Medical Colleges; and to explore liaisons with other colleges. The argument for developing a specialty of integrated critical-care medicine implies that current programs are deficient and cannot provide a holistic, integrated approach to rural acute care. Hore and colleagues argue that “there is no formal program for training specialists for multidisciplinary rural critical-care practice”. I must correct them on this point. Their proposal in fact eloquently describes the elements of the JFICM training program, which has existed since 1977. An internationally recognised and comprehensive intensive-care/critical-care training program, its status has been confirmed with its successful accreditation by the Australian Medical Council. The authors also suggest that “critical care” is in some way different from “intensive care”. This is not contemporary reality. The terms “intensive care” and “critical care” are one and the same. Healthcare workers in rural and remote locations have collaboratively developed multidisciplinary working relationships that provide comprehensive acute and non-acute healthcare. The same approach should be used by authoritative bodies to resolve important issues for rural specialists and training programs. The issues do not require establishing a separate specialty. The above comments notwithstanding, the suggestion by Hore and colleagues that specialties involved in acute care lead a collaborative process to strengthen clinical links is to be applauded. The discussions need to be inclusive of medical specialists working in intensive care medicine.

Neil T Matthews

John Stokes Director of Intensive Care, Mater Private Hospital, Fulham Road, Pimlico, QLD 4812. john.stokesATmatertsv.org.au To the Editor: Hore et al1 raise some very pertinent issues relating to the delivery of integrated critical care in the rural setting and raise the possibility of a new specialty to help solve the problem. The issue of providing many services in rural, remote and regional Australia will not be solved by more subspecialisation, which is actually having the effect of centralising services in major metropolitan centres distant from important and productive portions of our population. Rather than propagate another group of subspecialists, our medical colleges, and in particular the Australian Medical Council (AMC), need to look at new ways to empower specialists and generalists who work in regional areas to continue to provide services without their expertise being undermined in the eyes of the public. We need to encourage state governments to spread services more widely rather than to centralise and remove rural services. The push for so-called “centres of excellence” that draw all patients to a few centres is for the convenience of the few and is financially attractive to governments. Artificial standards for care (produced by the medical colleges), with restrictions on practice related to the number of patients treated or the number of patients ventilated, are unrelated to the quality of care delivered to individual patients. These restrictions may soon lead to many specialties not being sustainable outside capital cities or major urban centres because of insufficient caseload to meet the guidelines. In regional areas, specialists (such as anaesthetists) who have the experience to provide additional services (eg, intensive care), but not the formal recognition, are being discouraged from doing so by the college guidelines and the current legal climate. My observation of the actions of most medical colleges is that, by their good intention to maintain standards, they are supporting the concentration of services but are discouraging the wide delivery of services. Surely, when we do studies that demonstrate that care is better delivered in special or centralised units, the aim should be to find out why, and to seek ways to deliver that expertise in less specialised and more decentralised units, rather than to immediately call for more centralisation of services. This, I believe, is the real challenge for our AMC and our Committee of Presidents of Medical Colleges.

John Stokes

Craig T Hore,* William Lancashire,† John B Roberts,‡ Robert Fassett§ * Director of Critical Care, † Director of Critical Training, ‡ Director of Emergency Medicine, Port Macquarie Base Hospital, PO Box 2466, Port Macquarie, NSW 2444; § Director of Renal Unit, Department of Medicine, Launceston General Hospital, Launceston, TAS. horeATmaynegroup.com In reply: We thank the correspondents for their interest, insights and discussion. In general, there appears to be much common ground between our views and theirs, although a few points of clarification need to be made. We do not argue that a “committee of subspecialty experts” undertakes critical care in tertiary centres, as O’Leary suggests. The subspecialists we refer to are those within the discipline of critical care, particularly intensivists, emergency physicians and anaesthetists. In tertiary settings, these specialists operate predominantly within their base critical-care “subspecialty”. In rural settings, they are also involved in the other phases of critical care on a regular basis. Hence, while the principles of critical care are similar in rural and metropolitan settings, their effective delivery differs. We do not question that the Joint Faculty of Intensive Care Medicine (JFICM) provides a comprehensive intensive-care training program. However, there are very few JFICM-accredited intensive-care units in Australia outside metropolitan centres, and few JFICM-endorsed specialists working in the public sector in rural and remote intensive-care units.1 Unfortunately, this suggests that the current JFICM program is not addressing the needs of rural and remote centres. Indeed, in their recent review, the Australian Medical Council encouraged the JFICM to give more opportunity and encouragement for trainees to gain rural experience.2 The steps being undertaken by the JFICM that Matthews outlines are encouraging. We believe the statement by Matthews that “intensive care and critical care are one and the same” is insular and at odds with the reality of critical care, especially outside tertiary metropolitan centres. It is pleasing to note that O’Leary includes emergency medicine as a “traditional critical-care discipline”. There are strong clinical and curriculum similarities between emergency medicine and intensive-care medicine that cannot be overlooked. In this respect, rural centres may be leading the way in further breaking down barriers. The formation of the JFICM has been a positive step, but it remains a liaison of only two bodies. A greater presence from emergency medicine, rural anaesthesia, rural medicine and surgery would be beneficial and a significant step towards a truly multidisciplinary specialty. We reaffirm that, to ensure high standards of critical care for rural patients, solutions need to match the existing realities of rural practice. We agree that these must be collaborative and inclusive. The integrated critical-care model has been successful in a number of rural hospitals and offers potential for wider implementation.

Craig T Hore · William Lancashire · John B Roberts · Robert Fassett

Ian G Jacobs,* James Tibballs,† Peter T Morley,† Jennifer Dennett,‡ Jeff Wassertheil,§ Vic Callanan,¶ John Hall** (ARC executive committee on behalf of the Australian Resuscitation Council) * Chairman, Australian Resuscitation Council, C/- Royal Australasian College of Surgeons, Spring Street, Melbourne, VIC 3000; † Physician, Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC; ‡ Nurse Unit Manager, Central Gippsland Health Service, Sale, VIC; § Director of Emergency Medicine, Peninsula Health, Frankston, VIC; ¶ Head, Anaesthesia, Townsville Hospital, Townsville, QLD; ** Superintendent, Divisional Office, Ambulance Service of NSW, Hurstville, NSW. ijacobsATcyllene.uwa.edu.au To the Editor: With the increasing availability of biphasic defibrillators for use in both the manual and shock-advisory modes, considerable confusion has developed as to the appropriate energy levels to be used with these devices. This confusion has arisen partly because of differing recommendations from manufacturers, partly as a result of limited clinical evidence and partly because of the clinical availability of both monophasic and biphasic defibrillators. The differences between these waveforms are the way energy is delivered. Biphasic energy is delivered in two directions, whereas monophasic energies are delivered in one direction. Recommendations of the International Liaison Committee on Resuscitation state that biphasic energies less than or equal to 200 J are as efficacious as escalating higher-energy monophasic shocks.1 Lower-energy biphasic shocks cause less myocardial injury and postresuscitation myocardial dysfunction, and so potentially improve the likelihood of survival.2 Faced with the lack of data with respect to biphasic energy levels, the Australian Resuscitation Council makes the following recommendations: 1. When using manual biphasic defibrillators, energy levels of 150 J should be used for defibrillating ventricular fibrillation and pulseless ventricular tachycardia in adults. The basis of this recommendation is as follows: one randomised controlled trial in people in out-of-hospital ventricular fibrillation compared monophasic and biphasic shocks delivered by automated external defibrillators (AEDs).3,4 This study showed that 150 J biphasic shocks achieved higher rates of defibrillation and return of spontaneous circulation than higher-energy (200 J/200 J/360 J) escalating monophasic shocks. No differences were observed in the proportion of patients discharged from hospital. As clinical superiority of one particular biphasic waveform over another has yet to be demonstrated, it is appropriate to recommend this single energy level to achieve a consistent approach. 2. Biphasic energy levels of 1–2 J/kg should be used for defibrillating ventricular fibrillation and pulseless ventricular tachycardia in children. The basis of this recommendation is as follows: extrapolation from adult data, supported by studies in “child” and “infant” animal models, suggests that the dose for biphasic shocks in children should be 1–2 J/kg (about half the monophasic dose). Higher doses (up to 4 J/kg) are not likely to be harmful and are more efficacious than equivalent monophasic shocks.5 Biphasic shocks may be delivered in a fixed dose of 50 J by an AED. The use of AEDs in children less than 1 year of age is not recommended, as in this situation these devices are unable to differentiate between shock-able and non-shockable rhythms (eg, ventricular fibrillation v pulseless electrical activity). Energy levels for AEDs when used in automatic mode have been pre-set by the manufacturer, and do not require an energy level to be set by the user.

Ian G Jacobs · James Tibballs · Peter T Morley · Jennifer Dennett · Jeff Wassertheil · Vic Callanan · John Hall

Saul Wiener Allergist, Royal Melbourne Hospital, 46 Balaclava Road, East St Kilda, VIC 3183. To the Editor: In their study on the effectiveness of antivenom for redback spider bite, Isbister and Gray cast doubt on the current method of administering antivenom intramuscularly.1 Any study on the outcome of treating bites by venomous animals is limited by factors beyond the control of the investigator. These include the variability of the venom content in the animal’s venom apparatus, uncertainty regarding how much and where venom has been injected, and the delay before treatment. Between 1955 and 1957, I dissected the venom glands of 590 redback spiders for the production of antivenom.2 The yield of freeze dried venom per spider varied from 0.08 mg to 0.32 mg. Based on these findings, and to allow for dilution of antivenom by body fluids, “it was considered that 500 units of antivenene would constitute a suitable initial dose for the treatment of a bite by L. hasseltii”.3 This amount of antivenom will neutralise 5 mg of venom in vitro, and the antivenom is still issued in this strength by CSL Ltd. No fatalities have occurred from redback spider bite since antivenom became available in 1956,4 and reports from doctors have confirmed its efficacy and safety.5 If symptoms persist after the initial dose, or if diagnosis has been delayed, the initial dose of 500 units may have to be repeated. As Banham et al have wisely stated “treatment should be titrated against response”.6 Because of the risk of anaphylaxis, intramuscular injection, which has stood the test of time, is safer than the intravenous route.

Saul Wiener

Geoffrey K Isbister Clinical Envenoming Research Group, University of Newcastle, Newcastle Mater Misericordiae Hospital, Locked Bag 7, Hunter Region Mail Centre, NSW 2310 gsbiteATferntree.com In reply: We thank Wiener for his comments on our study. Although we challenge the use of intramuscular redback spider antivenom (RBS AV) in the article, we only suggested that the use of intramuscular antivenom needs review and that randomised controlled trials comparing intravenous and intramuscular RBS AV should be undertaken. Two such trials, in Western Australia and Newcastle, are currently in progress. There are no pharmacokinetic studies of RBS AV, but studies of other antivenoms suggest that the intramuscular route is less effective.1 In Tunisia, the intramuscular use of scorpion antivenom, which is also an F(ab')2 antivenom, similar to RBS AV, has been questioned for similar reasons.2,3 Studies in a rabbit model demonstrated that intramuscular antivenom induced only partial and delayed neutralisation of circulating toxins.3 More importantly, in a study of scorpion stings of children, the intramuscular administration of antivenom had far less effect on plasma venom concentrations and patient recovery times.2 We do not dispute that repeated doses of antivenom may be required, but the implication that only an initial dose was used in our study is incorrect. Half of the treated patients required repeat doses (6 ampoules in one patient). In a recent series of four patients with redback spider bites, intramuscular antivenom was ineffective, even though three patients received two or three ampoules. Subsequent intravenous antivenom was effective in all cases.4 There is no evidence that appropriately administered intravenous RBS AV (diluted in 200 mL of normal saline, over 20–30 minutes) is less safe than intramuscular antivenom. There is insufficient reason to prevent the use of intravenous antivenom if it is shown to be more effective than intramuscular antivenom. Although it is too early to change recommendations for the administration of RBS AV, it is essential that controlled trials be done.

Geoffrey K Isbister

Has enthusiasm overwhelmed judgement? Although advocates of the use of tissue plasminogen activator (tPA) in acute ischaemic stroke suggest that this “is one of the most important advances in stroke medicine”,1 a recent Cochrane meta-analysis also supports “clinicians who choose . . . not to use the treatment at all”,2 and all three major emergency medicine associations in North America have declined to endorse it as “standard of care”.3 In a recent issue of the Journal, Szoeke and colleagues’ audit of tPA use in a tertiary-care hospital concluded that “favourable outcomes . . . were similar to those achieved in international . . . trials in specialised centres”,4 while an accompanying editorial highlighted that “the absolute benefits of stroke care unit management clearly outweigh those of . . . tPA administration”.1 Several letters in this issue of the Journal raise important concerns about the report of Szoeke et al, as well as the overall risks and benefits of the use of tPA in ischaemic stroke (page 386).5-7 A single dose of aspirin provides benefit to about 15 times as many stroke patients as does tPA,1 at far less risk. This is true even assuming tPA benefits one in every eight patients treated, which is based on a point estimate taken from the National Institute of Neurological Diseases and Stroke (NINDS) trial,8 the only randomised controlled trial which found a benefit for its primary endpoint. This does not take into account the wide confidence intervals in the NINDS trial, the negative results of multiple other randomised controlled trials,9,10 and the far worse results in non-expert hands. Even under a “maximum benefit” scenario, with further assumptions that overestimate the impact of tPA (including that it could be given safely and effectively to 10% of acute stroke patients, rather than the 1%–3% non-protocol-violation treatments in typical community studies),11,12 tPA would have only minimally greater impact than aspirin. Ultimately, regardless of who is correct about the available evidence, the overall impact of tPA in acute ischaemic stroke is at most marginal, which makes it difficult to understand why “so much has been made of so little”.7 Perhaps it has to do with enthusiasm for what is frequently called the “first treatment for stroke”, although, as noted, there are far more important (but far less dramatic) treatments available. Readers will have to decide for themselves whether it also has something to do with money,3 or if this is truly “extending conspiracy theory to its limits”, as Donnan and colleagues claim (page 388).13 Previous critiques of the use of tPA in ischaemic stroke have raised the following issues: There is a paucity of positive evidence; all but one small randomised controlled trial failed to find benefit in the primary outcome, or found substantial harm.14,15 Even in the NINDS trial, the benefit was primarily in patients treated less than 90 minutes after symptom onset16 (almost no such patients exist in actual community practice), so the number needed to treat in the 91–180-minute group is surely far higher than the “eight patients needed to treat” widely quoted. “Effectiveness” in a community setting is far different from “efficacy” as reported in the NINDS trial (even if NINDS is taken at face value).15,16 Let me add the following observations. Most supporters of tPA claim that three trials involving streptokinase are irrelevant (including one done in Australia, with very negative results10). However, in the absence of studies directly comparing them, there is no reason to believe that tPA should be better than streptokinase for treating ischaemic stroke. In head-to-head cardiac megatrials (ISIS III, GISSI II, and GUSTO I), tPA consistently caused more intracerebral haemorrhage than streptokinase, which is likely to be even more important in patients with stroke. Furthermore, the GUSTO I trial, which provided the only remotely credible (albeit controversial) evidence suggesting tPA might be a bit more effective than streptokinase in coronary patients, was explicitly based on the notion that adjunctive intravenous heparin must be given with tPA — an approach contraindicated in stroke. Excluding streptokinase trials from the analysis of thrombolytics in stroke because they happened to be negative is simply inappropriate. Although Szoeke et al’s report is not strictly an “efficacy” study, neither is it a community practice “effectiveness” study, as treatment was by experts in a tertiary care facility. Thus, in no case should the results be extrapolated to other practice environments. Furthermore, it is critical to note the report’s limitations: Most obviously, there were no randomised controls, and outcomes were measured unblinded to the use of tPA, creating enormous potential for measurement bias. The study failed to meet most of the methodological criteria considered critical for chart reviews17 (eg, use of trained abstractors [ideally other than the authors], standardised abstraction forms and multiple independent reviewers for at least some of the charts, with some measure of agreement between reviewers; use of explicit criteria for coding of outcomes and explicit definitions for interpreting absent or inconsistent data). Outcomes among 30 patients receiving tPA may have been “consistent with” the NINDS result, but, given the small numbers and extremely wide confidence intervals, were also consistent with virtually any result. The report may well represent publication bias. Indeed, the most positive “effectiveness” study reported results from 57 of 83 centres that participated in a proprietary randomised controlled trial18 — what happened to the other 26? The only two reports that included all patients receiving tPA in a given community each documented unacceptable outcomes.11,12 Finally, there is the problem of interpretation bias. Szoeke et al classified one of the deaths after tPA therapy as a protocol violation, which will allow advocates to claim the results “would have been even better if . . .”. But this was based on an exclusion criterion that was not part of the NINDS protocol (ie, “early signs on computed tomography [CT] suggesting infarct of more than a third of the territory of the middle cerebral artery”), and despite the fact that the study’s expert CT readers did not agree whether this patient even met that criterion! This example (out of many) should provide insight into the way the “spin” of enthusiastic authors can lead to conclusions that are rosier than results actually justify. Many of us believe that thrombolytic therapy in stroke remains far from proven, so that its use should be restricted to further randomised controlled trials. This would not only enable us to determine whether this therapy produces more good than harm, or vice versa, but might also allow identification of subgroups in whom it is, or is not, indicated. We could then avoid giving a potentially fatal drug to a patient in whom it increases risk unacceptably, while also allowing current sceptics to use it in a different patient likely to benefit — assuming such patients, in either category, could be identified. If tPA use becomes more widespread, a very small number of patients may receive great personal benefit, while a very few others may be subjected to great personal harm. However, the broader implications of this debate are substantial. Modern health policy traditionally rests on the “precautionary principle”, which requires that no new practice be widely introduced until it is shown to be safe. This principle is under fierce attack in postmodern society by advocates of the contrary “Kehoe principle”, which asserts that if something may have value it should be accepted unless it’s proven dangerous.19 It is, of course, almost impossible to prove such danger, and, once approval is given, it may take many years — and a great deal of harm — before the decision can be reversed. Such was the case with leaded gasoline, which was termed “a gift of God” by its discoverer, Robert Kehoe, after whom this dangerous principle is named,19 and which was used ubiquitously for over 60 years, despite widespread understanding of its terrible public health impact. Whether or not the medical community insists on real evidence that tPA will do more good than harm in acute ischaemic stroke will also reflect how we feel about the introduction of all manner of potentially beneficial, but also potentially dangerous, new treatments.

Jerome R Hoffman MA, MD

After the Bali bombing on 12 October 2002, many injured Australians required evacuation to Darwin, and then to burns units around Australia. Many patients were evacuated from Denpasar by Qantas, with assistance from staff of civilian medical retrieval services. The transport of patients from Darwin to specialist burns units involved a coordinated response of civilian and military services. Some issues in responding to such disasters were identified, and a national coordinating network could improve future responses. On Saturday evening, 12 October 2002, two bombs exploded in a crowded nightclub area at Kuta Beach, Bali. The explosions killed more than 180 people and injured several hundred others. Injuries were principally burns and shrapnel injuries. Local healthcare resources, which do not include a specialist burns capability, were rapidly overwhelmed. Many of the injured were Australian citizens, who required evacuation to Australia. The military response has been described previously.1 Civilian evacuation flights directly from BaliActivationEarly in the morning of Sunday, 13 October, Qantas Security asked Qantas medical staff to organise a medical team to fly to Bali to assist in evacuating injured people. Two doctors and three nurses, medical equipment from Qantas Aviation Health Services, and several members of Qantas Security travelled to Bali on a Boeing 767, departing Sydney at 17:00 EST on Sunday. During the day, NSW Health and the Medical Retrieval Unit of the Ambulance Service of New South Wales offered medical teams to fly to Bali to care for any patients who presented at the airport with injuries. Thus a team of four doctors and two paramedics drawn from CareFlight and the Sydney Aeromedical Retrieval Service was dispatched on a second Qantas Boeing 767 flight at 18:00. A consignment of medical equipment, including a large quantity of burns dressings, analgesic and intravenous fluids, was also transported. When the first aircraft arrived in Denpasar, hundreds of passengers were queued at check-in, many with obvious burns and shrapnel injuries. A treatment area was set up within the departure lounge, and triage commenced. The medical personnel began cleaning and dressing wounds for people departing on the first flight to Sydney. The arrival of the second aircraft provided additional resources, and enabled medical personnel to accompany each Qantas flight that departed Denpasar. First Qantas flight from Denpasar to SydneyTriageAs soon as they arrived in Bali, a doctor and paramedic team from CareFlight transferred to the first aircraft, which was ready for departure. This team walked around the cabin with a flight attendant to estimate the number of injured passengers and the type of injuries. This initial assessment guided the decision on what equipment was to be taken on the flight, and what was to be left for subsequent flights. After take-off, patients were triaged using the Homebush triage taxonomy2 (Red, Immediate; Yellow, Urgent; Green, Not Urgent) and the CareFlight triage algorithm.3 Although appropriately coloured tags were available, they were not used to indicate patient priority. Instead, they were positioned so that they protruded from the top of patients’ seats, simply indicating the location of an injured passenger in the cabin. About 20 passengers who would require treatment were identified. To facilitate assessment, treatment, and observation, the cabin crew seated the injured passengers together. The pilot’s rest cabin was used as a treatment room. Although narrow, the cabin has a recliner seat that allowed semi-supine positioning of patients, and the door provided privacy. The doctor assessed individual patients, documenting injuries on the triage tag, and treatment to be instituted in flight. One of the uninjured passengers was a medical colleague of the treating doctor, and volunteered to assist, providing invaluable assistance in assessing patients and obtaining intravenous access. As expected, given that the passengers were ambulant and had boarded by themselves, no critically injured patients were identified. Therefore, the triage system was modified to reflect the order of medical attention. Red priority was allocated to patients with burns, dehydration or multiple injuries, and those in severe pain. Yellow priority was allocated to stable patients with injuries that might deteriorate. Green priority was allocated to patients with emotional disturbance or minor injuries. TreatmentAll patients with burns were re-examined to obtain accurate estimates of burn area and intravenous fluid requirements. Those with significant burns (20%–30%) were managed with moist burn dressings, intravenous fluid therapy, and intravenous analgesia. The injuries (Box 1) were consistent with previous reports from terrorist bombings,4-6 but generally less severe, as the patients were ambulant. The patient with a depressed skull fracture had no neurological deficit and remained stable for the duration of the flight. Equipment was available to enable intubation, ventilation and administration of osmotic agents if the patient’s condition had deteriorated. The most common interventions were bandages, dressings and intravenous fluid. Giving sets for intravenous fluids were hung from overhead luggage bins with hooks made from coat hangers. The requirements for analgesics and anxiolytics were less than expected; many people were prepared to tolerate significant pain knowing they were safe and on their way home. Morphine supplies had been left in Denpasar, so ketamine was used to provide analgesia during the flight. Unlike morphine, ketamine does not cause respiratory depression, an important consideration in a commercial aircraft, where the high altitude and resulting low cabin pressure render passengers relatively hypoxic. Although the dose was kept to less than 0.5mg/kg, some patients experienced transient dysphoric effects. On arrival at Sydney (Kingsford-Smith) Airport, the aircraft were met by ambulance and medical personnel. Passengers with minor injuries were asked to refer themselves for further assessment to the medical teams at the airport or to their local hospitals and general practitioners. Subsequent flights from DenpasarWhen the second flight back to Sydney was ready for boarding, a doctor and paramedic did a quick walk-through of the area where passengers waited. As there were no severely injured people, the paramedic alone accompanied the flight back to Sydney. During transit, about 25 patients were identified with injuries, including minor burns and shrapnel wounds. The medical personnel who remained in Denpasar screened passengers for the subsequent flights. A doctor was positioned at the check-in line. Many passengers attempted to conceal injuries, believing that they would be refused transport if their injuries were identified. Passengers with injuries were more readily identifiable when walking, as limps, bandages, slings, and undressed wounds were more difficult to conceal. These passengers, who required reassurance that they would still be allowed to travel, were asked to go to the treatment area. About 55 passengers who required medical interventions were identified in this way. These passengers principally required analgesia and wound dressings, and boarded subsequent flights. A further five Sydney Aeromedical Retrieval Service doctors and paramedics were dispatched from Sydney on the Monday evening, allowing all additional flights to return to Sydney with medical personnel on board. In total, Qantas operated nine special evacuation flights, returning more than 4500 people to Australia. More than 2000 kg of medical supplies were also carried. The response in DarwinThe most severely injured patients repatriated to Australia were evacuated from Bali on five Hercules C-130 military transport aircraft.1 These flights transported 65 patients to Royal Darwin Hospital (RDH) for stabilisation and initial surgery. Fifty-three of these patients were listed as serious or critical. The RDH disaster plan, which had revealed no operational deficiencies when recently tested for the East Timor conflict, was activated 16 hours before the arrival of the first C-130, allowing the intensive care unit, emergency department and an entire surgical floor to be essentially emptied and prepared. Many RDH staff volunteered for duty, and resources were pooled from the adjacent private hospital. At 15:00 CST on Sunday, 13 October, the Commonwealth Department of Health and Ageing accepted an offer from the Royal Adelaide Hospital (RAH) of 10 staff to complement the resources of the RDH. The RAH teams (a burns surgical team of three, a critical care medical team of five doctors, and two critical care retrieval nurses) reached Darwin before the arrival of the first C-130 carrying injured patients at 01:30 on Monday. The most senior burns surgeon and the critical care teams were initially placed at Darwin airport. The patients, especially on the first C-130, had had minimal resuscitation only and were retriaged at Darwin airport by a four-person medical team comprising an RDH anaesthetist, an RAH intensivist, the RAH burns surgeon and a doctor from the Australian Defence Force (ADF). Although only three patients on the first two C-130s were intubated, within a few hours of arriving at RDH many others required intubation and other critical care support. Patients were probably protected from airway swelling by the lack of fluid resuscitation provided in Bali and on the flight to Darwin. When effective fluid resuscitation was initiated at RDH, airway swelling and other problems became apparent, necessitating admission to the intensive care unit. The RAH staff assisted in the RDH intensive care unit, performing complex intubations and central line insertions, as well as more than 100 burns surgical procedures. Secondary transports from DarwinRDH does not have a burns unit or the capability to provide ongoing management for large numbers of severely injured patients, so, after the second C-130 arrived, a request was made to Emergency Management Australia, the federal organisation responsible for disaster coordination, training and research, for patients to be transported from RDH. Two critical patients were transported directly from Darwin Airport to RAH, after being assessed and stabilised at the airport before the 4-hour flight. Most of the secondary aeromedical evacuations occurred over the next 24 hours, although they continued intermittently for 5 days. The critical care patients could only be transported one or two to a plane, as medically equipped civilian aircraft do not have the capacity of the military aircraft. A summary of the critical care aeromedical evacuations from Darwin is included in Box 2. Box 3 shows a team preparing a patient for transport. Patients were allocated to destinations on the basis of their stability when transport was available, their home state, and a desire to distribute unstabilised patients between aircraft. Seventeen critical patients were evacuated from Darwin, although many who were categorised as serious would have been classed as critical in normal circumstances. RAH, RDH and ADF staff worked together to coordinate the use of civilian and military aircraft to transport the 17 critical and 37 serious patients to burns units in other states. Civilian–military coordination was facilitated by two RAH staff who held dual military and civilian positions. This enabled changes in transport allocation for a number of patients as their condition changed during Monday afternoon and evening. Improving the response for future disastersAlthough the ADF bore the major responsibility for evacuating victims of the bombing from hospitals in Denpasar to Darwin, most of the critical care transfers from Darwin to interstate centres were performed by civilian retrieval services. In conjunction with Qantas, many ambulant patients were also evacuated directly from Denpasar by civilian aeromedical teams. Several issues became apparent in the coordination of the civilian aeromedical evacuation from Darwin. These were: Lack of knowledge by federal emergency coordinators of available civilian aeromedical resources, which led to delay in activation; Lack of a national coordination system for medical retrieval, so transport from Darwin was organised by personal contacts and offers of assistance rather than a systematic approach, resulting in ad hoc utilisation of services; Insufficient coordination between personnel organising the transports and the receiving burns centres, resulting in unequal distribution of patients to interstate burns units; Substantial delays while funding was found to charter jets for transporting critical patients. In Australia, most disaster planning is done at state level, and essentially all disaster response resources, with the exception of the ADF, are held at state level. Although the ADF has the capability to carry large numbers of patients, their aeromedical evacuation teams have little peacetime exposure to critical care transport and their equipment is limited. Some incidents require specialised medical or rescue responses that exist only in the civilian setting.7 A mechanism is required for rapidly accessing these specialist state-based resources for incidents that overwhelm the resources of an individual state or occur outside Australia. Medical retrieval resources are another highly specialised resource held only at state level. However, most state services do not have experience in the coordination and logistics required (or even the capability) for very long distance transport, so devolving overall responsibility to the states in situations like the Bali bombing is not practicable. Therefore, a national coordination system that is aware of individual service capabilities and that can tailor the response accordingly is required. A possible model for a national retrieval networkIn Australia, a national network coordinates specialist burns services in the event of a major burns incident. The burns network currently functions by direct liaison between the states’ burns unit directors as required. The burns network can identify beds for burns victims in other states when the resources of one state are overwhelmed. However, there is no system for coordinating the transport of patients. A network of civilian retrieval providers with long distance capability, functioning in a similar manner to the burns network, could be established to coordinate responses to events such as the Bali bombing, which require distribution of casualties across states outside of usual referral patterns. Such a national medical retrieval network would require no ongoing funding, as it is essentially an informal network of service directors. However, funding sources for aircraft charter and a streamlined mechanism for contacting federal and state officials are necessary if the network is to be able to mount rapid, coordinated responses. Advantages of a national retrieval network include: Coordination of patient transfers, in conjunction with other specialist services such as the burns network; Systematic activation of civilian retrieval services, taking into account individual service capabilities; A single access point for retrieval network activation by federal or state agencies, and a dedicated medical officer for liaison with the ADF, if required; and Single-phone-call access to specialist medical retrieval advice, activation of appropriate specialist medical personnel, mobilisation of medical equipment and transport resources, and overall coordination of the medical response by personnel with many years of experience in long distance (interstate and international) critical care transport. In events outside Australia where security is not in doubt, a civilian reconnaissance team sent by commercial or charter jet may be of considerable value while the slower, larger ADF aircraft are in transit. Civilian jet aircraft that can transport teams of up to 10 medical personnel plus equipment could be rapidly mobilised to perform initial intelligence gathering, and resuscitate and prepare patients for transport before arrival of military transport aircraft. A number of organisations have expressed interest in developing a national retrieval network, including the Australasian College for Emergency Medicine and the two largest state-based retrieval services with international capability. Implementation of such a network should result in more timely and better coordinated utilisation of civilian retrieval resources in any future mass casualty incident. 1: Summary of patient injuries on the first Qantas flight from Denpasar Triage category (number of patients) Injury types Treatments required Red (8) Burns ranging from 20% to 30% (including facial), dehydration, lacerations, fractures, shrapnel injuries, blast injury to eye. Intravenous fluid, analgesia, dressings, and antiemetics. Yellow (6) Depressed skull fracture, limb fractures, lacerations, chest and neck pain, abdominal pain, anxiety, blast injury to ear and eyes. Bandaging, sedation, and observation. Green (5) Lacerations and emotional disturbance. Assessment and support. 2: Critical care aeromedical evacuations from Darwin Departure* Aircraft Team Patients Patients’ homes Destination 08:50 Mon Lear 35 (2 stretchers) Royal Adelaide Hospital 2 Melbourne; Melbourne Adelaide 14:00 Mon Lear 36 (1 stretcher) Royal Adelaide Hospital 1 Sydney Adelaide 17:30 Mon Super Kingair (2 stretchers) Royal Flying Doctor Service (QLD) 2 Sydney; New Zealand Brisbane 18:00 Mon Super Kingair (2 stretchers) Royal Flying Doctor Service (QLD) 2 Brisbane; Sydney Brisbane 19:00 Mon Lear 35 (2 stretchers) Royal Adelaide Hospital 2 Darwin; Perth Adelaide 21:00 Mon Westwind (2 stretchers) CareFlight (NSW) 2 Melbourne; Brisbane Sydney 23:30 Mon Lear 36 (1 stretcher) Royal Adelaide Hospital 1 Canada Melbourne 01:00 Tues Hercules C-130 Royal Australian Air Force 2 Perth; Perth Perth 05:00 Tues Citation Medical Emergency Adult Retrieval Service (VIC) 1 Brisbane Melbourne 03:00 Tues Hercules C-130 Royal Australian Air Force/Royal Adelaide Hospital 1 Melbourne Melbourne 17:50 Fri Lear 35 (1 stretcher) Royal Adelaide Hospital 1 South Africa Adelaide * Departure times are Australian Central Standard Time (UTC +09:30). 3: A team from CareFlight Sydney preparing a patient for transport to Sydney

Minh D Tran MB BS, BSc(Med) · Alan A Garner MB BS, FACEM, MSc · Colin Xavier MB BS, FACEM · Ion Morrison DipPH, FAFPHM, FRAeS · Peter H Sharley FJCICM, FANZCA, FFICANZCA · William M Griggs FANZCA, FJCICM, DipAvMed

After the Bali bombing on 12 October 2002, injured Australians were evacuated to Darwin. The first patients arrived at the Royal Darwin Hospital (RDH) 26 hours after the blasts. RDH assessed and resuscitated 61 patients (including 20 intensive care patients, with 15 requiring ventilation, 19 surgery and more than 20 escharotomies). RDH evacuated 48 patients to burns centres around Australia within 36 hours of the first patient arrivals at the hospital and 62 hours after the bomb blasts. The response was successful, but improvements are needed in coordination between the different groups involved in such operations. At 07:45 CST on Sunday, 13 October 2002, a patient was seen in the emergency department (ED) of RDH with minor lacerations and a remarkable story. The patient described being in a nightclub in Kuta Beach, Bali, about 10 metres from the primary blast. He escaped by climbing through a collapsed roof, past dismembered bodies, and then ran to the airport, where he caught the next flight out of Bali. External Disaster Plan activationAt 09:30, the Director of Emergency Medicine notified the General Manager and Medical Superintendent of RDH, and Level 1 of the External Disaster Plan was activated. Over the next few hours, the only news came from television reports and Australian doctors in Bali using mobile telephones to ask for assistance. On the Sunday morning, like many organisations in Australia, RDH offered to send retrieval teams to Bali. The main impediments to this were that aviation companies were not willing to fly into an uninsured environment and ground clearance for landing was difficult to obtain — the first RAAF Hercules C-130 aircraft only obtained landing clearance as it approached Denpasar. During the morning, key clinicians and administrators considered the capacity of RDH to respond. This information was conveyed to the Northern Territory’s Chief Minister, who contacted senior officers of the Commonwealth Department of Foreign Affairs and Trade. The decision was made to use Darwin as the first Australian retrieval port for seriously injured victims. Darwin is geographically uniquely placed to act as a forward general hospital for disasters in our region. Located 1765 km from Denpasar, a little more than two hours by air, Royal Darwin Hospital (RDH) was the closest tertiary referral facility in Australia for victims of the Bali bombing. RDH is 10 minutes by ambulance from the international airport. In sustained air evacuations, pilot hours are often a rate-limiting step; small increases in cycle time (length of flight and turnaround time) can have major effects on pilot availability. At 14:00, the first RDH control-room meeting occurred, and Level 2 of the External Disaster Plan was initiated (ie, fully prepare RDH to receive the injured). Control-room meetings occurred every few hours over the next 24 hours. At this stage, little was known; we planned for between 50 and 200 patients, with 50% being “walking wounded”. At 15:00, RDH was informed that it would be the sole initial receiving hospital for the Bali victims. We did not receive information on patient numbers or injury severity until the first wave of patients arrived. Preparing to receive bomb victimsBetween 14:00 and 18:00, 24 RDH inpatients were transferred to the collocated Darwin Private Hospital. Specialist-led discharge rounds cleared a further 20 beds. This enabled the establishment of a 48-bed receiving ward. All outpatient clinics and operating lists for the following five days were cancelled, with affected patients contacted. The local media broadcast announcements informing the community of the events about to unfold and asking potential patients with non-urgent conditions to make alternative arrangements. Despite this, there was no decrease in the number of usual attendances, probably because RDH has the only ED in the region. Additional linen, stores and pharmacy supplies were distributed to the ED, intensive care unit (ICU), theatres, and receiving ward. Additional equipment was borrowed from Darwin Private Hospital. Nearly 600 RDH staff were recalled by telephone cascades and deployed over the next few hours. The ED mobilised its disaster stores and augmented supplies of consumables (particularly cling wrap for temporary burns dressings, morphine, ketamine, rocuronium, tetanus toxoid, antibiotics and O Rh-negative blood). A fibreoptic intubating scope was added to the usual “difficult airway” boxes. All suxamethonium was removed from the ED to prevent a depolarising relaxant being used in error. Before the arrival of the first patients, group tutorials were held covering burns dressings, escharotomies, and fluid and airway management. The lines of command were made explicit. The ICU occupancy could, fortuitously, be reduced to one patient before the Bali patients’ arrival. The ICU is designed for eight patients, but can accommodate 12 ventilated patients. Four additional beds were created in the adjacent coronary care unit and another four in Darwin Private Hospital. Six ICU bays were set up as emergency primary receiving resuscitation bays in the event of ED saturation. All hospital albumin supplies were sent to the ICU and more were ordered from the Red Cross Blood Bank. Four operating theatres were made available for bomb victims, with a fifth theatre kept for other emergencies. The rostered staff of the day prepared three of the theatres with invasive monitoring, fluid-warming devices and forced-air warmers. Equipment limitations meant the fourth theatre was set up for less critically ill patients. At 15:00, the first of five Hercules C-130 aircraft from RAAF Base Richmond, near Sydney, landed in Darwin before proceeding to Bali. Two specialists (an anaesthetist and a general surgeon) from RDH joined the flight with surgical supplies. The familiarity of the Darwin-based medical Army Reservists to both civilian and military sectors facilitated the rapid acquisition of additional supplies and equipment in Darwin. The Australian Defence Force (ADF) team’s involvement has been previously described.1 At 18:00, RDH was ready to receive patients. There followed an 8-hour wait until the first arrivals. Patients arrive at Darwin airportAt Darwin airport, the Site Medical Commander (the Director of Anaesthesia) headed a hospital team of two anaesthetists with ICU experience, two ICU nurses and two aeromedical retrieval doctors. This team met each of the Hercules C-130 aircraft (which were carrying between 11 and 22 patients), and the Site Medical Commander received handover from the aircraft’s ADF medical staff. This too was facilitated by many ADF staff being known to RDH staff (reservists working in RDH or living locally). The Site Medical Commander was in mobile phone contact with the ED Director for a brief handover of the critically ill patients. He also liaised with the ambulance controller to maintain ambulance departure rates so that one patient arrived at the ED every 3–5 minutes. Just two patients were directly transferred interstate from the airport by interstate retrieval teams. Most patients required stabilisation before further transport could be considered. The RDH staff accompanied the most critically ill patients to RDH, continuing resuscitation in transit to the ED, where they led ongoing resuscitation efforts and followed through to ICU or operating theatres. This streamlined care by obviating the need for multiple handovers. Patients arrive at RDHOn arrival at the ED, each patient was triaged by the ED Director with the assistance of a senior ED nurse. Four patients were triaged directly to ICU when ED capacity (18 simultaneous resuscitations) was approached. No patients were triaged directly to the operating theatre or to palliative care only. Understandably, minimal documentation arrived with the patients. Some patients remained unidentified for many hours. Patient tracking (with a team of three ED receptionists) was initiated at triage. Each patient was tagged with a preset Hospital Record Number, and a pre-made disaster documentation pack was attached to the patient’s bed. The disaster pack contained pre-printed labels, trauma sheets, burn charts, medical record continuation sheets, blood and radiology forms and a labelled bag for clothing and belongings. A fourth member of the patient tracking team consolidated the computer record for each patient before the patient left the ED. The ED was divided into four clinical areas and six teams (Box). The clinical areas comprised resuscitation (6 beds), majors (6 beds), minors (6–10 beds in an adjacent outpatient area) and a fourth area for “non-Bali” patients. An ED consultant led each of the disaster receiving areas. It rapidly became apparent that there were no “walking wounded” patients. One man with 50% burns was triaged to the minors area when there were 12 more seriously injured patients already occupying the resuscitation and majors beds. ED junior medical staffing was augmented with residents and registrars from non-ED areas to create 18 receiving teams. Medical students were used to provide a delivery service between areas, assist with investigations and look up results, and to help compile complete and accurate medical records for each patient. Important assistance was also provided by a floating general surgeon, orthopaedic surgeon and radiologist, facilitating rapid decision making. After being assessed and resuscitated in the ED, patients were reassessed by surgical teams on entry to the receiving ward. It quickly became apparent that these teams were becoming overwhelmed, and a blanket referral was made to the hospital’s physicians for assistance. Four physician-led “metabolic” teams were rotated through the receiving ward, re-assessing, continuing fluid resuscitation and detecting some missed injuries.2 Despite ongoing resuscitation, two patients initially sent to the receiving ward were promptly identified by the medical teams as requiring ICU transfer. Twenty ICU admissions resulted from the disaster. Offers of assistance came from interstate doctors in Darwin, but it was difficult to find tasks for them, and at times crowding in the ICU from staff without tasks made management more difficult. In contrast, late on the evening of 13 October a requested Royal Adelaide Hospital specialist burns team arrived. They immediately fitted into our teams and performed surgical burns care unstintingly for the next 24 hours, before returning to Adelaide to continue work on Bali victims. Patterns of injury and resuscitative proceduresTwenty-eight of the 61 patients seen in RDH had major trauma (Injury Severity Scores of 16 or greater). The full range of blast injury sequelae were seen, including severe burns, missile injuries from shrapnel, limb disruption and pressure-wave injury to ears, lung and bowel. Several patients had undergone surgery in Bali, including escharotomy, amputation, laparotomy and suturing of blast wounds (which subsequently were laid open owing to overt infection). Only patients with injuries deemed of immediate surgical importance underwent surgery in Darwin. Fifty-five escharotomies were performed (mostly in the ED and ICU), and, in the operating theatres, 43 other surgical procedures (on 20 patients) were performed, using 50 hours of theatre time. Three patients arrived intubated from Bali, a further 12 patients were intubated in RDH: two in the ED, four in the operating theatre and six in the ICU. Most were difficult intubations because of facial and airway burns and oedema. Suboptimal fluid resuscitation before arrival may have been fortuitous in maintaining patent airways, as increasing airway oedema with fluid resuscitation in RDH necessitated expert airway skills and ventilatory support that may not have been available in Bali. Despite fluid resuscitation, three patients with blast injuries required haemofiltration because of severe acidosis, rhabdomyolysis and rising serum potassium levels. Evacuation to specialist burns unitsOnce the extent of the disaster was known, it was evident that patients would need to be evacuated from Darwin to specialist burns units throughout the country. No single hospital in Australia has the capacity to effectively manage 61 patients with severe burn and blast injuries. A teleconference between RDH and representatives from the Commonwealth and state health departments was held on Monday, 14 October, at 14:00 to coordinate the mobilisation of resources. The RAAF would evacuate the ward patients to their home states in Hercules C-130 aircraft. Critical care trained retrieval teams from Queensland, New South Wales, Victoria, South Australia and Darwin evacuated ICU patients to interstate burns units. Within 24 hours of the initial teleconference, 14 ICU patients were evacuated. Three additional patients were evacuated to interstate burns units over the next few days. The Darwin ambulance service was pivotal in the ICU evacuations. The ward patients were evacuated by four RAAF flights of about 10 patients each, with 2 hours to transport and load each flight. The flights went to Perth, Brisbane, Sydney, and Melbourne (via Adelaide). The first C-130 flight, at 24:00 on Monday, 14 October, also carried two ICU ventilated patients. In total, 48 patients were evacuated from RDH. The evacuation was successful in achieving the aim of sending patients safely to definitive burns care, in most cases in patients’ home states. CommunicationOf critical importance in all phases of the response, from Level 1 (Alert) to Level 4 (Stand Down), was communication. While our emergency procedure manual clearly outlined communication protocols, as an offshore external disaster Bali presented a number of unique challenges. From the earliest phases, communication was established with the Northern Territory External Disaster Committee and with national disaster coordinating bodies. Within the Northern Territory, although most of the activity occurred at the hospital and the airport, a central disaster command centre was established at the police headquarters, with the task of assisting in the coordination of the police, fire and emergency response, and local government and non-government agencies. From a federal perspective, communications needed to be maintained with various organisations, including the Australian Defence Force, the Commonwealth Department of Health and Ageing, the Australian Customs Service and the Australian Federal Police. Initial information about the extent of the disaster was confused and inaccurate. The most accurate reports were those conveyed directly to the hospital from Bali. RDH army reservist medical officers were deployed to the disaster site on the first flights, resulting in improved information flow. Direct communication within the hospital quickly exposed the pitfalls of electronic mail (too busy to check), mobile telephones (lack of reception) and land lines (not mobile), and revealed the future potential benefit of “hands free mobile communications devices” between key individuals. Directors of departments met in the control room every few hours, and this enabled effective anticipation, flexibility of planning, dissemination of information, and resource management. Given the unique nature of the event, the hospital became a centre of national and international media convergence. The response involved round-the-clock media management, additional security, cleaning, catering, administrative and engineering services to deal with a range of contingencies. Relatives and friends of those in Bali required a constant, up-to-the-minute information service. An RDH hotline was manned by finance staff and administrative officers. Psychological aftermathOverview debriefing sessions were centrally organised for all staff, starting on Tuesday, 15 October. These were run initially by lead clinicians, and continued by the hospital counselling service, until all involved staff within and outside the hospital had been given an opportunity to attend. In debriefing staff, a cognitive approach was taken to dealing with acute stress disorder3 after the event, in the realisation that we were unlikely to be able to affect long term rates of post-traumatic stress disorder.4 Sessions aimed to put team efforts in perspective, so that people were able to see their role in the overall disaster management process. Focus was placed on coping with normal feelings of sadness and loss. Small group sessions were also held in all workplaces to give work colleagues the opportunity to share their feelings and coping strategies. It was also important for staff to get progress information on patients for whom they had cared. Formal and informal debriefing continued for four weeks, during which time a sense of camaraderie and achievement developed. This was helped by messages of appreciation from other hospitals, professional bodies, people from all over Australia and the victims and their families. Patient outcomesAt the time of writing, it is our understanding that, of the 61 patients retrieved to RDH, one died in RDH, three died after interstate transfer, and one remains hospitalised. The other 57 patients have been discharged home. It is our opinion that the survival rate is higher than expected given the nature of the injuries, the environment of the disaster and the time taken to delivery of definitive care. The successful outcome is attributable to teamwork at every link in the chain of care from Bali to the eventual discharge of patients. One of the defining experiences of those 62 hours was the level of teamwork between organisations, departments, professional groups and individuals. It is a rare privilege to work in an environment completely stripped of hidden agendas and professional boundaries. ConclusionsEffective federal command, control and communication for multijurisdictional disasters is crucial, and worked reasonably well in the Bali evacuation. However, these experiences must be built upon. An Australia-wide disaster plan should be reworked in the light of the Bali experience, especially for remote and offshore areas. In particular, the military–civilian interface needs development; there needs to be central coordination of non-government retrieval teams (especially in the initial response); and lines and methods of communication need reinforcement. The concept of a “forward general hospital” to resuscitate injured evacuees is an established military model and worked well in this operation. The RAAF is the only organisation in Australia with the capability to evacuate large numbers of injured by air, and should be included in disaster planning for remote Australia. If a model of a “forward general hospital” is accepted for remote areas, then these hospitals should be designated and funded for the task. If there is no available forward general hospital, the Australian Defence Force has the capability to airlift a temporary tent hospital close to the disaster site, and this should be included in the disaster planning for those areas. In disaster medicine at all levels, from federal government to individual emergency departments, detailed plans are in place for most contingencies, but these are rarely tested beyond tabletop exercises. In our experience, tabletop exercises are of limited value, as they only identify theoretical problems in communication, equipment, personnel availability and timing — real problems can remain hidden. Disaster exercises with mobilisation of assets and “real time” communication should be set as the benchmark for testing disaster plans. Such exercises, especially at the complex interorganisational interfaces, require funding. In some ways, the Australian Bali response was straightforward — delayed patient arrival, single retrieval agency, single receiving hospital. If a bomb exploded in a crowded Australian nightclub, the required immediate response would be infinitely more complex. RDH has acted as the advanced receiving hospital in Australia’s largest-ever offshore disaster requiring urgent evacuation. It recognised its limitations and acknowledged the need for assistance immediately, safely disseminating a large number of patients to home bases after clinical stabilisation. Panoramic view of the emergency department (ED), and schematic of the ED command structure

Didier J Palmer FRCS, FFAEM, FACEM · Dianne Stephens FANZCA, FJFICM · Dale A Fisher FRACP · Brian Spain MRCA, FANZCA · David J Read FRACS · Len Notaras LLB, BMed, MHA

Objective: To determine the effect on cardiac arrests and overall hospital mortality of an intensive care-based medical emergency team.Design and setting: Prospective before-and-after trial in a tertiary referral hospital.Patients: Consecutive patients admitted to hospital during a 4-month “before” period (May–August 1999) (n = 21 090) and a 4-month intervention period (November 2000 –February 2001) (n = 20 921).Main outcome measures: Number of cardiac arrests, number of patients dying after cardiac arrest, number of postcardiac-arrest bed-days and overall number of in-hospital deaths.Results: There were 63 cardiac arrests in the “before” period and 22 in the intervention period (relative risk reduction, RRR: 65%; P < 0.001). Thirty-seven deaths were attributed to cardiac arrests in the “before” period and 16 in the intervention period (RRR: 56%; P = 0.005). Survivors of cardiac arrest in the “before” period required 163 ICU bed-days versus 33 in the intervention period (RRR: 80%; P < 0.001), and 1353 hospital bed-days versus 159 in the intervention period (RRR: 88%; P < 0.001). There were 302 deaths in the “before” period and 222 in the intervention period (RRR: 26%; P = 0.004).Conclusions: The incidence of in-hospital cardiac arrest and death following cardiac arrest, bed occupancy related to cardiac arrest, and overall in-hospital mortality decreased after introducing an intensive care-based medical emergency team.

Rinaldo Bellomo MD, FJFICM · Donna Goldsmith RN · Shigehiko Uchino MBBS · Jonathan Buckmaster FJFICM, FANZCA · Graeme K Hart FJFICM, FANZCA · Helen Opdam FJFICM, FRACP · William Silvester FJFICM, FRACP · Laurie Doolan FANZCA · Geoffrey Gutteridge FJFICM, FANZCA

The medical emergency team (MET), which may be summoned by anyone in a hospital to treat a patient who appears acutely unwell, has been generally accepted as scientifically rational, with no adverse clinical outcomes and only modest resource requirements. Despite this, many centres appear to be awaiting “gold standard” evidence of its effectiveness. We suggest that the quest for evidence is providing scientific justification for institutional inertia, and that further delay in implementing this system may even be unethical. We propose that decisions about changes in healthcare should consider scientific rationality, clinical reasonableness and resource implications, as well as evidence and ethical implications. A medical emergency team (MET)1 can be simply described as a cardiac arrest team with changed calling criteria. Anyone in a hospital may summon the team to a patient who appears acutely unwell, even if the patient has not actually had a cardiac arrest. The introduction of a MET may be accompanied by education on better recognition of acute illness, and an ongoing audit and education process. There is an implied and unquantified increase in the workload of the intensive care unit (ICU) staff, and a need for them to shift the focus of their work (at least temporarily) outside ICU. The in-hospital response to acute illness has been shown to be suboptimal.2 As a remedy, the MET system appeals to many, but has been the subject of ongoing debate. There have been no suggestions that there may be adverse clinical outcomes from a MET; rather, the concept has been challenged on the basis of the quality of the evidence.3 In this age of evidence-based medicine (EBM), such a challenge is justification for a pre-emptive halt to change, while evidence is accumulated. Possible resource implications have also been a point of discussion.4 Perhaps the most important (though unstated) factor preventing implementation of the MET system is that it represents a change to established hospital systems, hierarchies, and departmental responsibilities. In this regard, we feel that the quest for evidence has provided scientific justification for institutional inertia. New evidence for the MET systemThose who have been following the debate about the possible benefits of the MET in hospitals will welcome the study by Bellomo and colleagues5 in this issue of the Journal. In a major teaching hospital, introducing a MET was associated with a 65% reduction in cardiac arrests. Perhaps more surprisingly, there was a 26% reduction in the overall hospital death rate, equivalent to three lives per 1000 admissions. The authors did not limit their study to patient outcomes, but also considered some resource implications of the MET system and characterised the interventions by the MET. The increased workload does not appear to be excessive. Interestingly, most interventions appeared relatively “simple”, a finding somewhat reminiscent of that in a study of interventions by a hospital trauma team.6 Are patients dying while we wait for evidence? The results of Bellomo et al support the findings of others,7 and appear to strongly support the MET system. However, those who enjoy academic disputation should not lose heart — there are plenty of opportunities to dispute some aspects of the study, and the MET system generally. This ongoing controversy may also teach us much about the possible ethical implications of misuse of the concepts of EBM, and the dangers of attempting to base decisions about the delivery of medical care solely on “evidence”. The limits of evidence-based medicineEBM may be misused in scientific debate. Desire for scientific certainty and enthusiasm for scientific rigour may lead to inappropriate discounting of anything less than Level 1 evidence. The more rigorously EBM is applied, the less the evidence that the intervention being studied is effective — the “stainless steel” law of evaluation.8 This can lead to an apparent inability to prove anything, so that EBM produces a lot of “negative” outcomes. These limitations have been well recognised by Sackett et al9 and others.10 Despite this, there remains a widespread perception that EBM requires high-level evidence, such as randomised controlled trials. It is easy to misconstrue the resulting absence of evidence of benefit as being evidence of absence of benefit. The conclusions drawn from examining the evidence can be determined by the framing of the question and the standard of proof required — both of which can be controlled by those with established power or authority. The EBM website, Bandolier, comments: “The trouble is that people use phrases like ‘evidence-based medicine’, or ‘meta-analysis’ or ‘systematic review’ as some form of talisman. Attach one of these phrases to a point of view and an argument is won!”.11 Armed with the talisman of EBM, opponents of change can point to lack of evidence, or, if evidence is abundant and homogeneous, to weaknesses in study design. With apparent impartiality, other, less convincing reasons for conservatism may be concealed. Earlier in the ongoing MET debate, Buist et al reported on the introduction of a MET,7 with similar results to the study by Bellomo and colleagues. The extensive correspondence that the article by Buist et al generated drew attention to confounding factors, lack of applicability in other settings, failure to describe a mechanism of benefit, the use of historical controls, the possibility of a Hawthorne effect, and even accused the British Medical Journal of using an inaccurate and sensational cover title and a fake photo.12 Many of these criticisms are justifiable in (inappropriately rigorous) EBM terms, but we may be seeing the “stainless steel” law of evaluation at work — the more rigorously the criteria for EBM are applied, the less the evidence that the intervention is effective. Ellis (and Sackett) et al recognised the limitations of EBM in regard to life-saving treatment in emergency settings.13 In 1995 they acknowledged that certain interventions were “self-evident”, defined as interventions that, if omitted, would do more harm than good. “Face validity” may be accepted on the basis of “convincing non-experimental evidence”. This must be possible if innovation in acute, life-saving medicine is to continue. Ethical aspects of EBM misappliedThere have been a number of recent critiques of EBM and ethics, including some by Australian authors.14-16 Many of the issues raised, including funding and service decisions, and impact on research activity, are of some relevance to the MET controversy. Enthusiasm for EBM has grown at a time of increasingly overt economic constraint in healthcare. In this setting, EBM has been used as a justification for rationing decisions. At a national level, politicians have proposed that health funding should follow evidence (as defined by EBM).17 At a hospital level, “lack of evidence” may provide a useful justification to avoid shifting funds to facilitate system change, particularly for changes (such as a MET) that may result in “turf wars”. Regardless of funding, “lack of evidence” may provide service managers or clinician leaders with a justification to avoid involvement in service activity they would prefer to avoid for reasons unrelated to patient welfare. Uncritical application of EBM may also change the “respectability” of research or other activity that is not organised in the EBM paradigm. This may divert scarce resources (dollars, intellectual energy and enthusiasm) into research involving large randomised controlled trials. In many areas of healthcare, greater improvement in patient outcomes could be achieved by locally focused effort, based on quality improvement or process redesign methodology. It is interesting to speculate on what else could have been achieved with the funds, energy and intellect that have been and are being expended on research to produce evidence about the MET system. Implications for MET implementationMost of the foregoing discussion may seem to be of interest to philosophers, but only a diversion to clinicians. But consider the implications of the “quest for evidence” with regard to the MET. The MET concept was established at Liverpool Hospital, Sydney, in February 1990. Reports of the initial results, and experience with the MET, were presented at various conferences after 1991, and formal publications in peer-reviewed journals were produced after 1995. The concept was generally accepted as a scientifically rational and clinically reasonable response to the challenge of acute in-hospital illness. No adverse clinical outcomes have been suggested, and the resource requirements for the MET system are modest. Many would suggest that in a “reasonable” health system the MET system would have been introduced generally by (say) 1997, with appropriate audit of the effects of implementation. In fact, despite attracting international interest in the concept, introduction of the MET system in Australia has been patchy (about 25% of hospitals with ICUs). Many centres appear to be awaiting evidence — in particular, the multicentre trial of the concept sponsored by the Australian and New Zealand Intensive Care Society (the MERIT study) currently being conducted. But if the results of the study by Bellomo et al are extrapolated across Australia, introducing the MET system nationwide would prevent some 5000 hospital deaths annually. Could it be that thousands of Australians have died waiting for evidence to be collected to justify an intervention that is scientifically rational and clinically reasonable, with modest resource implications? Appropriate evidence-based decision-makingAll changes in healthcare have some risk of adverse outcomes, cost implications, and, once implemented, may be difficult to reverse. Clearly, decision-making must be based on something other than intuition or whim. It is appropriate to require some level of evidence for any decision (whether to change or to not change). But in some areas of medicine, it is unrealistic to ever expect evidence approaching the “gold standard”. In these areas, asking for “gold standard” evidence may be mischievous. We propose that decisions about changes in healthcare should consider three Rs and two Es. Is the proposal scientifically rational? Is it clinically reasonable? What are the resource implications? Is there evidence to guide our decision? What are the ethical implications? The three Rs should allow the proposal to be broadly categorised on the basis of risk (including cost) and benefit. The requirement for evidence should be proportional to the apparent risk and benefit. For interventions with a high risk (cost) and marginal benefit, particular rigour may be worthwhile in assessing the evidence. Recent examples of such interventions include activated protein C18-20 and cyclooxygenase-2 (COX-2) selective inhibitors,21,22 in which evidence was produced to support the intervention, but the cost of the evidence-based decision was high for a marginal benefit. If the evidence was even slightly flawed, the conclusion could have been very different. Conversely, in the case of interventions with high apparent benefit and low risk (including cost), it may be more illuminating to rigorously examine the motivation for opposition to the change, rather than accept as justified the demand for better or more evidence. We would suggest that the MET system fits the latter category. ConclusionThere is no doubt that the “best available evidence” is an important component of medical decision-making. EBM should be seen as a powerful method to identify the best available evidence to assist decision-making. However, EBM is not an impartial or value-neutral force in modern medicine, and has as much capacity for abuse as any other double-edged sword forged by science. EBM should not be enlisted as a tool to prevent healthcare changes that may benefit patients but are uncomfortable or challenging to the established order. In many areas of medicine, when considering possible interventions that are rational, reasonable, and with modest resource implications, it is appropriate to implement change without “absolute” evidence. It may even be unethical to delay change while inappropriately demanding more evidence. How many people should be allowed to suffer or die in the absence of “Level 1 evidence”, when reason suggests change, and our duty of care demands it?

Ross K Kerridge MB BS, FRCA, FANZCA · W Peter Saul MRCP, FRCA, FFICANZCA

Necrotising arachnidism should be a diagnosis of last resort The article by Isbister and Gray (page 199),1 documenting 130 confirmed cases of bites by white-tail spiders, will, we hope, become one of the last acts in a prolonged and sad medical fable in Australia, regrettably now exported beyond our shores.2 In 1982, a paper on possible spider bite necrosis in Australia was presented at the International Society on Toxinology World Congress in Brisbane,3 and followed by an editorial in the MJA in 1983.4 In 1987, Spring reported a case of severe skin damage following a presumed spider bite;5 the article and the associated editorial6 mentioned the white-tail spider. Speculation about the causative spider continued, with two “likely” candidates charged with the crime by the non-medical media,7 supported by a few in the medical community. These spiders were the wolf spider and the white-tail spider. The former was suspected partly because of evidence from Brazil, subsequently debunked, implicating these spiders in causing skin necrosis. The actual cause in Brazil has since been shown to be recluse spiders (loxoscelism).8 However, it was the white-tail spider, Lampona cylindrata, that was the principal focus of attention. Within a short time, at least a few doctors were diagnosing necrotising arachnidism caused by these spiders, and within about five years the popular association of these spiders with skin necrosis was well established. The lack of strong evidence to support this association seemed to be a triviality to be ignored. Research projects were proposed and funded to examine white-tail spider venom to understand its necrotic potential. Calls were made for governments to fund development of an antivenom. General practitioners regularly and confidently diagnosed skin lesions as “white-tail spider bite”. A few voices called “foul”. Where was the evidence to support the veracity of this new venomous scourge of urban Australia? Some confirmed bites by white-tail spiders were published, with no evidence of skin damage.9 Early research on the venom found no necrotic activity.10 The spider is native to Australia, yet most people ignored questions about the absence of cases of necrotising arachnidism in the 200 years before Spring’s article. Arachnologists questioning the validity of white-tail spider bite necrosis were also dismissed. In both the general and the medical community, the era of “white-tail spider bite necrosis” had arrived. But the evidence cast ever stronger doubt about the veracity of white-tail spider bite necrosis, despite occasional published “cases”. What was needed was a large number of cases of confirmed white-tail spider bite to clearly show the true range of its effects. Isbister and Gray’s article defines a clear and consistent pattern of clinical effects, based on a large series, with no evidence of necrosis. As the authors point out, the inappropriate diagnosis of spider bite in cases of skin damage is not isolated to Australia or the white-tail spider, but our episode is particularly disturbing, because there was never any strong evidence to link this spider with necrosis. Publication of Isbister and Gray’s article should herald the demise of the spurious diagnosis of white-tail spider bite necrosis. This will, we hope, bring an end to conditions such as basal cell carcinoma being misdiagnosed as spider bite, and to cases of feigned white-tail spider bite necrosis (where the patient inflicts skin damage with chemicals, then claims a spider bite). This does not mean spider bite never causes necrosis. Recluse spiders have clearly been shown to cause necrosis in some parts of the world, including two cases in Australia,11 where the spiders have been introduced. However, there is no evidence recluse spiders are widespread in Australia, and it would be erroneous to now label skin damage of uncertain origin as “loxoscelism” instead of “white-tail spider bite”. When presented with skin damage of initially uncertain origin, medical practitioners must look for all the many and varied non-spider-bite causes for such damage, leaving necrotising arachnidism as a diagnosis of last resort and uncertain validity after all other possibilities are excluded. Any future research into necrotising arachnidism in Australia should focus on accurately determining the cause.

Julian White MB BS, MD, FACTM

Objective: To investigate the circumstances and clinical effects of bites by white-tail spiders, including the two species Lampona cylindrata and L. murina commonly encountered by humans, and the incidence of necrotic lesions.Design: Prospective cohort study of definite white-tail spider bites. Cases were only included if there was a clear history of bite, the spider was caught and was identified by an expert.Setting: Calls to Australian poisons information centres and emergency departments.Patients: 130 patients with a definite bite by a white-tail spider from February 1999 to April 2002.Results: There were 79 bites by L. cylindrata and 51 by L. murina. Bites occurred in warmer months, 95% indoors and 75% between 16: 00 and 08: 00. The activity at the time of the bite was characteristic and the spider was encountered between bedclothes, towels or clothing. 25% of bites occurred on distal limbs. Pain/discomfort occurred in all cases, and was severe in 27%. Other effects included puncture marks (17%), redness/red mark (83%) and itchiness (44%). Systemic effects occurred in 9%. There were no cases of necrotic ulcers (97.5% CI, 0–2.8%) or confirmed infections. Median duration of effects was 24 hours (interquartile range, 1–168 hours). There were three distinct clinical patterns: pain only (21%), pain and red mark for < 24 hours (35%), and a persistent painful or irritating red lesion (44%).Conclusions: Bites by Lampona spp. cause minor effects in most cases, or a persistent painful red lesion in almost half the cases. White-tail spider bites are very unlikely to cause necrotic ulcers, and other diagnoses must be sought.

Geoffrey K Isbister BSc, MB BS, FACEM · Michael R Gray MSc, PhD

Objective: To determine the spectrum of severity and early diagnostic predictors of redback spider bites (Latrodectus hasselti ), and to examine the effect of intramuscular redback antivenom.Design and setting: Prospective cohort study of calls to New South Wales, Queensland and Western Australian poisons information centres and presentations to Royal Prince Alfred Hospital and Royal Darwin Hospital emergency departments.Patients: 68 people with definite redback spider bites in which the spider was immediately collected and expertly identified (1 February 1999 to 30 April 2002).Interventions: Intramuscular redback spider antivenom in a smaller cohort of hospitalised patients.Main outcome measures: Pain severity and duration, local effects and systemic envenomation (effects, prevalence, and persistence > 24 hours).Results: The median duration of effects was 48 hours (interquartile range, 24–96 hours). Pain occurred after all bites and was severe in 42 (62%). Forty-five patients (66%) had pain lasting longer than 24 hours, and 22 (32%) were unable to sleep because of pain. Systemic effects occurred in 24 (35%). Increasing pain over one hour occurred in 37 cases (54%), and local/regional diaphoresis in 23 (34%); both these features were highly predictive of L. hasselti bites compared with bites of other spiders. One of six patients treated with intramuscular antivenom (17%) had no pain at 24 hours, compared with two of 17 untreated patients (12%) (difference, 5%; 95% CI, –36% to +64%; P = 0.95). There was no difference in duration of systemic effects with antivenom administration.Conclusions: Most redback spider bites cause severe and persistent effects. Intramuscular antivenom appears to be less effective than previously thought and its use by this route needs review.

Geoffrey K Isbister BSc, MB BS, FACEM · Michael R Gray MSc, PhD

Objectives: To conduct a systematic review of how short-stay observation units (SOUs) affect the efficiency of healthcare delivery and the quality of services provided.Data sources: MEDLINE, CINAHL, Best Evidence and The Cochrane Library were searched for the period 1 January 1960 to 31 July 2000.Study selection: Studies were eligible if published in English and rated at National Health and Medical ...

Sue Daly RN, MN, FRCNA · Donald A Campbell MD, FRACP · Peter A Cameron MB BS, FACEM

Forewarned is forearmed Severe Acute Respiratory Syndrome (SARS) is now a global phenomenon, but it remains heavily clustered in mainland China, Hong Kong, Toronto, Singapore and Hanoi.1-5 The world is fearing a global pandemic, but it is not happening as initially predicted. Although there are some uncertainties regarding particular clusters of cases, such as the Amoy Garden Estate in Hong Kong (where about 300 people in one block of flats were affected), the primary mode of spread appears to be by infected droplets, and healthcare staff taking strict barrier precautions appear to be protected. There is some evidence that the virus is present in all body fluids, including faeces and urine, so taking precautions with waste disposal are also recommended. World Health Organization case definitions of severe acute respiratory syndrome (SARS) The WHO case definitions of SARS, revised as of 1 April 2003, for a suspected and a probable case of SARS: 6,7 A "suspected" case of SARS is a person presenting after 1 November 2002, who gives a history of high fever (> 38°C), and cough or breathing difficulty and one or more of the following exposures during the 10 days before the onset of symptoms — close contact with a person suspected of having SARS, or a history of travel to or residing in an affected area. A "probable" case of SARS pneumonia is a suspected case (as defined above), with radiographic evidence of infiltrates on chest x ray consistent with pneumonia or respiratory distress syndrome, or a suspect case with autopsy findings consistent with the pathology of respiratory distress syndrome, but without an identifiable cause. The World Health Organization case definitions of "suspected" and "probable" SARS are given in the Box. The clinical course of the disease follows a 2–16-day incubation period,4,5 with high fevers, chills, rigors and myalgia. In contrast to the WHO definition, respiratory symptoms are not prominent and many cases have presented with diarrhoea, abdominal pain and loss of appetite (unpublished observations). There are very few patients with abnormal findings on chest examination at presentation, but these changes develop in severe cases after admission to hospital.5 Laboratory tests typically show a reduced white cell and lymphocyte count, with a mild increase in the platelet count. Usually after 2–3 days of symptoms, x-ray changes become apparent. Typically, the changes are air-space consolidation, predominantly peripheral and often unifocal initially, but progressing over days to bilateral, multifocal changes. At around 7–10 days, about 20%–30% of cases deteriorate and require admission to an intensive care unit. Of these, about half require assisted ventilation. The overall mortality rate is 3%–5%, but may be higher in elderly people. Treatment has been largely empirical and usually has included an antiviral agent, such as ribavirin, and steroids.5 High-dose steroids have been effective in reducing fever and progression of x-ray changes, with the clinical response and radiological features suggesting bronchiolitis obliterans organising pneumonia as the possible underlying pathology.5,8 It is unclear whether any of these treatments alter the ultimate course of the disease. Intravenous administration of convalescent plasma has also been trialled, in the belief that antibodies may halt the progression of the disease,5 despite a theoretical risk of introducing another viral load. Currently, there are a number of possible aetiological candidates, with corona virus being the most likely;9-11 however, a metapneumovirus from the paramyxovirus group12 has also been suggested. Unfortunately, in our experience, field testing for the viruses has so far been unconvincing. It is unlikely that, in the short term, there will be a reliable diagnostic test or vaccine, although work is progressing at a rapid rate. In Australia, the response to SARS has been dichotomous — varying from panic that SARS will be another pandemic to complacency that this is another region's problem. It is likely that Australia will be less affected than countries with open land borders and crowded cities with poor hygiene control. However, the outbreak in Toronto shows that any Western city may have to manage such an outbreak.3 If this disease spreads in clusters rather than sweeps through communities, then the public-health response must be different. It is clear that hospitals and healthcare workers are particularly at risk. In Hong Kong, in the first weeks of the outbreak, 25% of patients with SARS were healthcare workers.5 The healthcare sector has to be particularly prepared, as this is most likely where a cluster will start. Revision of infection control, with meticulous attention to detail, is important. At the Prince of Wales Hospital, Hong Kong, it took three weeks to bring the secondary infections in staff down to near zero. Despite this experience, other hospitals in the region did not take heed, and many more staff in these hospitals became infected because of suboptimal infection control procedures. It is to be hoped that hospitals in Australia will learn from this experience. Screening potential cases of SARS is particularly difficult, as the signs and symptoms are vague and consistent with virtually any viral illness. Following up patients over a number of days is the only way of ascertaining whether they have SARS. The question of whether to admit all suspected cases to hospital is also an issue. If suspected cases are admitted, they may actually contract the disease in hospital. If they are discharged, they may infect their families and friends. In our recent experience of screening about 1000 people with suspected SARS, we uncovered over 100 confirmed SARS cases. We found that there was no secondary spread among the suspected cases followed at home with strict quarantine instructions. All people with confirmed SARS were admitted to hospital. Guidelines for screening high-risk contact and low-risk non-contact subjects have recently been published, although there are no good studies evaluating their utility or the quality of the supporting evidence.13 SARS will fundamentally change the interaction between primary healthcare workers and patients, in much the same way that AIDS changed the way we handle blood products, with universal precautions to protect ourselves from potential HIV infection. It is likely that, in the future, all healthcare providers in regions where SARS is endemic will use the standard droplet precautions of a mask, goggles, gown and gloves for all patient contact. SARS has the potential to totally disrupt the healthcare system of cities or states. Apart from the potential to use hundreds of general ward beds — a disaster in itself given the bed capacity of most Australian hospitals — the biggest threat is the need for intensive care unit (ICU) beds. If 20%–30% of cases required care in ICU, and a cluster of 200 cases occurred in Melbourne or Sydney, there would be little likelihood of finding 50 ICU beds at short notice. A further problem is that ICU staff are likely to contract the disease (unpublished data). If a number of staff contract the disease in an already overstretched ICU system, this may precipitate a fall in morale and staff departures. Furthermore, many nurses are of child-bearing age, and the antiviral agents and high-dose steroids used in the treatment of SARS are likely to be teratogenic. Health authorities need to think about their ability to provide "surge capacity" — not only in terms of ventilators, but also in terms of trained staff. This might include multiple-skills training for nurses and doctors working in non-intensive-care areas. Some healthcare epidemiologists have suggested that this disease is no more serious than the usual winter influenza outbreaks, and not nearly as serious as a new mutation of the influenza virus would be.14 The difference is that previously we have not seen a healthcare system paralysed for a period of months from the impact of one infectious agent. The annual reported death toll from influenza is mostly due to its impact on elderly people, who may die anyway. SARS puts young healthy people into ICU, and otherwise healthy people die. The death toll from SARS is undoubtedly higher in the elderly, and we have not yet seen what may eventuate if a SARS outbreak occurs in a retirement home. The sensible response of Australian health authorities is to remain on high alert, review infection control procedures within hospitals, develop contingency plans for a possible surge in demand for general and ICU beds, and develop an evidence-based approach to screening and quarantine procedures for potential cases.

Peter A Cameron MB BS, FACEM, MD · Timothy H Rainer MB BCh, FHKCEM, MD, FHKAM · Pieter De Villiers Smit MB ChB, FACEM

This is the first time I have felt threatened by the work that I do It begins on Tuesday afternoon, 11 March, with another bothersome call from hospital administration. They want to take over our Emergency Department (ED) observation ward because the Department of Medicine has a couple of doctors who feel ill. They think that this illness may be contagious to other staff and patients, so a ward with a separate entrance and separate air-conditioning would be ideal. I make them aware that this action would severely hamper operations within the ED and that they should manage these doctors the same way we have treated the five ED doctors who, at the moment, have some viral illness: send them home. My answer to their request: no way. A short time later, the Professor of Medicine and the hospital's CEO visit my office — a very unusual event. They say they are very concerned because not just two but up to eight medical staff and a number of nurses are febrile and feel unwell. Being a pragmatic ED doctor, I point out that we have to make sure that this illness isn't just one of the many benign URTIs we see at this time of the year. After all, about 20% of our ED attendances relate to URTIs. So, we all agree to callback 40 medical and nursing staff and have them examined that evening. If it turns out they are suffering from some unusual disease, I will be more than happy to hand over the observation ward. I go home at 7 pm in the certain knowledge that I will have a relaxed evening with my family and will turn up to work tomorrow to greet a red-faced professor, apologising profusely for trying to disrupt our emergency service. But, at 9 pm, I take a call from the medical team: they have screened the first few patients and all have high fevers and pneumonic change on chest x ray. Within hours, 20 staff are patients in the observation ward, not desperately unwell but a little anxious about what will happen next. An over-reaction?The following day, we held a meeting of all the chiefs of clinical services to discuss what we should do next. Among many of the senior people, there was a fair degree of scepticism and more than a suggestion that we were over-reacting to this mystery illness. Could it just be that influenza or mycoplasma infection was affecting a disproportionate number of our staff? An over-reaction to the usual round of spring respiratory infections? We had heard of an outbreak of atypical pneumonia in Guangzhou, but the reports were that this was now under control, although rumours suggested otherwise. Certainly, the features of the illness were typical of the reports of severe acute respiratory syndrome (SARS) in Vietnam. We decided to work on the assumption that all three of the illness clusters were related in some way. The ED staff who had been away from work with a "viral illness" were assumed to have the same disease. Despite their protests that it was just another minor illness, they were forced to come in and be admitted to hospital. More medical and nursing staff became ill, as did patients from the same hospital ward. A number of senior staff refused to come into hospital until they became very ill; this resulted in the spread of the infection to their families. Early scareDespite treatment, the condition of all the patients seemed to deteriorate over the first few days. It was not clear whether anyone was going to improve. Only five days after the illness first became apparent in our hospital, I was facing the real prospect that a member of my own staff would die. One of my residents, gravely sick, now required intensive care; even with 100% oxygen, he could not maintain adequate arterial oxygen saturations. I prepared myself for his death and let my other staff know that it was likely that he would die. Overnight, he was given high-dose steroids; he improved marginally. By some miracle, his condition continued to improve and he survived. However, at this stage of the outbreak, eight other staff from my ED, as well as over 50 other healthcare workers, were still patients in hospital. This illness looked like it could eventually involve all the hospital staff; potentially, any or all of us could end up in the ICU. Empirical experienceMedical treatment was largely empirical because the causative agent responsible for the illness was unknown to us. Patients were initially treated with oseltamivir and broad-spectrum antibiotics to cover all likely known pathogens. Ribavirin and steroids were used, but there was no way of knowing whether this was altering the basic course of the disease. With experience, it became apparent that high-dose steroids had a major impact in halting deterioration late in the illness. Managing an illness that you know little about, under the scrutiny of your colleagues (as your patients), is very difficult. The pressures on all medical units and ancillary staff were enormous. The whole medical department was involved in treating the patients, and the number of staff affected grew steadily to more than 150. After considerable negotiation with the health authorities, normal operations within the hospital were suspended. Fortunately, there was a high degree of altruism and cooperation among the medical staff; all departments contributed to both staffing (in a high-risk situation) and to the overall management of this disaster. There were daily meetings of chiefs of services and forums for regular staff. Daily, factually accurate updates were posted electronically. It was simply incredible to see staff turning up to work each day despite the fact that, in the first two weeks of this experience, each day about four or five more staff members would succumb to the illness. From Day 1, all staff wore masks and gowns but we were still getting breakthrough cases. With meticulous attention to infection control, watched over by infection control "police" in each ward, we were able to reduce this occurrence to near zero. Like a stakeoutAt a personal level, this is the first time I have felt threatened by the work that I do. Perhaps, it's a similar experience to that of a policeman on his first "stakeout", when he realises he might get shot. As a doctor, you know you are potentially vulnerable to the getting of all sorts of illnesses, but rarely a devastating, life-threatening one. I was worried about going home in case I would infect my family. When I did get home, I felt physically exhausted and emotionally drained, and didn't really want to talk to anyone. I would not and could not touch my wife or children for fear of giving them the disease. I slept in a separate bedroom; I ate separately. Clothes and fomites were washed separately and chlorine bleach was everywhere. My youngest boy developed a nervous twitch as he was told tales of the disease and harassed to wash his hands and wear a mask. Some of my colleagues began sleeping in their offices, refusing to go to their homes at all for fear of infecting their families. It wasn't a situation I could go on living with. My wife and I decided it would be easier for all of us if my family returned to Australia. A couple of weeks after they left, I realised how isolated I had become outside of my work setting. No one wanted to come near me for fear of getting the disease; any social encounters became uncomfortable. Even in the carpark, people would skirt around me to avoid close contact. There was little time off work, anyway, because of the constant meetings and service commitments occasioned by the outbreak. By strange coincidence, news of the Iraqi war was being broadcast continuously on television. Disturbing as the images of this war were, I realised that the battle we were fighting here might well have a more long-lasting, devastating impact. Missing the pointWhen I spoke with friends in Australia, I was struck by how little they had heard about the outbreak in the first weeks and how little preparation authorities seemed to have undertaken. Some "armchair experts" were even saying that it was irrelevant to Australia, just another "beat-up". In their minds, influenza was much more important. I tried to remember the last time influenza had put 250 healthcare workers into hospital, with 20% of them in an ICU. I tried to remember the last time all the ICU beds in a city had been filled by influenza cases. As far as I was concerned, these "experts" had clearly missed the point. Also, initially there seemed to be a high degree of misinformation about the symptoms, signs and mode of spread of this disease. In general, the only definite symptom was fever. In the early stages of the illness, cough, rhinitis and other URTI symptoms were actually less prevalent in the SARS group than in other patients. I believe that information being promulgated by WHO and the Centers for Disease Control and Prevention (CDC) was, in some instances, inaccurate and at other times misleading. For example, early enthusiasm surrounding diagnostic tests proved misplaced when we found only a 10% positivity rate. I felt compelled to make time for some radio and television interviews to raise awareness of SARS. Late warningsIn Hong Kong itself, I believe the authorities were initially very keen to keep the public "in the dark". This was followed by an attempt to blame the hospital (and staff) for allowing the disease to spread. Initially, for fear of creating pandemonium, no moves were made to educate the public about preventive measures. We tried, through official channels, to get these messages out; unfortunately, most officials seemed to me to be more concerned with protecting the economy and preventing panic than containing disease. Unfortunately, this response seems to have been the typical one in some other jurisdictions as well. Although the Hong Kong government has since adopted widespread public health measures, at time of writing it still maintains that there is no crisis. I do not agree; there is no obvious end in sight. More and more of the public are becoming infected. There is a high likelihood that more healthcare workers will be struck down. It is distinctly possible that if the numbers of affected patients continue to rise the whole public health system may collapse. The most likely pressure point will be the intensive care setting: with over 100 cases already requiring intensive care, it is inevitable that untrained staff will have to manage critically ill patients. Also, hospitals will have to "triage" patients, allocating intensive care beds and technology to those most likely to benefit before those with a lesser or low chance of survival. Today, despite my concerns for the community, my personal fear has receded. I feel more capable of managing this threat than I did in my first fortnight's experience of it. Although I am not 100% sure of the cause of this illness (despite the confident reports from scientists), I do understand something about its course and how to control its spread, at least within the hospital. I know that most people will survive the disease. However, I remain extremely frustrated that others are not learning the lessons that we have learnt regarding the need for stringent infection control. Most medical staff think they know about infection control and how to manage a crisis, and are unwilling to take advice. As a result of this attitude, and despite direct knowledge of our experience, I believe that about 20 staff at another hospital in Hong Kong have contracted the disease. As a healthcare worker, the likelihood of contracting an infectious disease that will kill you is usually quite small. When a new, mysterious illness smites down a whole hospital and its workers, it hits at the heart of the health system.

Peter A Cameron MB BS, FACEM, MD

To the Editor: The editorial by Cameron and Campbell on access block is an excellent summary of the causes and potential solutions to access block.1 The effects of overcrowding in the emergency department (ED) have been previously reported, including risks to patient safety, prolonged pain and suffering, and decreased clinical productivity and effectiveness.2 Access to emergency care is impaired. The fundamental problem is that while demand has increased, the capacity of the system has decreased.3 This is best exemplified by the significant reduction in hospital bed numbers. Healthcare in Western societies has been through a period of severe economic rationalisation, resulting in closure of thousands of beds in the acute hospital system. For example, in the United States, the number of medical and surgical beds declined by 18% in the period 1994–1999. From 1990 to 1999, attendances at EDs increased 15%. There have also been many aged care beds closed or changed to community-based facilities.4 It has been suggested that the problem is "a badly flawed approach to financing health care that values profits over patients."5 Spare bed capacity is essential for the effective management of emergency admissions. At least one study has found that if hospital bed occupancy rates exceed 85%, then bed crises occur.6 In fact, the Guinness Book of World Records now has a category for longest wait on a hospital trolley!7 The official record currently stands at 77 hours 30 minutes, although anecdotes report longer times. It is paradoxical that other departments within a hospital cannot exceed 100% occupancy, and yet the ED, which may contain some of the most seriously ill or injured, is allowed to exceed the safe level of 100% occupancy. The ED has always been available to help if all else fails in the healthcare system. That basic tenet is now being challenged, and the general public may no longer be able to rely on EDs for quality and timely emergency care, placing the safety of people at risk.8 In addition, Derlet has stated that should there be a major infectious disease epidemic or national catastrophe, EDs and hospitals could not accommodate the demand, undoubtedly leading to increased suffering and excess mortality.3 For all patients, increasing the capacity of the hospitals across the system (viz beds) would really make a difference.

Daniel M Fatovich

To the Editor: The series of articles concerning access block1 indicates that access block is a major health issue in this country. It is remarkable that, despite all these efforts to avoid admissions and reduce inpatient length of stay, only a few occasions of brief success at reducing ambulance diversions were described, and only one case of reducing access block (Royal Melbourne Hospital). We contend that it is now time to increase available beds. In several cases, the association between worsening access block and closure of beds was noted (Australian Capital Territory, Queen Elizabeth Hospital, Royal Perth Hospital). Available data show a steady reduction in hospital beds per thousand population in Australia, from 3.3 in 1995–96 to 2.8 in 1999–2000,2 a decrease of more than 11%. Keeping inpatient occupancy below a threshold percentage is important to controlling access block.3,4 Reducing occupancy by increasing available beds is the logical recommendation.

Peter A Roberts · Paul A Cunningham

To the Editor: I was interested in the letter by Marks et al,1 indicating that the efforts of over-worked medical staff in emergency departments to introduce patients to local general practitioners had been largely unsuccessful. A few years ago I noted the success with which this problem was handled by the emergency department management at Huddinge University Hospital in Stockholm. All patients were charged 60 krone at triage. Those who sat in the waiting room were confronted by two large electronic signs. The first listed the waiting time for the 10 most common GP-type ailments. The second listed 10 local GPs, where the consultation fee was then 50 krone, with the offer to refund their initial payment if they chose to take their business elsewhere. I was told that this was the very successful first of eight "barriers" between the emergency department door and the intensive care unit. Since the middle of last century, Sweden has been held up as a model provider of an egalitarian and "free" healthcare service. Perhaps our country could benefit from the revisions and improvements that the Swedes have made over recent decades.

Peter J Burke

Objective: To evaluate the impact of a chest-pain guideline on clinical decision-making and medium-term outcomes of patients presenting to a hospital emergency department (ED) with non-traumatic chest pain.Design: Before-and-after guideline implementation study.Setting: Bankstown–Lidcombe Hospital, Sydney, NSW (454-bed metropolitan teaching hospital), in the six-month periods before and after guideline implementation in February 2001.Participants: Patients presenting to the ED with non-traumatic chest pain who had chest-pain assessment forms completed by ED doctors, comprising 422/768 (54.9%) of those presenting before and 461/691 (66.7%) after guideline implementation.Main outcome measures: Appropriateness of admission/discharge decisions compared with decision of senior cardiologist based on guideline; death, recurrent chest pain, ED re-presentation and hospital readmission in the ensuing three months.Results: After guideline implementation, appropriate admission/discharge decisions increased significantly from 180/265 (68%) to 261/324 (81%) (difference, 13%; 95% CI, 6%–20%). The largest increase was for patients at moderate risk of death or acute myocardial infarction within six months, from 39/96 (38%) to 57/103 (55%) (difference, 18%; 95% CI, 4%–31%). Increases were seen for both junior doctors (interns and resident medical officers) (18%; 95% CI, 7%–30%) and senior doctors (11%; 95% CI, 2%–19%). Logistic regression showed that implementation of the guideline, seniority of assessing doctor and patient history of coronary disease were independent predictors of appropriate decisions. There was a significant decline in re-presentations to ED with recurrent chest pain in patients previously presenting with cardiac or possibly cardiac pain, from 46/201 (23%) before implementation to 32/247 (13%) after (difference, 210%; 95% CI, 217% to 23%).Conclusions: The chest-pain guideline resulted in a significant improvement in clinical decision-making in the ED and reduced re-presentations with cardiac/possibly cardiac chest pain.

Soufiane Boufous MPH(Hons) · Bin B Jalaludin PhD, FAFPHM · Charles H Pain FAFHPM · Susan Ieraci FACEM · Anne-Louise Gray BAppSc, PGCertMgt · Susan E Harris B Phty, MPH · Craig P Juergens FRACP · Peter W Kelleher FRACP · Linda M Dann FANZCA, FACEM

Objective: To determine the proportion of patients in Victoria treated within the British Heart Foundation 90-minute call-to-needle (CTN) time benchmark for thrombolysis of ST-elevation myocardial infarction (STEMI), and to validate the British Heart Foundation 90-minute benchmark with respect to mortality.Design: Cohort study.Setting: 20 hospitals and two ambulance services in the State of Victoria, Australia.Participants: 1147 patients with STEMI transported to hospital by ambulance and eligible for thrombolysis.Main outcome measures: CTN time, and in-hospital mortality.Results: Median CTN time was 83 minutes (mean, 93.2 min; range, 29–894 min). Median door-to-needle (DTN) time was 37 minutes (mean, 46.5 min; range, 0–853 min). 61% of patients received thrombolysis within the 90-minute benchmark. Patients with CTN times > 90 minutes had an increased risk of dying (relative risk, 1.8; 95% CI, 1.3–2.7). Factors associated with CTN time < 90 minutes were lower DTN time, prior notification of the receiving hospital and transport time less than 20 minutes.Conclusion: The British Heart Foundation CTN time benchmark is being met for 61% of eligible STEMI patients in Victoria. Strategies to reduce CTN time should be region-specific, and should include attempts to reduce DTN and to enhance ambulance–hospital communication. Prehospital thrombolysis may be appropriate for some regions.

Anne-Maree Kelly MD, FACEM · Debra Kerr BN, MBL · Ian Patrick BParamedStud, MICAcert · Tony Walker BParamedStud, GDipEd

To the Editor: This is the first report of the use of magnesium sulfate to treat Irukandji syndrome. A previously well 26-year-old commercial diver was stung on the neck by a jellyfish while collecting sea cucumbers in Barrier Reef waters off Townsville in February 2003. As is typical for an Irukandji syndrome, he was asymptomatic for about 30 minutes, after which he developed back and abdominal pain, nausea and headache. He was retrieved from the scene by helicopter and arrived in the emergency department (ED) two hours after the onset of symptoms. On retrieval he had a blood pressure of 150/90 mmHg, agitation, marked diaphoresis, piloerection and some dyspnoea. A typical carybdeid jellyfish sting mark was present on the neck. The cardiac troponin I level was elevated from the time of admission. En route and in the ED he was treated with intravenous morphine and diazepam. Skin scrapings were taken for nematocyst identification. After he had received 27.5 mg of morphine and 15 mg of diazepam, his pain settled somewhat, but abdominal discomfort, agitation and profuse diaphoresis persisted. Despite the dyspnoea, he showed no other overt clinical signs of cardiac failure. Concern with the patient's increasing hypertension (170/100 mmHg five hours after envenomation) led to his being transferred to the high dependency unit (HDU) six hours after envenomation. It was decided to try a therapeutic trial of magnesium sulfate for this patient in an attempt to control the hypertension. This decision was taken on the basis of: the unsatisfactory results of measures taken thus far, the postulated hyperadrenergic basis of hypertension in Irukandji syndrome, the known 20%–30% fall in systemic vascular resistance associated with magnesium administration in hyperadrenergic states,1 and considerable experience within the HDU with managing severe pre-eclampsia. Intravenous magnesium sulfate was administered as a loading dose of 10 mmol followed by an infusion of 5 mmol per hour. Sympathetic features and agitation resolved, and pain nearly completely resolved towards the end of the loading dose. Of note, an early reduction in the rate of magnesium sulfate infusion resulted in recrudescence of hypertension, back pain and piloerection. The infusion was uneventfully reduced to 3 mmol per hour at 11 hours after envenomation, and discontinued at 20 hours after envenomation. No adverse effects related to the magnesium infusion were noted. The patient subsequently remained well. The troponin I level rose to a peak of 6.4 μg/L, and an echocardiogram was normal at 20 hours after envenomation. Irukandji syndrome is produced by carybdeid jellyfish envenomation2 and has been shown (in animals) to be associated with dramatically elevated serum noradrenaline levels.3 Severe hypertension in Irukandji syndrome can be difficult to treat and has been associated with two deaths from intracranial haemorrhage. The origin of the extensive, severe pain associated with the syndrome is unknown. Postulated mechanisms include ischaemia from widespread small vessel vasoconstriction resulting from a hyperadrenergic state, and sodium channel opening in afferent pain fibres. Other mechanisms are equally likely. Induced catecholamine release or direct toxicity have been proposed as the cause of myocardial injury. This may produce overt, and occasionally severe, cardiac failure. Magnesium decreases both catecholamine release and sympathetic terminal receptivity to catecholamines1 via multiple sites of action, including most calcium channel subtypes (both at the cell membrane and intracellularly), as well as modifying other cation fluxes. It reduces catecholamine-induced myocardial necrosis in phaeochromocytoma (Professor M James, Department of Anaesthesia, University of Cape Town, personal communication) and is widely used in other hyperadrenergic states, such as phaeochromocytoma and pre-eclampsia.1 The apparent efficacy of intravenous magnesium in our patient suggests the need to further investigate this therapy. A larger case series, a multicentre randomised trial of magnesium sulfate administration in Irukandji syndrome and a dose-finding study are under way.

Michael A Corkeron

To the Editor: Both adult and paediatric hospital emergency departments (EDs) are subject to inappropriate use.1,2,3 Some families use the ED as a primary care provider,4,5 often claiming that they have no regular general practitioner.6 Such families may experience poorer overall health.7,8 We hypothesised that providing such families with information about GPs in their area and emphasising the benefits of having a GP responsible for their long term healthcare might: facilitate the establishment of ongoing relationships between patients and GPs; and encourage families to use GPs more as their primary source of care. We conducted a controlled trial (week-on, week-off randomisation) of families identified as having no regular GP who presented to the Royal Children's Hospital ED over four months. Information about the GPs interested in seeing children was located on a computer database. Medical staff were able to search for a GP whose surgery was close to the patient's street address. Families were provided with detailed information about the GP's practice (eg, opening times, languages spoken, etc). Parents were given a list of GPs and a map showing the locations of their surgeries, together with a letter of introduction; the families decided which GP they would attend. Families in the control group were just treated as usual. Families were then contacted after two months to see if they had visited a GP and whether regular contact had been established. Over the four months, 216 families were enrolled; 96 were allocated to the intervention group. Despite our active encouragement, the ED medical staff provided the intervention material to families in the intervention group on just 49% of occasions. We found that, two months after the initial ED visit, intervention-group families were no more likely to have established an ongoing relationship with a GP than control families (46 [38.3%] and 41 [42.7%], respectively; P = 0.5), irrespective of whether or not they received the intervention material. In summary, this single intervention was not sufficient to alter healthcare-seeking behaviour of families with no regular GP. It seems the motivation to obtain a GP lies with the family. Thus, it would seem necessary to design and deliver an intervention that addresses the beliefs of families about the roles of various facets of the healthcare system. With time and work pressures, ED medical staff may not be in the best position to provide such intervention.

Michael K Marks · Daniel Steinfort · Peter LJ Barnett

We need a coordinated approach to address the underlying problems in the health system The effects of access block on acute hospital services are most disturbingly reflected by patients on trolleys queued in emergency department (ED) corridors and ambulances circling hospitals, waiting to deliver acutely ill patients. The Australasian College for Emergency Medicine and the Australian Council on Healthcare Standards (ACHS) have defined access block for emergency patients as the percentage of all patients admitted, transferred or dying in the ED where their total ED time exceeds eight hours.1 For elective patients, access block is reflected in ballooning elective waiting list numbers and length of time spent waiting. Access block has been with us since the 1980s, but in recent years, in Australia, it appears to have become both endemic and critical across all our major cities.2,3 There is now evidence that access block causes poor patient outcomes and interferes with efficient hospital functioning.4,5 In this issue of the Journal (page 103) the impact of access block across Australia and potential solutions are outlined. Causes of access blockThe causes for this untoward development are not straightforward, but appear to correlate with major decreases in hospital bed numbers, community residential care facilities, and with changes in workforce and community attitudes. Bed numbers: In Australia, the total number of acute hospital beds has decreased over the past two decades, with a 15% decrease in public hospital beds occurring from 1995 to 2000.6 There have been concomitant decreases in inpatient length of stay, but the number of hospital admissions have also increased.7 There are now more day procedures and day admissions. Although some of these replace multiday stays, others represent new work or multiple admissions replacing a multiday, single admission.8 Concurrent with decreasing acute hospital bed numbers, access to residential care beds in the community has decreased, especially beds designated for high-dependency patients.9 This has increased demand on acute hospital services as elderly inpatients wait for long term placement or are inappropriately sent back to the community to avoid pressure on an already congested residential care system. Community-based treatments: Many patients with complex and chronic illnesses are now treated as hospital outpatients or in the community. However, when serious complications occur, patients frequently present to EDs, particularly if access to community healthcare services is not available. This lack of community support increases patient load on the acute care system. Workforce: No single person can master the high-technology solutions and complicated treatment regimens prevalent in acute care hospitals. At the same time, many elderly or infirm patients need basic nursing care, which at times is considered too mundane for highly trained hospital staff. Increasingly, the workforce model required in healthcare is team-based, with multidisciplinary input and multiple levels of expertise, even within disciplines.10,11 Training programs for doctors, nurses and allied health workers do not yet reflect this need. This imbalance between career aspirations, systemic needs and actual working environments results in dissatisfied workers or insufficient staff with necessary skills. These factors contribute to low morale, which further reduces workforce flexibility. Social changes: The demise of the extended family and changes in the demographics of marriage and childbearing have led to more elderly people living alone, and with greater feminisation of the workforce fewer people can be carers.7,12 Population projections indicate that the number of informal carers in the community (largely middle-aged women) will decline sharply as the baby boomers age and require care themselves. The default solution for many partially dependent people is referral to an acute hospital. Funding models: Payments to hospitals and healthcare providers are rigid and reward rapid treatment of uncomplicated conditions. In the community setting, payment is for episodes of care rather than continuity of care. Complicated emergencies, time-consuming conditions involving multiple medical specialties, and social issues stretch the time and financial resources required, and are dealt with piecemeal. Patients with complex or multiple problems frequently have no alternative but to attend a public hospital ED.11 Casemix payments in the acute care setting and fee-for-service models of payment in the community setting usually disadvantage patients who require longer stays and supported post-hospital care. Rigid rules around definitions such as "inpatient" versus "outpatient" treatment create financial risk for hospitals introducing innovative treatment strategies. Furthermore, public ED workloads increase as GP consultation rates in older age groups decline, along with a reduction in GP bulk billing and availability after hours.13 Increasing indemnity insurance premiums for procedural GPs and private specialists also lead to greater public ED demand. Potential solutionsSystematic management of access block is only just beginning to be discussed at a policy level. The extent of the issue is now such that a more strategic Australia-wide approach is necessary. The experiences described in this issue of the Journal show that hospitals can improve their individual performance with organisational changes. But, despite the impressive changes achieved with the outlined approaches to access block, it is apparent that our healthcare system has serious underlying problems that need to be publicly acknowledged by politicians and appropriately addressed. Workforce: Historically, the major solution to hospital access issues was to spend money and increase bed numbers by employing more staff. Recently, in Victoria, money was allocated for increased bed numbers and services, but there were insufficient staff to open more beds (see the Royal Melbourne Hospital report, page 109). Reasons for rigidity in work practice and roles within the healthcare workforce need to be explored, and, where there is no evidence to support limitations in practice, rules should be changed. Universities, clinical colleges and hospitals must work together to train healthcare professionals for the tasks required rather than for roles based on historical models. Funding: The innovative practices described in the hospital experiences were partly enabled by incentives from federal, State/Territory and hospital initiatives. The funding method can help direct healthcare services toward community needs. For example, funding hospitals for procedures, whether provided on an inpatient or outpatient basis, might allow a hospital to provide those services even when beds are not available. Casemix payments tend to favour hospitals that provide uncomplicated elective services — perhaps alternative models that encourage healthcare services to look after elderly, complicated, medical patients should be trialled. Funding that allows a hospital to experiment with new clinical pathways and not be financially penalised, such as the National Demonstration Hospitals Project14 (aimed at improved hospital service efficiency and utilisation) and the Hospital Admission Risk Program15 (aimed at decreasing hospital bed utilisation), should be encouraged. The next round of Australian Health Care Agreements should ensure balance in financial incentives between elective and emergency services. There should also be recognition of the need to better remunerate GPs for providing complex care, perhaps involving a trial of a capitated payment or managed competition model.16 Healthcare delivery systems: The central message conveyed by the experiences described in this issue of the Journal is that changing internal processes can improve access to inpatient resources. Initiatives such as medihotels, placing patients in a transit lounge before discharge, day-of-surgery admission for elective surgery, short-stay wards, and centralised bed control can all save bed-days. Encouraging clinicians to trial treating patients in different ways and objectively analysing outcomes requires leadership from clinicians and administrators. For high-volume conditions and procedures, there should be standardised treatment pathways to expedite inpatient stay. Efficient use of beds also requires accurate, transparent data collection with rapid feedback to clinicians. Many hospitals are unable to accurately account for every patient and the purpose of their continued inpatient stay. Similarly, many hospitals do not have an accurate bed census that identifies the variability in the number of beds that are open from shift to shift, nor do all have the ability to accurately count nursing sick leave rates by shift and day of the week. Residential care: It is important that use of residential care facilities is tightly controlled and residents are allocated to the appropriate level of care. However, the current problem is that patients are unable to access long term residential care facilities and are instead filling acute care beds. Reform within the subacute and residential/community care sector is necessary to improve efficiencies within the acute care sector and to provide appropriate long term care to patients. Attention to more appropriate locations to care for the small group of long-stay patients is likely to be the most efficient strategy to improve patient flow through the subacute sector. Service prioritisation: The public must become involved in the debate about which healthcare services are essential. The present rationing method is in essence a lottery — whether your ambulance is allowed to arrive at a certain hospital, or whether your elective surgery is on or off, depends on the capricious availability of beds. The healthcare system cannot provide every service, but basic emergency and elective services could easily be provided within present budgetary constraints. A more transparent and educated debate may allow healthcare providers to work in a more satisfying environment where expectations are matched with necessary resources. There remains considerable pessimism about the ability of the acute healthcare sector to deliver an effective service in the face of increasing demand and limited resources. There are solutions. However, political leadership and a coordinated national approach are necessary to resolve underlying structural issues surrounding workforce, work practice and funding.

Peter A Cameron · Donald A Campbell