Emergency medicine

A 61-year-old man was referred to our ophthalmology service 3 days after a tree branch injury to the left eye

Shivesh Varma · Yi Fan Tang · Salim Okera

Objective: To assess the analgesic efficacy and safety of single‐dose oral cannabidiol (CBD) as an adjunct to standard care for patients presenting to an emergency department with acute low back pain. Design: Randomised, double blinded, placebo‐controlled clinical trial. Setting: The tertiary emergency department of Austin Hospital, Melbourne. Participants: Patients who presented with acute, non‐traumatic low back pain between 21 May 2018 and 13 June 2019. Intervention: One hundred eligible patients were randomised to receiving 400 mg CBD or placebo in addition to standard emergency department analgesic medication. Main outcome measures: Pain score two hours after administration of study agent, on a verbal numerical pain scale (range, 0‒10). Secondary outcomes were length of stay, need for rescue analgesia, and adverse events. Results: The median age of the 100 participants was 47 years (IQR, 34‒60 years); 44 were women. Mean pain scores at two hours were similar for the CBD (6.2 points; 95% CI, 5.5–6.9 points) and placebo groups (5.8 points; 95% CI, 5.1–6.6 points; absolute difference, –0.3 points; 95% CI, –1.3 to 0.6 points). The median length of stay was 9.0 hours (IQR, 7.4‒12 hours) for the CBD group and 8.5 hours (IQR, 6.5‒21 hours) for the placebo group. Oxycodone use during the four hours preceding and the four hours after receiving CBD or placebo was similar for the two groups, as were reported side effects. Conclusion: CBD was not superior to placebo as an adjunct medication for relieving acute non‐traumatic low back pain in the emergency department. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12618000487213 (prospective).

Bronwyn Bebee · David M Taylor · Elyssia Bourke · Kimberley Pollack · Lian Foster · Michael Ching · Anselm Wong

To the Editor: The Coroners Court of Victoria made several recommendations in 2020 after a 38‐year‐old man died alone at home.1 The cause of death was determined to be sepsis in the setting of an adrenal crisis. The key coronial recommendations1 were to emphasise to the general medical community the non‐specific nature of symptoms of impending adrenal crisis (eg, fatigue, nausea, loss of appetite, vomiting),2 to record the diagnosis of adrenal insufficiency prominently as an alert in medical records,3 and to encourage endocrinologists to provide sick day or steroid stress dosing letters to patients, general practitioners, and family members and carers. The Endocrine Society of Australia (ESA) endorses these recommendations. A standard patient letter has been developed and is now available on the ESA’s Hormones Australia website.4 We strongly support medical record alerts for the diagnosis of cortisol deficiency due to Addison disease or hypopituitarism. It is crucial for doctors to have a high index of suspicion for the possibility of impending adrenal crisis in a patient with known adrenal insufficiency. The clinical syndrome evolves from acute adrenal insufficiency with symptoms of malaise, nausea and lethargy — all of which are non‐specific and may be considered part of another pathological process — to adrenal crisis, which is associated with hypotension initially manifest by postural blood pressure falls greater than 20 mmHg.2,3 Prevention involves advice on stress dosing:1 triple glucocorticoid dosing for 3 days (ie, the 3 × 3 rule),2 parenteral hydrocortisone at home (SOLU‐CORTEF Act‐O‐Vial, Pfizer) when unable to take tablets,3 and the availability of personal alerts (eg, a MedicAlert bracelet [MedicAlert Foundation], a steroid card) when the person is delirious or very unwell (Box). The incidence of adrenal crises is increasing in Australia.3 Missed cases or failure to treat them because of overestimation of the risks of glucocorticoid therapy are unfortunately too common. Box – Practical steps to reduce the risk of adrenal crisis Ensure that others are aware of the diagnosis of established adrenal insufficiency Prominent medical alert in GP and hospital medical records Patient carries either a steroid card, which lists diagnosis and glucocorticoid therapy, or uses a MedicAlert bracelet (MedicAlert Foundation) A sick day or steroid stress dosing letter should be provided by the endocrinologist to the patient with adrenal insufficiency, with a copy to their GP Encourage the patient with adrenal insufficiency to provide copies of the letter to their next of kin, close relatives or carer Have a high index of suspicion for an impending adrenal crisis Beware of non-specific symptoms of nausea, vomiting or lethargy in a patient with established adrenal insufficiency Prevent an adrenal crisis in patients with established adrenal insufficiency When unwell, follow the 3 × 3 rule (ie, three times the usual glucocorticoid dose for 3 days) and seek urgent medical attention if not improving Promptly treat an impending adrenal crisis The patient and/or carer should be trained to administer 100 mg SOLU‐CORTEF Act‐O‐Vial (Pfizer) intramuscularly* if vomiting occurs or the patient is unable to swallow tablets GP = general practitioner. * Some authorities recommend the off‐label use of a subcutaneous injection as this is easier for patient and/or carer to administer.

Peter S Hamblin · Bu B Yeap · David J Torpy

In Australia, an estimated 12.7% of patients with ST‐elevation myocardial infarction (STEMI) die or have recurrent myocardial infarctions within 30 days of diagnosis.1 Prompt reperfusion reduces morbidity and mortality, and guidelines consequently aim to minimise the time between symptom onset and reperfusion.1,2,3 Patients with chest pain may arrange their own transport to an emergency department or travel by ambulance. The risk period is shorter for patients without access to a defibrillator when they travel by ambulance, and they receive initial management more promptly. In Australia, only one in two patients with STEMI calls an ambulance.4 Characterising patients less likely to call an ambulance would inform targeted public health efforts to improve this situation. We analysed data contributed by 43 hospitals across Australia to the Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE)5 for patients with confirmed STEMI who presented to these hospitals during 23 February 2009 – 31 December 2017. We excluded patients who experienced out‐of‐hospital cardiac arrest or cardiogenic shock. We compared the clinical characteristics, time to reperfusion, and hospital outcomes, including death and major adverse cardiovascular events (MACE) — cardiac death, myocardial infarction, heart failure, or shock — for patients who arrived by ambulance or otherwise, after adjusting for Global Registry of Acute Coronary Events (GRACE) risk score6 at baseline. The statistical significance of differences in categorical variables was assessed in Rao–Scott χ2 tests and that of continuous variables in Wilcoxon rank‐sum tests. For adjusted analyses, we used multivariable logistic regression models in a generalised estimating equation (GEE) framework, adjusted for clustering by hospital. Analyses were conducted in SAS 9.4. Ethics approval for the study was granted by the Concord Repatriation General Hospital Human Research Ethics Committee (reference, HREC/08/CRGH/180). Of 2765 patients who presented with STEMI to CONCORDANCE hospitals during 2009–2017, 1616 (58.4%) arrived by ambulance and 1149 (41.6%) by other means. The median age of patients arriving by ambulance (64 years; interquartile range [IQR], 54–74 years) was higher than for the other patients (59 years; IQR, 51–67 years), and the proportions with hypertension, a family history of coronary heart disease, or prior myocardial infarction, atrial fibrillation, or stroke/transient ischaemic attack were larger (Box). Time between arrival at hospital and reperfusion (primary percutaneous intervention or fibrinolysis) was significantly shorter for patients who arrived by ambulance than for other patients (Box). After adjusting for GRACE risk score, the odds of death (adjusted odds ratio [aOR], 1.16; 95% confidence interval [CI], 0.65–2.08) and MACE (aOR, 0.89; 95% CI, 0.72–1.10) were similar for the two patient groups (Supporting Information). Our analysis of data from a large Australian registry indicates that fewer than 60% of patients with STEMI arrive at hospital by ambulance; those who do have a higher median age and larger proportions have histories of cardiovascular disease. Importantly, their median time to reperfusion is shorter than for those not arriving by ambulance, probably because STEMI is diagnosed by electrocardiography during their journey to the hospital, which facilitates priming of emergency departments (for fibrinolysis) and catheterisation laboratories (for percutaneous coronary intervention). Despite the less favourable risk profiles of patients who arrive by ambulance, their hospital outcomes are comparable with those of patients who present directly to hospital, presumably because of their more rapid access to reperfusion. Our finding that patients with STEMI who are older and have more comorbid conditions are more likely to call an ambulance is not novel,7 but does indicate that this has not changed in recent years. This underscores the value of calling an ambulance when chest pain develops, and suggest that this public health message should be more actively promoted. Box – Baseline characteristics and times to reperfusion of 2765 patients who presented with STEMI to CONCORDANCE hospitals, 2009–2017 table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Transport to hospital Characteristic Ambulance Other means P Number of patients 1616 (58.4%) 1149 (41.6%) Age (years), median (IQR) 64 (54‒74) 59 (51‒67) < 0.001 Sex (men) 1140 (71%) 933 (81%) < 0.001 English as first language 1383 (86%) 959 (83%) 0.44 Prior myocardial infarction 252 (16%) 151 (13%) 0.046 Prior heart failure 49 (3%) 27 (2%) 0.27 Prior percutaneous coronary intervention 177 (11%) 116 (10%) 0.46 Prior coronary artery bypass graft 52 (3%) 26 (2%) 0.10 Prior atrial fibrillation 96 (6%) 30 (3%) < 0.001 Prior bleeding 17 (1%) 14 (1%) 0.63 Chronic renal failure 73 (5%) 42 (4%) 0.17 Prior stroke/transient ischaemic attack 94 (6%) 32 (3%) < 0.001 Diabetes 321 (20%) 232 (20%) 0.80 Hypertension 853 (53%) 534 (47%) < 0.001 Dyslipidaemia 696 (43%) 473 (41%) 0.21 Family history of coronary heart disease 514 (32%) 477 (42%) < 0.001 Grace risk score (Fox), median (IQR) 114 (95‒135) 102 (85‒119) < 0.001 Reperfusion modality Primary percutaneous coronary intervention 919 (57%) 486 (42%) < 0.001 Fibrinolysis 434 (27%) 442 (38%) < 0.001 None 320 (20%) 273 (24%) 0.010 Hospital arrival to reperfusion (h), median (IQR) Primary percutaneous coronary intervention 1.2 (0.7‒2.1) 2.1 (1.4‒6.1) < 0.001 Fibrinolysis 0.6 (0.3‒1.3) 0.8 (0.5‒1.3) 0.002 IQR = interquartile range; STEMI = ST‐elevation myocardial infarction.

Eleanor Redwood · Karice Hyun · John K French · Leonard Kritharides · Mark Ryan · Derek P Chew · Mario D'Souza · David B Brieger

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has raised concerns of a subsequent increase in suicides,1 but limited empirical data are available on this topic.2,3 We analysed numbers of suicidal presentations (including suicidal ideation, non‐suicidal self‐injury and suicide attempts) to emergency departments (EDs) within the Gold Coast Hospital and Health Service before and since the spread of COVID‐19 in Queensland, Australia. Cases were identified from ED administrative data through relevant diagnoses, presenting problems and keywords, followed by a manual investigation of triage narratives to exclude false positive cases, such as non‐deliberate injuries or poisonings. The numbers of ED visits between January and August 2020 were compared with the projected numbers, calculated by applying an annual increase of 13.5%4 to presentations during the same period in 2019. From March 2020 onwards, a marked divergence between observed and projected numbers is noted, corresponding to the oscillations in the numbers of diagnosed COVID‐19 cases in Queensland (Box). At the peak of the pandemic, the reductions in suicidal presentations were the largest (29.8% in March and 23.6% in April 2020). Over the next 2 months, daily numbers of diagnosed COVID‐19 cases remained low and the difference between observed and projected numbers gradually narrowed (20.8% in May and 14.6% in June 2020). In July 2020, observed numbers exceeded projected numbers by 11.4%, but then declined again in August 2020, coinciding with another resurgence of COVID‐19. Between March and August 2020, the Gold Coast Hospital and Health Service had 554 less suicidal presentations than expected. The well documented negative impact of COVID‐19 on all aspects of society, including mental health,5 suggests that a substantial reduction of suicide risk during this time is unlikely. Instead, our results may reflect changes in help‐seeking behaviour, with fewer people willing to seek help for suicidality through in‐hospital consultations due to fears of contracting COVID‐19.6 Ongoing promotion of telehealth and enabling safe hospital presentations or alternatives to ED7 is therefore needed to prevent the adverse outcomes of the COVID‐19 pandemic due to delayed access to care. Limitations of this work include potential underestimations of suicidal presentations due to coding issues8 and the inability to differentiate between types of suicidal presentations. Box – Numbers of suicidal presentations to the Gold Coast Hospital and Health Service in 2019 and 2020, and numbers of daily coronavirus disease 2019 (COVID‐19) cases in Queensland, Australia Error ranges for the projected 2020 numbers are 95% confidence intervals.

Jerneja Sveticic · Nicolas JC Stapelberg · Kathryn Turner

CHRIS supported the Victorian ICU response during the COVID‐19 pandemic The coronavirus disease 2019 (COVID‐19) pandemic put an unprecedented strain on intensive care resources throughout the world. Initially in Wuhan (China)1 and then in Lombardy (Italy),2 London (United Kingdom) and New York (United States),3 demand exceeded capacity, with 10–15% of the patients admitted to hospital developing critical illness. Australia has 191 adult and paediatric intensive care units (ICUs), with over 2300 ICU beds.4 This is equivalent to 8.9 ICU beds per 100 000 population, more than the UK but fewer than Italy and the US.5,6 In late March 2020, rising numbers of COVID‐19‐related admissions to ICUs were observed throughout Australia.7 The Australian and New Zealand Intensive Care Society (ANZICS) and the Australian Government Department of Health recognised that ICU demand was unlikely to be uniform, that capacity might be exceeded in one region but not in another, and that matching ICU resources to areas of greatest need might be required. A single sentence encapsulated the approach: “Why would we let a patient die in Western Australia if we can see a spare ventilator in Sydney?” A nationwide system to monitor ICU demand and capacity in Australia A nationwide dashboard of ICU activity, the Critical Health Resources Information System (CHRIS), was rapidly developed as a collaboration between Telstra Purple, Ambulance Victoria, ANZICS and the Australian Government Department of Health. All adult and paediatric ICUs (public and private) in Australia were instructed to enter data twice daily. This manual data entry typically took 5 minutes. Each ICU was immediately able to see patient numbers and resources available within every ICU in their region and also see an aggregate summary of all ICUs in Australia. CHRIS was available to all state and territory health departments, to all patient transport and retrieval agencies, and also to ICUs in New Zealand. The system went live on 1 May 2020, after 26 days of development. Three weeks later, 184 out of 188 eligible ICUs (98%) in Australia were contributing data. The ICU response to the second wave of COVID‐19 in Victoria After a decline in severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infections throughout Australia, notifications rose again in Melbourne at the end of June 2020.8 In response, ICU directors from the lead hospitals of the nine designated Victorian health care clusters commenced a daily morning meeting with representatives from Ambulance Victoria, Safer Care Victoria and the Victorian Department of Health and Human Services. The group committed to maintaining standards of care expected under normal (non‐pandemic) conditions and to achieving this by proactively transferring patients (with or without COVID‐19) to another ICU if delivery of care was compromised by high local demand. Decisions to transfer patients were informed by data from CHRIS. Pre‐existing critical care transfer systems run by Ambulance Victoria were used. From the beginning of July to the end of September 2020, there were 237 ICU admissions with COVID‐19 pneumonitis, of which 210 (88%) occurred in July and August. Admissions were predominantly to public hospitals in north‐western Melbourne.9 The rapid and localised nature of presentations meant that it was faster to transfer patients to ICUs with vacant capacity than to open and staff additional beds, despite physical ICU bed spaces being available. Transfers from the emergency department or ICU at the four north‐western metropolitan hospitals alone accounted for 35% (46/133) of all critical care transfers in Victoria during July and August. Spare ventilators were available at all sites on all days. On six occasions in August, there were more than 140 ventilated patients (with or without COVID‐19) in Victoria. On each of these days, there were more than 500 spare ICU ventilators available (Box 1 and Supporting Information, graphic 1 in the video). Despite individual hospitals indicating transient increases in ICU bed numbers, there was no overall increase in open staffed ICU beds. As COVID‐19 cases rose, so too did numbers of critical care staff unavailable due to COVID‐19 exposure or illness, with 15 consecutive days when there were more than 60 staff unavailable (Box 2). Lessons learned CHRIS provided real‐time data on ICU activity and capacity. In addition to facilitating the transfer of critically ill patients, CHRIS also enabled early diversion of ambulance presentations to emergency departments at hospitals where ICUs had capacity. These approaches were integral to ensuring standards of care were maintained by clinicians, retrieval agencies and the Victorian health department. At the same time, there was visibility to the Australian Government Department of Health, which would, if required, coordinate a national response to overwhelmed ICU services. Although several individual ICUs came under strain, retrieval and critical care systems in metropolitan Melbourne were not overwhelmed. Strategies to redistribute critical care demand are likely to have contributed to high survival rates for ventilated patients with COVID‐19 in Victoria.9 Timely transfers to ICUs with open available beds could be facilitated. Availability of staff was more important in determining capacity to deliver care than availability of ventilators. The role for CHRIS in the future The local application of a national tool (CHRIS) for real‐time display of ICU activity and resources was a key component of the response to the COVID‐19 pandemic in Victoria. CHRIS has the potential to augment existing ICU monitoring systems. The tool may also assist in the response to local and national public health emergencies, such as mass casualty events, bushfires10 or thunderstorm asthma.11 Automated linkage of CHRIS to existing state‐based and national systems should be investigated. In addition, it may have potential use in monitoring health policy impacts more broadly. Box 1 – Snapshot of the Critical Health Resources Information System (CHRIS) summary page for Victoria during August 2020 ACT = Australian Capital Territory; COVID‐19 = coronavirus disease 2019; ECMO = extracorporeal membrane oxygenation; HDU = high dependency unit; ICU = intensive care unit; NSW = New South Wales; NT = Northern Territory; NZ = New Zealand; QLD = Queensland; SA = South Australia; TAS = Tasmania; VIC = Victoria; WA = Western Australia. Box 2 – Number of ventilated (dark blue) and non‐ventilated (light blue) patients in Victorian intensive care units and the number of critical care staff unavailable to work due to coronavirus disease 2019 (COVID‐19) exposure or illness (green dots), listed each morning in the Critical Health Resources Information System (CHRIS) LOWESS = locally weighted scatterplot smoothing.

David Pilcher · Nicholas R Coatsworth · Melissa Rosenow · Jason McClure

An emergency imaging pathway based on local and international guidance tailored to the Australian health care setting Imaging in coronavirus disease 2019 (COVID‐19) is primarily helpful in diagnosing COVID‐19‐related complications and identifying alternative diagnoses that may explain a patient’s presentation. It can also be useful in the risk stratification of patients by identifying the presence and severity of comorbidities.1,2 Imaging is of limited use in screening for COVID‐19 in asymptomatic individuals, and in many cases where COVID‐19 symptoms are mild.1,3 Indiscriminate use of imaging in patients with confirmed or suspected COVID‐19 not only exposes the patient to unnecessary radiation but also represents an unnecessary infection risk and logistic demand for medical imaging departments. Existing international COVID‐19 imaging pathways have been derived in clinical environments significantly different from Australia, often where there is high COVID‐19 prevalence and constrained resource availability. Some centres preferentially use chest x‐ray, whereas others perform various types of computed tomography (CT) imaging of the chest. There is also inconsistency in the reporting of imaging studies in suspected or confirmed COVID‐19, with some reports following traditional didactic format, and others using synoptic template reports as recommended by a variety of medical bodies.4,5 Here we describe an imaging pathway developed at the Royal Adelaide Hospital, the designated COVID‐19 hospital in South Australia. This pathway aims to outline the imaging indications, technique and reporting of chest imaging in an emergency setting, at a time of low COVID‐19 prevalence. We incorporate current available international pathways and best practice guidelines for emergency imaging of COVID‐19 patients into a simple pathway relevant to Australian practice. Imaging pathway development We reviewed consensus and position statements from the Royal Australian and New Zealand College of Radiologists, the Australian and New Zealand Society of Thoracic Radiology, the Fleischner Society and the British Society of Thoracic Imaging. Recommendations pertaining to high COVID‐19 prevalence environments and resource‐constrained environments were modified to suit a scenario of low prevalence. When local guidelines conflicted with international organisations, priority was given to local recommendations on the basis of relevance. Recommendations were subsequently integrated into a clinical imaging pathway in consultation with local specialists in radiology, emergency medicine, general medicine, respiratory medicine and infectious diseases (Box). Reporting terminology The pathway incorporates standardised reporting terminology for patients with COVID‐19 as recommended by the Australian and New Zealand Society of Thoracic Radiology.5 Categorisation of study findings as “normal,” “indeterminate,” “typical” or “other diagnosis favoured” improves report clarity and creates actionable imaging outcomes. Appropriate use of CT The main role of CT in this pathway is to exclude complications and alternative diagnoses in patients with confirmed or suspected COVID‐19. The pathway prompts clinicians to consider CT for patients who are hypoxic (or have an oxygen requirement) and who have a chest x‐ray that is either “normal” or “indeterminate for COVID‐19”. In this instance there is a clinicoradiological discrepancy, and either a complication (such as a pulmonary embolus) or an alternative diagnosis is suspected. In keeping with British Society of Thoracic Imaging guidance, a low‐dose unenhanced CT of the chest is the CT scan of choice, with strong consideration given to an additional CT pulmonary angiogram.4 There is accumulating evidence that patients with COVID‐19 are abnormally prothrombotic, and conventional clinical decision rules and blood tests (especially D‐dimer) may not be applicable.3 Clinicians should have a lower threshold than usual for performing a CT pulmonary angiogram. The unenhanced CT functions primarily as a baseline, as the presence of intravenous contrast can artifactually simulate ground glass. Whenever possible, the non‐contrast CT scan and the CT pulmonary angiogram should be performed on the same occasion to minimise infection control risk and operational demands on medical imaging departments. Baseline imaging for patients at risk of deterioration Patients with comorbidities are recognised as being at higher risk of deterioration. Defined risk factors vary between institutions but include older patients, requirement for oxygen supplementation, significant comorbidities (especially cardiac or respiratory) and immunosuppression. The consensus statement from the Fleischner Society supports imaging in patients who have a positive test result for COVID‐19 and risk factors for disease progression, regardless of their clinical status. The use of imaging in this situation is to establish a baseline for future comparison and determine the extent of comorbidities. Imaging may also inform the intensity of follow‐up monitoring, either in the community or an inpatient setting.1 Incidental findings suspicious for COVID‐19 Although there are no radiological findings pathognomonic for COVID‐19, there are radiological findings commonly associated with infection.5 When imaging findings typical for COVID‐19 are seen in a patient who is not suspected of having infection, the pathway prompts the radiologist to discuss the findings with the referring emergency physician. Patient isolation and COVID‐19 testing may be required. This is intended as a safety net for patients who may not be identified by current clinical screening processes, acknowledging that patients with COVID‐19 may be asymptomatic, may present with atypical symptoms and do not necessarily have knowledge of close contact with an infected individual. Ultrasound There is some evidence that point‐of‐care ultrasound can be used in the imaging of patients with COVID‐19; however, given variability in specialist expertise and availability, this has not been incorporated in this pathway.1 Conclusion Chest imaging in suspected or confirmed COVID‐19 in a low prevalence environment is best used to detect complications and rule out alternative diagnoses. The pathway described here aims to clarify imaging indications, technique and reporting of studies performed on patients with suspected or confirmed COVID‐19 in an acute care setting. Box – COVID‐19 emergency imaging guidelines AP = anteroposterior; ANZSTR = Australian and New Zealand Society of Thoracic Radiology; COVID‐19 and COVID = coronavirus disease 2019; CT = computed tomography; CTPA = computed tomography pulmonary angiogram; CXR = chest x‐ray; ED = emergency department.

David Ngan · Suzanne McKeen · Meegan Gun · Daniel Haustead · Andrew Low · Brett Lorraine · James Bewes

To the Editor: As the coronavirus disease 2019 (COVID‐19) pandemic spread across Europe, we worked in the intensive care unit (ICU) of a Swedish university hospital. We share our experiences and offer some thoughts regarding Sweden’s pandemic response. The decentralised Swedish health system works on three levels (Box). These traditional divisions may partially account for the lack of coordination between care services in the initial phases of the pandemic, where large numbers of deaths occurred in care homes. As the pandemic intensified, safety checks were implemented to protect residents of aged care facilities. This resulted in a quick containment of infections, although tragically too late for many. Our health care region received the fourth highest number of hospitalisations in Sweden.1 We were privileged to work in a system that was well organised, without political conflict and with pre‐existing disaster plans that were quickly converted to pandemic plans. A pandemic‐specific leadership established a centralised inventory and oversaw the acquisition and distribution of beds, staffing, medical equipment, essential drugs, personal protective equipment and disinfection agents. An eight‐step plan ensured a rapid escalation of regional ICU capacity. Intermediate care units were opened, reducing demand for ICU beds. Projected numbers of patients were calculated daily, based on models provided from the Public Health Agency of Sweden and local data. Anaesthesia and intensive care are a combined speciality in Sweden. This enabled the rapid deployment of a large workforce of anaesthetists and nurse anaesthetists to ICUs. Despite these resources, our tripled ICU capacity meant significant staffing challenges, with additional difficulties because of staff illnesses and quarantines. Our impression is that the Swedish response has been controlled and planned for the long term. Daily public announcements from the Public Health Agency became a regular part of our lives and Swedes were generally compliant with recommendations regarding physical distancing and hygiene routines. We are perplexed by reports in the media that life went on as usual in Sweden. In fact, life was very different. Most people worked from home, large numbers were furloughed, many institutions were closed and public events were cancelled. Travel was discouraged and fell dramatically.2 What sets the Swedish approach apart from others is that these measures were largely voluntary, with generally good public support. We avoided an overwhelming wave of patients with an undercapacity of ICU beds, as seen in many other countries. We maintained normal criteria for ICU admissions. This is notable given that Sweden has the second lowest number of ICU beds per capita in Europe.3,4 Results from intensive care are encouraging, with mortality rates generally lower than previously reported.5 Challenges included staff burnout, a shortage of usual sedatives and lack of clinical experience with this new disease, resulting in the use of futile and potentially harmful treatments. However, guidance from a national group of senior clinicians provided regular recommendations6 and there was excellent compliance with advice from regulatory authorities. Up to 70% of elective surgeries were cancelled during the first half of 2020. Cancer‐related surgeries continued to be prioritised during the pandemic, but the longer term effects of cancelled surgeries, outpatient clinics and altered illness behaviour are not known. We are heartbroken at our inability to provide enough comfort to relatives of our patients who succumbed to COVID‐19 when hospital visits were prohibited. As two Australian emigrants working in a Swedish ICU, we are humbled by our ability to contribute to the care of patients during the pandemic. Our Australian medical training instilled in us a sense of duty, tempering any feelings of helplessness. We applaud the tenacity of our Swedish colleagues. We wish our Australian colleagues well and hope that Australia will be protected from the horrors of COVID‐19. Box – Decentralised organisation of the Swedish health care system

Michelle S Chew · Thomas Halliday

To the Editor: Elasticated straps — also known as “octopus” straps or bungee cords — are used to secure loads of various shapes and sizes. Unexpected release of the potential energy stored in these straps can cause catastrophic injuries. The Royal Victorian Eye and Ear Hospital (RVEEH) is the largest eye hospital in Australia and is well positioned to assess and treat a variety of ocular injuries. We explored trends in presentations to the RVEEH emergency department (ED) for such injuries between 2007 and 2018, using the ED triage database and information relating to total numbers of ocular trauma presentations. This study was approved by the RVEEH Ethics Committee (09/886H). Between 2007 and 2018, there were 169 presentations involving an elasticated strap‐related eye injury (145 male and 24 female; mean age, 43.4 years). While most patients had multiple injuries, the most common primary diagnosis was traumatic hyphaema, followed by corneal abrasion and open globe (full‐thickness wounds) injuries (Box). There were 23 admissions, of which 21 required surgical intervention, with vitrectomy, orbital wound exploration and closure, and lensectomy being the most common procedures. The final visual acuity measurements of the 17 patients who were admitted and able to be followed up were 6/36 or better for nine patients and 6/60 or worse for eight patients. While males presented more frequently than females, the absolute number of yearly presentations by gender was stable. Elasticated strap‐related injuries accounted for 0.23% of the total 72 663 ocular trauma presentations in the period. While it is problematic to compare incidence with previous studies, due to factors such as growth of the RVEEH ED, growth of other hospitals around Melbourne, and population growth, elasticated strap‐related eye injuries remain a significant contributor to presentations at the RVEEH. These straps were a known danger in the early to mid‐1990s1 and they remain dangerous more than 20 years later, causing severe ocular damage and requiring operative intervention in 12.4% of patients. Although the total number of elasticated strap‐related eye presentations does not appear to be dramatically rising, the continued presence of severe eye injuries necessitating admission for surgical intervention is cause for concern. Multiple steps can be taken to address the continued challenge of elasticated strap‐related injuries. Thorough assessment of the patient remains crucial to facilitate prompt treatment of vision‐threatening diagnoses. In addition, preventive measures should be undertaken to lessen the likelihood of visual loss caused by these devices. This includes patient education and encouraging the use of alternative devices that are functionally similar but pose no risks to eyesight, such as non‐elasticated straps that can be gradually tightened, braided metal locking straps, or even self‐contained soft roof rack and strap combinations. Regulators should also consider whether the convenience of elasticated straps justifies the danger they continue to pose to eyesight almost half a century after they were first introduced to Australia and the first eye‐related injury was reported.2 Box – Primary diagnoses of elasticated strap‐related eye injury sequelae table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Primary diagnosis* Total cases Traumatic hyphaema 63 (3.3%) Corneal abrasion 42 (24.9%) Open globe injury 11 6.5%) Conjunctival/lid/canalicular laceration 7 (4.1%) Commotio retinae 8 (4.7%) Traumatic iritis/mydriasis/uveitis 7 (4.1%) Periorbital haematoma 3 (1.8%) Corneal foreign body 2 (1.2%) Subconjunctival haemorrhage 2 (1.2%) Traumatic glaucoma 2 (1.2%) Conjunctival abrasion 1 (0.6%) Vitreous haemorrhage 1 (0.6%) Posterior vitreous detachment 1 (0.6%) Retinal detachment 1 (0.6%) Lens dislocation 1 (0.6%) Other injury 5 (3.0%) No abnormality detected 7 (4.1%) Patient did not wait to be seen 5 (3.0%) Total 169

Philip Rothschild · Peter Meagher · Thomas G Campbell

Adequate capacity — beds, equipment, consumables, and, crucially, trained personnel — is needed to cope with a surge of critically ill patients

Mervyn Singer

The prognosis may not be as poor as overseas, but the intensive care resource burden may be greater

Aidan JC Burrell · Breanna Pellegrini · Farhad Salimi · Husna Begum · Tessa Broadley · Lewis T Campbell · Allen C Cheng · Winston Cheung · D James Cooper · Arul Earnest · Simon J Erickson · Craig J French · John M Kaldor · Edward Litton · Srinivas Murthy · Richard E McAllister · Alistair D Nichol · Annamaria Palermo · Mark P Plummer · Mahesh Ramanan · Benjamin AJ Reddi · Claire Reynolds · Tony Trapani · Steve A Webb · Andrew A Udy

Switching trauma specialist services to pandemic management would be unwarranted

Teagan L Way · Seth M Tarrant · Zsolt J Balogh

Fit testing of respirators is recommended to ensure proper fit for individual health care workers and is required to comply with respirator standards

Adrian Regli · Britta S Ungern‐Sternberg

The coronavirus disease 2019 (COVID‑19) pandemic has forced many countries to take extraordinary measures to prevent spread of disease. In New South Wales, public health orders introduced during 18–26 March 2020 required the closure of major industries and prohibited non‐essential gatherings of more than 100 people or allowing less than 4 m2 space per person. On 29 March, further public health orders prohibited people leaving home other than for work, study, shopping, medical care, or exercise.1,2 Changes in patterns of presentations to emergency departments (EDs) have been reported during COVID‐19 lockdowns overseas, including reduced numbers of patients with certain high acuity conditions, such as acute coronary syndrome (ACS) and stroke.3,4,5 Understanding the situation in Australia is important for public health policy during this and future pandemics. The Western Sydney Local Health District is a metropolitan health network in NSW of four hospitals (each with EDs) with a total capacity of 1925 beds, serving a catchment of 950 000 people. We analysed triage, International Classification of Diseases, tenth revision, Australian modification (ICD‐10‐AM) coding, and separations data for ED presentations during 29 March – 31 May in each of 2019 and 2020. Differences in mean daily presentation numbers for each triage category and selected presentation types were assessed in non‐paired Student t test with Bonferroni correction. All data analysis was performed in Excel (Microsoft). As a quality assurance project, the study was exempted from formal ethics approval. The number of ED presentations during 29 March – 31 May was almost 25% lower in 2020 than in 2019 (26 617 v 35 268). Presentation numbers in all triage categories were lower in 2020 (P < 0.001), except for category 1 (resuscitation) (506 v 445, 14% increase; P = 0.40). The proportion of patients discharged from the ED was greater in 2020 (60% v 53%) and that of patients who did not wait for treatment smaller (1% v 5%). The number of patients admitted to hospital was lower in 2020 than 2019 (8047 v 11 838), as were the proportions admitted to hospital (30% v 34%) (Box 1). ED presentations with fourteen selected diagnoses were further examined: common infectious diseases (infectious enteric disease, pneumonia), conditions frequently seen in EDs (wrist or hand fractures, femur fractures, appendicitis, renal calculi), conditions for which fewer ED presentations have been reported during COVID‐19 restrictions overseas (stroke or cerebral haemorrhage, ACS, chest pain, transient ischaemic attacks), and conditions that may be exacerbated or for which follow‐up in routine medical services may be reduced by COVID‐19 and its associated restrictions (mental health problems, substance misuse, malignancy). The numbers of presentations with infectious enteric disease, pneumonia, wrist or hand fractures, stroke or intracerebral haemorrhage, and chest pain not resulting in another diagnosis were lower in 2020 than in 2019. The numbers of presentations with ACS were similar. The number of presentations with mental health problems was higher in 2020 (daily mean, 8.4; standard deviation [SD], 3.1) than in 2019 (daily mean, 6.9; SD, 2.6; difference, +1.5 presentations per day; 95% confidence interval, +0.1–2.9) (Box 2; online Supporting Information). Social distancing may have reduced the spread of infectious enteric diseases and community‐acquired pneumonia, and home isolation may have led to fewer fractures. However, lower numbers of presentations with chest pain or stroke (also reported overseas4) may reflect factors other than lower incidence, such as suspension of outpatient clinics and elective procedures, social distancing measures, and public anxiety. COVID‐19 has profoundly affected health care delivery. We found concerning reductions in ED presentation numbers that may indicate delayed seeking of appropriate medical attention. Public health messages should encourage timely presentation of people with time‐sensitive, potentially life‐threatening conditions, even during pandemics. Equally concerning is the higher number mental health‐related presentations, which may reflect anxiety about COVID‐19, loss of job security, or prolonged isolation. Studies of patients presenting to health care services as they re‐open are required to fully appreciate the health implications of the COVID‐19 epidemic. Box 1 – Emergency department presentations to Western Sydney Local Health District hospitals during corresponding two‐month periods in 2019 and 2020 Triage category Resuscitation Emergency Urgent Semi‐urgent Non‐urgent Total 29 March – 31 May 2019 Total number of presentations 445 8910 12 464 10 726 2723 35 268 Daily presentations, mean (standard deviation) 7.0 (3.2) 139 (15.9) 195 (19.3) 168 (22.3) 42.5 (10.7) 551 (41.8) Admitted to hospital 350 (79%) 4550 (51%) 4524 (36%) 2156 (20%) 258 (9%) 11 838 (34%) Discharged: treatment complete 38 (9%) 3350 (38%) 6155 (49%) 7093 (66%) 2039 (75%) 18 675 (53%) Transferred to another hospital or service 26 (6%) 521 (6%) 577 (5%) 299 (3%) 68 (2%) 1491 (4%) Did not wait 0 65 (1%) 560 (4%) 735 (7%) 239 (9%) 1599 (5%) Discharged against medical advice 7 (2%) 413 (5%) 646 (5%) 442 (4%) 81 (3%) 1589 (5%) Died in emergency department/dead on arrival 24 (5%) 11 (< 1%) 2 (< 1%) 1 (< 1%) 38 (1%) 76 (< 1%) 29 March – 31 May 2020 Total number of presentations 506 7609 9095 7346 2061 26 617 Daily presentations, mean (standard deviation) 7.9 (2.6) 119 (18.4) 142 (17.5) 115 (17.9) 32.2 (8.4) 416 (40.6) Admitted to hospital 370 (73%) 3112 (41%) 3072 (34%) 1279 (17%) 214 (10%) 8047 (30%) Discharged: treatment complete 62 (12%) 3836 (50%) 5146 (57%) 5324 (72%) 1525 (74%) 15 893 (60%) Transferred to another hospital or service 26 (5%) 424 (6%) 461 (5%) 304 (4%) 136 (7%) 1351 (5%) Did not wait 0 22 (< 1%) 84 (1%) 170 (2%) 107 (5%) 383 (1%) Discharged against medical advice 9 (2%) 210 (3%) 328 (4%) 267 (4%) 64 (3%) 878 (3%) Died in emergency department/dead on arrival 39 (8%) 5 (< 1%) 3 (< 1%) 0 15 (1%) 62 (< 1%) Change in presentation numbers, 2020 v 2019 +14% –15% –17% –32% –25% –25% table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Box 2 – Mean changes (with 95% confidence intervals) for numbers of emergency department presentations with selected diagnoses (ICD‐10‐AM codes), 29 March – 31 May 2020 v 29 March – 31 May 2019 ICD-10-AM = International Classification of Diseases, tenth revision, Australian modification. * Not resulting in another diagnosis. † Excluding cases without mention of obstruction.

Andrew W Kam · Sarah G Chaudhry · Nathan Gunasekaran · Andrew JR White · Matthew Vukasovic · Adrian T Fung

A 5-year-old girl sustained partial thickness facial burns from oleander leaves that she applied as pretend make-up

Sarah Oudtshoorn · Sanchita Gera · Parshotam Gera

Resource‐limited emergency departments responding to the COVID‐19 pandemic face many challenges — their strength lies in their unique solutions The coronavirus disease 2019 (COVID‐19) pandemic is stretching hospital resources around the world. Emergency departments (EDs) are on the frontline of care and have been impacted significantly by the surge of patients with both suspected and confirmed infection.1,2 Resource‐limited EDs in low and middle income countries are particularly vulnerable. Pre‐existing issues, including a limited workforce supply, have been exacerbated, and new threats, such as a lack of personal protective equipment (PPE) and oxygen, have emerged.1,2 This article explores the impacts of the COVID‐19 pandemic on resource‐limited EDs across the Indo–Pacific. It considers the unique challenges for the region and describes opportunities for building system resilience at a time of unprecedented demand for emergency care. Emergency departments and the COVID‐19 pandemic Emergency care systems are essential for universal health coverage.3 Effective emergency care improves health outcomes, and is critical to achieving the health‐related Sustainable Development Goal targets.4 EDs are the cornerstone of emergency care systems, enabling access to facility‐based care for patients with acute illness and injury. They provide an interface between community and hospital care, and address unmet needs for vulnerable patients. These roles are augmented during communicable disease outbreaks, when EDs fulfil surveillance, triage and clinical care functions.3,4 Since the World Health Organization (WHO) declared COVID‐19 a global pandemic in March 2020, most low and middle income countries across the Indo–Pacific have reported cases. About 20% of patients require hospital admission, and early recognition and resuscitation can help reduce mortality.1 EDs therefore have a key role to play in risk‐stratifying patients, providing initial therapy, establishing goals of care, and identifying patients who may benefit from advanced interventions. Pandemic preparedness The Indo–Pacific encompasses the eastern Indian Ocean and Western Pacific regions, connected through South‐East Asia. The region is characterised by cultural, geographical and economic diversity.5 The Global Health Security Index reflects a country's ability to detect, communicate and respond to a communicable disease outbreak.6 Most low and middle income countries across the Indo–Pacific score below the average preparedness level of 40.2 (on a scale of 0–100) and are among the least prepared countries.6 These findings reflect pre‐existing gaps in health care capacity that are likely to be exacerbated during a public health emergency.7 A historical lack of investment in emergency care systems across Indo–Pacific low and middle income countries means that many EDs have limited resilience in times of increased demand.3,4 Emergency care has not been a focus for international donors,4 and sequential reductions in the Australian Government's development assistance budget for health have further compromised capacity building efforts.8 Although these projections foreshadow a devastating impact on low and middle income countries across the region, the global experience of the COVID‐19 pandemic has illustrated the limitations of preparedness modelling. Several of the most prepared countries are now disease epicentres with overstretched health services, in part reflecting an initial reluctance to follow WHO advice regarding testing and contact tracing.9 Indo–Pacific nations may have strengths that protect against this trend, such as recent epidemic experience.10 Nimble and innovative responses may help build resilience, potentially providing globally relevant lessons that would typically be expected from high income countries. Challenges in public health response A major determinant of the pandemic's impact on EDs will be the success of broader public health interventions. Low and middle income countries, including those in the Indo–Pacific, will face unique challenges in disease containment.2 As demonstrated by several Pacific countries, island states have greater ability to shut their borders and limit inward passage of the virus. However, a freeze on international access will have a significant socio‐economic impact and is unlikely to be sustainable. It may also affect the supply of essential medical equipment, surveillance capacity (given that certain countries rely on foreign pathology services for COVID‐19 testing) and retrieval systems. An important mechanism to disrupt community transmission of COVID‐19 is physical distancing. This is antithetical to many sociocultural practices across the Indo–Pacific, where communal living is common and regular congregation at community meeting places is the norm. Modelling from a Papua New Guinean setting has demonstrated that physical distancing measures in that community were 60–70% less effective compared with Australia.11 Public health responses across the region have already been complicated by extreme weather events and humanitarian crises. Examples include Cyclone Harold, a category 5 cyclone that recently affected the South Pacific, and the climbing infection rate in the worlds’ largest refugee camp at Cox's Bazar in Bangladesh.12 Worsening climate change will further exacerbate the incidence and severity of natural disasters and disease outbreaks. Challenges for emergency departments As community transmission increases, demand for ED care will escalate. The impact may be more pronounced among Indo–Pacific communities as a result of high rates of non‐communicable disease.13 COVID‐19 appears to be more severe in patients with diabetes, hypertension and chronic pulmonary illness, all of which are prevalent across the region.13 Increasing demand is likely to expose pre‐existing deficiencies in ED systems and resources, including scarce critical care capacity.1,2 A survey of emergency care clinicians in the Pacific recently identified minimal integration of surge response with routine emergency care, and a lack of essential processes, such as triage and patient flow.7 Consistent with these data, Box 1 lists key challenges in systems, spaces, supplies and staff that have become evident to Indo–Pacific clinicians during COVID‐19 response planning.2 Emerging data suggest that frontline clinicians are at an increased risk of death from COVID‐19, in part due to suboptimal PPE.14 Limited access to PPE is a major threat and will place ED clinicians at increased risk of infection. Low and middle income countries face challenges in PPE procurement because of supply chain limitations as well as market‐based competition with high income countries.1,2 Illness among health care workers will stretch an already fragile health care workforce. In the event of a surge, EDs will require significant increases in staffing, and the challenge may be exacerbated by high rates of comorbidities, absenteeism and inadequate training.7,13 Additionally, many Indo–Pacific EDs rely on a sole medical leader for clinical and administrative decision making.15 The pandemic may place these clinicians at risk of burnout, illness and death, thereby exacerbating the mismatch between supply and demand for care. Unintended consequences To meet these challenges, EDs will need to make substantial changes to their processes. However, there is a risk that distraction from pre‐existing health priorities will worsen the overall impact. Patients with chronic disease have poor outcomes at times of increased health system stress, as occurred in West Africa during the 2014 Ebola epidemic when resources were diverted away from routine care.16 Lockdown measures will make it difficult for some patients to access emergency care, and fear of acquiring COVID‐19 in hospital may create a further barrier to ED attendance. Additionally, the socio‐economic consequences of public health interventions are likely to contribute to poor health outcomes in the longer term. There is also a risk that donor funding will target resource intensive equipment (such as ventilators) that may be unsuitable in a low and middle income country context. Many resource‐limited ED clinicians are accustomed to a low cost essential care approach.1 Rather than emphasising expensive and high risk interventions, a focus on simple measures such as rigorous infection control and oxygen therapy is likely to be advantageous.1 The pandemic has already had a gendered impact, exacerbating the “triple burden” of productive, reproductive and community work responsibilities imposed on women.17 This has been particularly evident in low and middle income countries, where women make up a larger proportion of frontline workers and are disproportionately expected to fulfil unpaid household duties.17 Addressing immediate needs Addressing these challenges requires urgent action. While high level guidelines such as the WHO Emergency and Disaster Risk Management Framework18 exist, these often neglect the practical challenges faced by EDs. COVID‐19 guidance for Indo–Pacific EDs must complement WHO recommendations, and be culturally appropriate, fiscally responsible and immediately actionable2 (Box 2). Indo–Pacific ED leaders are already implementing COVID‐19 response plans. Examples from across the region are profiled in Box 3. These early success stories highlight the capacity of local clinicians to lead disaster response activities and provide meaningful care in the face of escalating health care demand. The Australian Government has provided some support for this effort by contributing funds to the WHO response plan and deploying specialist advisors to selected Indo–Pacific countries.8 Opportunities An increasingly interconnected world, combined with climate change and mass migration, will result in more frequent communicable disease outbreaks. COVID‐19 provides an opportunity to build resilient EDs that are better prepared for this challenge. The pandemic is also a chance to enhance the sustainability of routine emergency care through system strengthening, facilitated by multisectoral collaboration between clinicians, governments, technical organisations and donors.3 This effort should be informed by existing guidance for the enhancement of human resources, infrastructure, governance and processes to improve regional emergency care capacity.7 Australian agencies, such as the Indo–Pacific Centre for Health Security, have a key role to play in resourcing this activity. The pandemic provides a unique opportunity for the Australian Government to advance its commitment to strengthening health care systems and deliver on the promise of its Pacific Step‐up.5,8 It also offers a chance to leverage Australia's expertise in emergency care for the benefit of the region.3 Conclusion Time will determine the full impact of COVID‐19 on the Indo–Pacific, but global trends suggest that ED capacity may be severely stretched. Responses should target the unique challenges for disease control and emergency care delivery across the region. Although local ED clinicians are already demonstrating leadership and adaptability in their surge planning, the pandemic provides an opportunity to build resilience in emergency care systems and enhance future capacity for both routine care and outbreak response. Australian clinicians, organisations and governments have a key role to play in supporting this effort. Box 1 – Challenges for COVID‐19 preparedness and response in emergency departments (EDs) Variable Challenge (and selected examples) Systems Disaster and surge plans Many EDs and hospitals do not have standard operating procedures for surge events and communicable disease outbreaks: “ED COVID‐19 operations need a focal point of command at hospital executive level so that ED preparatory activities can be prioritised and fast tracked” (Solomon Islands) Triage Some EDs have no formalised triage systems. Implementing a triage system, for the first time, during a pandemic is fraught with difficulty Patient flow Overcrowding, interdepartmental communication barriers and a lack of ward beds can delay care for both COVID and non‐COVID patients Space Isolation and resuscitation areas Many EDs lack the physical space and infrastructure to adequately provide safe and effective routine care. In the context of the pandemic, a lack of dedicated isolation and resuscitation areas will be a major challenge Storage capacity Attempts have been made stockpile essential resources; however, there is a lack of dedicated on‐site storage space at many hospitals Supplies Personal protective equipment (PPE) and cleaning agents PPE supply is a major and ongoing concern: “There is not a standby supply of PPE … in a normal working day. [There is no] process to ensure a consistent supply of PPE in the department” (Fiji) “Our hospital is not a central level hospital, [so] we [were not given] much supplies” (Myanmar) Laboratory testing There is often limited laboratory capacity, and staff have competing priorities beyond EDsMany testing facilities are offsite or overseas, resulting in delayed isolation, identification and treatment of patients with COVID‐19, placing staff and other patients at risk Oxygen There is a lack of portable oxygen cylinders and oxygen concentrators in many facilities. Relatively few facilities have capacity for intubation and ventilation Novel therapies There is uncertainty surrounding the therapeutic benefits of agents such as hydroxychloroquine, azithromycin and remdesivir. In some countries, these medications are difficult to source, and with international demand increasing, supply will become even more scarce. This will impact the availability of these medications for patients who require them for other indications Staff Critical care training There are few formally trained critical care staff in many EDs. Additionally, there are concerns about workforce shortages and the reliance on volunteers Some hospital staff do not appreciate the importance of early recognition and treatment: “[Some staff lack an] initial understanding of the role of ED in the approach to COVID‐19” (Fiji) Staff morale and safety concerns Many staff are concerned about the risk to themselves and their family members if they are required to care for patients with suspected COVID‐19 without adequate protection: “[There are] difficulties in commuting due to strict curfew/modified lock down and restrictions on inter district transport. [There is] COVID phobia created by the media” (Sri Lanka) “I don't want them to infect, I don't want them to exhaust, I don't want them to depress, I want to create safe and less stress environment” (Myanmar) Box 2 – Strategies for optimising emergency department (ED) preparedness and response* Systems Ensure ED processes are consistent with broader public health and hospital management strategies Utilise local case definitions to identify suspected cases Establish a clearly marked screening and triage process at the entrance to the hospital, and stream patients based on the acuity of their presentation. For example, low acuity patients might be redirected to a co‐located surge clinic Maintain infection prevention and control to the highest possible standards. Ensure patients and staff practice physical distancing, cough etiquette and hand hygiene Minimise the volume of patients in the ED and isolate symptomatic patients from others by establishing a respiratory zone Develop clear admission/discharge criteria and establish ceilings of care for the facility Space Establish a clearly marked screening and/or triage station at the entrance to the facility Ensure the ED and surge clinic (if established) have designated waiting areas for patients with respiratory symptoms Allocate separate areas in the ED for the management of symptomatic, medium and high acuity patients Supplies Anticipate equipment needs and stockpile to the extent that is possible, especially disposable items that will be in high demand (oxygen cylinders, antipyretics, personal protective equipment, etc) Follow World Health Organization guidelines on resource stewardship. For example, implement clear thresholds for providing supplemental oxygen, such as SpO2 < 90% on room air for stable patients, SpO2 < 92% on room air for pregnant women, and SpO2 < 94% on room air for patients with respiratory distress Avoid use of therapies that are likely to increase virus transmission (eg, nebulisers) Develop safe processes for cleaning and reusing equipment based on World Health Organization infection prevention and control advice Staff Make sure that all staff feel included, empowered, motivated and supported Update the staff contact list and plan for absenteeism Identify staff who are high risk for infection and reallocate them to other areas Train staff in the systems and processes that have been developed Remind staff that they should not work if they have acute respiratory symptoms Use ancillary staff and other community members for non‐technical tasks Remind others that COVID requires a whole‐of-government, whole‐of-health and whole‐of-hospital response; the ED cannot do it alone Ensure ED staff are involved in the post‐pandemic review process to promote ongoing systems improvement and sustainability * Adapted from Australasian College for Emergency Medicine. Managing COVID‐19 across the Indo‐Pacific: a guide for resource limited EDs. Melbourne: Australia, 2020. https://acem.org.au/getmedia/3930cc60-abb1-4517-b7af-36da918a3f7b/Managing-COVID-19-across-the-Indo-Pacific-(G763) (viewed Aug 2020). Box 3 – Examples of successful COVID‐19 preparedness and response strategies employed across Indo–Pacific emergency departments (EDs) Variable Strategy (and selected examples) Systems Leadership and coordination Many countries have developed national coordinating bodies that include ED clinicians as key stakeholders. This is a recognition of their pivotal role in crisis coordination: “Once there were initial reports of care in China, the Ministry of Health had formed a National Taskforce and … ED was invited to participate in it as stakeholders” (Fiji) Identification of key leaders at each stage of the patient journey has been essential: “The hospital formed its Taskforce and we had devised operating procedures and a flow chart with important contact persons at each stage” (Fiji) Triage, screening and patient flow There has been a rapid development of triage, screening and flow systems based on specific criteria: “For patients with respiratory symptoms and fever … the high acuity patients can be stabilised in the ED respiratory resus and transferred to ICU. Medium acuity patients to be stabilised in the step down area of the respiratory section of the ED. Ambulance will transport patients to the isolation wards and ICU” (Solomon Islands) Space Isolation and resuscitation areas Guided by experience from Africa during the Ebola outbreak, EDs in Solomon Islands, Fiji, Myanmar and Sri Lanka have undergone significant restructuring of limited spaces to facilitate separate areas for screening, isolation, resuscitation and storage Supplies Infection prevention and control, and personal protective equipment (PPE) Drawing on experience during the 2009 H1N1 pandemic, EDs have adapted guidelines for the judicious use of PPE, while emphasising that staff safety is a priority: “Within the storage area in ED of consumables, a cupboard is allocated to store PPE kits and this is tallied and replenished by the Hospital Infection Control team” (Fiji) “Health care worker exposure assessment protocol was designed” (Sri Lanka) “Luckily we have many people who want to donate what we need so we are still ok” (Myanmar) Resource utilisation Early decisions have been made about distribution of limited resources: “No CPR will be done on COVID‐19 high acuity patients who have (deteriorated) despite maximal non aerosol generating treatment” (Solomon Islands) “We decided to do respiratory team with only three people, because … when positive case came to our ED only these three need PPE” (Myanmar) Novel therapies These are not being used until there is proven evidence of benefit. Local guidelines have been developed: “Cautious use of fluids except in shock. Use of metered dose inhalers (rather than nebulisers) for asthma exacerbations” (Solomon Islands) Staff Critical care training Countries have begun re‐training staff in critical care and there has been redeployment and re‐training of staff from non‐essential areas to the ED. Non‐medical staff are also being utilised to assist with operational requirements such as cleaning and transportation Staff morale and safety There is a focus on open communication and staff wellbeing: “We did meeting every night with zoom and discussed the problems faced in their duty time … we asked their working capacity … and redrew duty roster” (Myanmar) “Special quarantine centres with all the facilities were designated for staff members who had problems in home isolation” (Sri Lanka) “Staff are undergoing medical checks. Staff with comorbidities will not be working in the respiratory section of the ED” (Solomon Islands)

Isobelle G Woodruff · Rob D Mitchell · Georgina Phillips · Deepak Sharma · Patrick Toito'ona · Krishantha Jayasekera · Khine Shwe Wah · Megan Cox · Gerard M O'Reilly

Although infection risks posed by COVID-19 influence all aspects of adult cardiac arrest management, the basic principles of resuscitation remain the same

Simon Craig · Mya Cubitt · Ashish Jaison · Steven Troupakis · Natalie Hood · Christina Fong · Adnan Bilgrami · Peter Leman · Juan Carlos Ascencio‐Lane · Guruprasad Nagaraj · John Bonning · Gabriel Blecher · Rob Mitchell · Ellen Burkett · Sally M McCarthy · Amanda M Rojek · Kim Hansen · Helen Psihogios · Peter Allely · Simon Judkins · Lai Heng Foong · Stephen Bernard · Peter A Cameron

For most patients, life continues beyond the intensive care unit, and this is where action is needed

Paul J Secombe · Alex Brown · Michael J Bailey · David Pilcher

Objectives: To assess long term outcomes for Aboriginal and Torres Strait Islander (Indigenous) Australians admitted non‐electively to intensive care units (ICUs). Design: Data linkage cohort study; analysis of ICU patient data (Australian and New Zealand Intensive Care Society Adult Patient Database), prospectively collected during 2007–2016. Setting: All four university‐affiliated level 3 ICUs in South Australia. Main outcomes: Mortality (in‐hospital, and 12 months and 8 years after admission to ICU), by Indigenous status. Results: 2035 of 39 784 non‐elective index ICU admissions (5.1%) were of Indigenous Australians, including 1461 of 37 661 patients with South Australian residential postcodes. The median age of Indigenous patients (45 years; IQR, 34–57 years) was lower than for non‐Indigenous ICU patients (64 years; IQR, 47–76 years). For patients with South Australian postcodes, unadjusted mortality at discharge and 12 months and 8 years after admission was lower for Indigenous patients; after adjusting for age, sex, diabetes, severity of illness, and diagnostic group, mortality was similar for both groups at discharge (adjusted odds ratio [aOR], 0.95; 95% CI, 0.81–1.10), but greater for Indigenous patients at 12 months (aOR, 1.14; 95% CI, 1.03–1.26) and 8 years (adjusted hazard ratio, 1.23; 95% CI, 1.13–1.35). The number of potential years of life lost was greater for Indigenous patients (median, 24.0; IQR, 15.8–31.8 v 12.5; IQR, 0–22.3), but, referenced to respective population life expectancies, relative survival at 8 years was similar (proportions: Indigenous, 0.78; 95% CI, 0.75–0.80; non‐Indigenous, 0.77; 95% CI, 0.76–0.78). Conclusions: Adjusted long term mortality and median number of potential life years lost are higher for Indigenous than non‐Indigenous patients after intensive care in hospital. These differences reflect underlying population survival patterns rather than the effects of ICU admission.

William G Mitchell · Adam Deane · Alex Brown · Shailesh Bihari · Hao Wong · Rajaram Ramadoss · Mark Finnis

An integrated approach that includes a central role for pathology laboratories is necessary Mass casualty events (MCEs) are defined as events or other circumstances “where the normal major incident response of one or several health organisations must be augmented by extraordinary measures to maintain an efficient, suitable and sustainable response”.1 Haemorrhage is a leading cause of mortality in MCEs, accounting for almost 50% of deaths in the first 24 hours,2,3 and transfusion emergency preparedness is increasingly recognised as a critical element of an integrated approach to MCEs,4 with timely availability and appropriate delivery of blood components being an essential part of management. On 20 January 2017, an MCE occurred in Melbourne, Victoria, when a car struck pedestrians in the Bourke Street Mall in the central business district, killing six people and injuring more than 30. The injured were taken to various adult and paediatric hospitals around Melbourne, including designated trauma centres and non‐trauma hospitals, both public and private. A Code Brown was activated at some of these hospitals. This is a hospital alert activated internally when notification of an external incident is received, usually by emergency services or health departments, which requires mobilisation of additional capability and capacity within that facility to receive an influx of patients.5 In Victoria, the users of blood products, including public and private hospitals and pathology laboratories, are represented by the Victorian Blood User Group. The Blood User Group meets quarterly with Australian Red Cross Lifeblood (previously Australian Red Cross Blood Service) to discuss issues relevant to the use and supply of blood products. In February 2017, Blood User Group members highlighted concerns with communication during the Bourke Street incident. Poor communication from hospitals to their pathology laboratories was noted during activation of hospital Code Brown alerts. There was also uncertainty and lack of transparency surrounding supply of blood components from Lifeblood to hospitals in Victoria, not only to those involved in the incident but also those awaiting delivery of routine blood inventory. In response to these concerns, the Blood User Group held a forum in August 2017 to discuss these issues and to make recommendations to assist planning for future incidents. Blood User Group representatives and invited guests, including National Blood Authority representatives, heard presentations from the Victorian Department of Health and Human Services, Lifeblood and four hospitals that received patients, outlining issues and learnings from the incident, followed by further discussion. A summary of recommendations was circulated to forum attendees. This article highlights issues and recommendations pertinent to hospitals and associated pathology laboratories, in particular their haematology and transfusion laboratories. Recommendations Pathology staff must form part of hospital critical incident management teams In some hospitals, the associated pathology laboratory is not part of the critical incident management team, and when these hospitals were notified of the Bourke Street MCE by emergency services, this was only communicated to the pathology laboratory via public address systems or other informal means. Updates received by hospitals from emergency services throughout the event were similarly not always communicated in a planned way. Key pathology representatives in some hospitals also attended their emergency departments in person, which was invaluable for communication but occurred on an ad hoc basis rather than being part of a documented protocol. Without streamlined communication, pathology representatives can often only respond to blood component requests and transfusion specimens when they arrive, leading to potential delays in blood product provision. As transfusion support remains a core component of management in MCEs, a key recommendation is that pathology staff must form part of any hospital's critical incident management team. This should be documented in the critical incident protocol, and involves active pathology staff participation during critical incidents. Further formalised pathology roles, such as physical attendance at critical sites in the hospital (eg, emergency department) to streamline communication with the laboratory, are also encouraged. This ensures that pathology services receive adequate notification of critical events, and enables direct involvement in ongoing management of the incident in a systematic way with clear lines of communication. It also allows pre‐emptive action such as pre‐thawing of clinical plasma, and review and management of current inventory including appropriate use of emergency blood components. Implement safe, non‐sequential allocation of unit record numbers for consecutive emergency patients One hazard noted at the forum was a lack of specific labelling protocols for identifying patients presenting to some emergency departments, resulting in potentially dangerous patient identifiers being used; for example, consecutive unit record numbers for consecutive patients, or the same prefix on all patients. This may facilitate clerical errors and patient misidentification. It is recommended that institutions ensure that allocation of unit record numbers for consecutive unknown patients is performed in a safe way, which minimises the risk of patient misidentification. Ensure adequate levels of pathology staff familiar with critical event management Staffing levels were an issue at some sites during the Bourke Street MCE, owing to senior staff being on leave. Similarly, when critical incidents occur after‐hours, staffing is often limited and senior personnel may not be on site, resulting in less experienced staff enacting their critical incident management plans. Extra staff may be required and there may be difficulty of access to workplaces if the incident results in road closures. Working during the incident can be physically and emotionally tiring, and replacement staff will be required after the event.4,6 Therefore, it is recommended that all staff, irrespective of experience, should be familiar with their local critical incident management plan, and that consideration be given to how staffing levels are managed during and after a critical incident. Include pathology staff in practice disaster scenarios All hospitals should practise responses to disaster scenarios and involve pathology representatives. During the Bourke Street event, hospitals other than the major trauma centres received multiple casualties. “Walking wounded” may also present at nearby hospitals, irrespective of whether these have emergency departments. Performing practice scenarios is therefore important to familiarise staff with their critical incident plans. Limitations of these scenarios are recognised, as they often do not encompass the practical issues faced by pathology teams, such as time taken to run multiple pathology samples, perform multiple crossmatches and accept into inventory large numbers of blood products. Despite these limitations, it is recommended that hospitals perform practice disaster scenarios and involve pathology staff to highlight areas of potential weakness. Consider standby phase in Code Brown responses One hospital activated their Standby Code Brown during the Bourke Street MCE, when it was first notified by emergency services of the possible arrival of casualties, but before patient numbers or severity of injuries were known. This standby phase alerted the critical response areas of the hospital, including the emergency department and pathology services, to an external incident, allowing review of department response plans such as staffing levels and blood product inventory without activating a full Code Brown response. The standby code remained in place until the hospital was advised of further details of presenting patients. It is recommended that hospitals incorporate such a standby phase in their emergency response plan. This alerts relevant departments to plan and prepare for escalation of an event when a critical incident is first notified to the hospital, but before further details are known or casualties have presented, without activating the full series of Code Brown activities which can be disruptive. Discussion Effective communication during MCEs is critical. It is common for many more blood components to be requested than are eventually transfused, and the overall requirement for products in these events is often lower than expected.7,8 Most blood use in MCEs occurs within the first 24 hours, particularly in the first 4 hours as the majority of severe casualties arrive within this time frame.2,7 Therefore, the key to managing these chaotic and rapidly evolving events is early, accurate and ongoing updated communication between emergency services, state health departments, hospitals, pathology laboratories and Lifeblood to ensure that blood components are urgently allocated to appropriate patients while limiting unnecessary ordering and cross‐matching of products. Local communication between hospital departments and pathology laboratories can be improved by implementing the above recommendations, in particular by involving pathology laboratories in critical incident management. Hospitals may use existing communication channels including email, intranet and paging or other messaging services; however, the protocol for using these should be clearly documented in the critical incident management plan. Broader statewide communication via health departments and Lifeblood would also allow other health care services to respond appropriately; for example, by managing blood inventory conservatively until the extent and impact of the MCE is known. This requires effective communication between health departments and Lifeblood, and it is imperative that information circulated via state jurisdictions and Lifeblood is consistent to avoid confusion. Forum attendees recommended that the National Blood Authority enable Lifeblood to disseminate information to pathology services through a web‐based blood product ordering system, BloodNet, which is used by transfusion laboratories throughout Australia. Health departments should similarly ensure that existing channels for communicating emergency information to hospitals, such as hospital personnel contact details, are current. Any communication must also be effective outside standard business hours. Fax or email messages are unreliably received after‐hours, and phone contact with appropriate hospital personnel may be more effective. The Bourke Street Mall MCE highlighted the challenges involved in supplying blood components during such events. The recommendations are similar to those published in a previous review on transfusion preparedness for MCEs4 and recognise the requirement for an integrated approach that includes a central role for pathology laboratories. Incorporating the lessons learnt from this incident will allow for more organised responses and streamlined communications between all departments and institutions.

Linda Saravanan · Amanda Ormerod

The prevalence of food allergy among Victorian children is rising.1 In Victoria, children with suspected food allergies can be on hospital outpatient clinic waiting lists for months before being assessed.2 This may lead families to consider alternative avenues, which can lead to poor allergy management and the need for emergency care. Increasing numbers of Victorian children are presenting to emergency departments,3 but we do not know whether the number visiting with food allergy is also rising. We analysed Victorian Emergency Minimum Dataset (VEMD) data for the period 2005–06 to 2014–15. The VEMD is a statewide administrative dataset that includes non‐identifiable patient‐level data for all Victorian public emergency department encounters. We included all food allergy‐related presentations by children and young people aged 0–19 years, selected according to International Classification of Diseases, tenth revision, Australian modification (ICD‐10‐AM) codes: T78.0 (anaphylactic shock due to a food reaction), T78.1 (other adverse food reactions, not elsewhere classified), T78.4 (allergy, unspecified: includes non‐food‐related allergies), and L27.2 (dermatitis due to ingested food). Presentation rates by age group were calculated using Australian Bureau of Statistics (ABS) age‐stratified population data for Victorians aged 0–19 years;4 rates for regions were calculated using ABS population data for Statistical Areas 2 (SA2).5 The study was deemed exempt from the need for formal ethics approval by the Royal Children's Hospital Human Research Ethics Committee. The number of children presenting to emergency departments with food allergy‐related problems increased from 2368 in 2005–06 to 4263 in 2014–15; the presentation rate increased from 18 to 29 per 10 000 population (Box 1). About half the children who presented with food allergy‐related problems were aged 0–4 years, the rate for this age group increasing from 38 to 55 per 10 000 population (Box 2). The proportion of presentations triaged as being more urgent (triage categories 1–3) also increased, from 51% to 63% (Box 1). The rate of presentations to metropolitan hospitals increased more (from 18 per 10 000 in 2005–06 to 32 per 10 000 in 2014–15; 78% increase) than did the rate for rural hospitals (26 per 10 000 in 2005–06 to 36 per 10 000 in 2014–15; 38% increase) (Box 1). Hospitals in the North‐West Melbourne region received about one‐third of all allergy‐related emergency department visits, and the number in this region doubled over the study period (706 in 2005–06; 1536 in 2014–15) (Box 3). These data indicate that the demand for emergency services associated with food allergy‐related problems in children increased during 2005–15. The increase was particularly marked for children aged 0–4 years and for children and young people in the North‐West Melbourne and Southern Melbourne regions. While the reason for the increased burden is not clear — that is, whether the prevalence of allergy had increased (including because of a change in population composition), management plans had changed, or access to community services was reduced — the consequence is greater demand on emergency services across Melbourne. Box 1 – Presentations to Victorian public emergency departments by childen and young people (0–19 years) with food allergy‐related problems 2005–06 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 2012–13 2013–14 2014–15 All food allergy presentations Number 2368 2680 2754 2991 3082 3159 3185 3422 3881 4263 Rate (per 10 000 population)* 18 20 21 22 23 23 23 24 27 29 ICD‐10‐AM diagnostic codes T78.0 141 (6.0%) 152 (5.7%) 154 (5.6%) 168 (5.6%) 233 (7.6%) 283 (9.0%) 289 (9.1%) 339 (9.9%) 437 (11.3%) 501 (11.8%) T78.1 800 (33.8%) 948 (35.4%) 962 (34.9%) 1127 (37.7%) 1167 (37.9%) 1152 (36.5%) 1117 (35.1%) 1288 (37.6%) 1464 (37.7%) 1624 (38.1%) T78.4 1234 (52.1%) 1351 (50.4%) 1441 (52.3%) 1488 (49.8%) 1552 (50.4%) 1597 (50.6%) 1633 (51.3%) 1702 (49.7%) 1881 (48.5%) 2031 (47.6%) L27.2 193 (8.2%) 229 (8.5%) 197 (7.2%) 208 (7.0%) 130 (4.2%) 127 (4.0%) 146 (4.6%) 93 (2.7%) 99 (2.6%) 107 (2.5%) Age Number 0–4 years 1202 (50.8%) 1364 (50.9%) 1424 (51.7%) 1537 (51.4%) 1520 (49.3%) 1595 (50.5%) 1593 (50.0%) 1759 (51.4%) 2015 (51.9%) 2152 (50.5%) 5–9 years 466 (19.7%) 515 (19.2%) 521 (18.9%) 573 (19.2%) 673 (21.8%) 608 (19.3%) 660 (20.7%) 702 (20.5%) 813 (21.0%) 967 (22.7%) 10–14 years 305 (12.9%) 335 (12.5%) 355 (12.9%) 405 (13.5%) 403 (13.1%) 426 (13.5%) 383 (12.0%) 433 (12.7%) 515 (13.3%) 561 (13.2%) 15–19 years 395 (16.7%) 466 (17.4%) 454 (16.5%) 476 (15.9%) 486 (15.8%) 530 (16.8%) 549 (17.3%) 528 (15.4%) 538 (13.8%) 583 (13.7%) Rate (per 10 000 population)* 0–4 years 38 42 43 45 43 45 44 47 53 55 5–9 years 15 16 16 18 21 18 19 20 22 26 10–14 years 9 10 11 12 12 13 12 13 15 16 15–19 years 12 13 13 13 14 15 15 15 15 16 Sex Number Boys 1284 (54.2%) 1435 (53.5%) 1476 (53.6%) 1625 (54.3%) 1663 (54.0%) 1723 (54.5%) 1779 (55.9%) 1867 (54.6%) 2158 (55.6%) 2388 (56.0%) Girls 1084 (45.8%) 1245 (46.5%) 1278 (46.4%) 1366 (45.7%) 1419 (46.0%) 1436 (45.5%) 1406 (44.1%) 1555 (45.4%) 1723 (44.4%) 1875 (44.0%) Rate (per 10 000 population)* Boys 19 21 21 23 24 25 25 26 29 32 Girls 17 19 20 21 21 22 21 22 24 26 Hospital region Number Metropolitan† 1560 (65.9%) 1860 (69.4%) 1907 (69.2%) 2008 (67.1%) 2071 (67.2%) 2194 (69.5%) 2186 (68.6%) 2345 (68.5%) 2781 (71.7%) 3149 (73.9%) Rural‡ 808 (34.1%) 820 (30.6%) 847 (30.8%) 983 (32.9%) 1011 (32.8%) 965 (30.5%) 999 (31.4%) 1077 (31.5%) 1100 (28.3%) 1114 (26.1%) Rate (per 10 000 population)* Metropolitan† 18 22 22 23 23 25 24 25 29 32 Rural‡ 26 27 27 32 33 31 32 35 35 36 Triage category Categories 1–3 1198 (50.6%) 1429 (53.3%) 1568 (57.0%) 1707 (57.0%) 1830 (59.3%) 1861 (59.0%) 1807 (56.8%) 2047 (59.8%) 2365 (61.0%) 2694 (63.2%) Categories 4, 5 1170 (49.4%) 1251 (46.7%) 1186 (43.0%) 1284 (43.0%) 1252 (40.7%) 1298 (41.0%) 1378 (43.2%) 1375 (40.2%) 1516 (39.0%) 1569 (36.8%) ICD‐10‐AM = International Classification of Diseases, tenth revision, Australian modification. * All presentation rates are per 10 000 children in Victoria aged 0–19 years in the corresponding category. † Victorian Emergency Minimum Dataset (VEMD) regions: North‐West, Southern, and Eastern Melbourne. ‡ VEMD regions: Loddon Mallee, Gippsland, Barwon South West, Hume, Grampians. Box 2 – Presentations to Victorian public emergency departments by people aged 0–19 years with food allergy‐related problems: rates per 10 000 population, by age group Box 3 – Presentations to Victorian public emergency departments by people aged 0–19 years with food allergy‐related problems, by hospital campus region

Rachel O'Loughlin · Harriet Hiscock

Usual care must be rapidly adapted to isolate, assess and test large numbers of patients during the COVID‐19 pandemic Coronavirus disease 2019 (COVID‐19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), emerged in China in late 2019.1 COVID‐19 is an example of a high consequence infectious disease that may present to an Australian hospital. These infections are uncommon in Australia and, in most cases, were imported from overseas. Less frequently, there is onward local transmission, such as during the influenza A(H1N1)pdm09 pandemic in 2009. High consequence infectious diseases present unique challenges to Australian hospitals. Their rarity leads to unfamiliarity and loss of institutional knowledge between events. Many hospitals operate at near maximal capacity between outbreaks and have limited surge capacity.2 Protocols designed to manage single patients require adaptation to situations where larger numbers of patients require isolation, assessment and testing for infection. While every Australian hospital has a mass casualty or disaster protocol, these are developed for all hazards and may not address problems specific to high consequence infectious diseases, including: the need to rapidly identify and isolate potentially infectious patients to prevent nosocomial transmission; the complexity of rapid triage and assessment on frequently evolving epidemiological and clinical grounds; the difficulty of differentiating high consequence infectious diseases from more common but clinically similar conditions;3 the absence of rapid diagnostic tests to aid clinical decision making; and the potential for a prolonged surge for weeks to months during which time the workforce may be affected by both infection and absenteeism. Here we describe the strategic approach of the Royal Melbourne Hospital to triage and screen patients who have presented at risk (or concerned that they are at risk) during the early phases of COVID‐19. Our resources may be of value to other organisations refining their triage and clinical algorithms. The Royal Melbourne Hospital response The Royal Melbourne Hospital is an adult tertiary referral centre and the designated state‐wide provider for quarantinable diseases. The emergency department (ED) treats over 80 000 patients annually. From 6 January 2020, we instituted tools to identify at triage those patients with risk factors for COVID‐19 and rapidly isolate them. Initially, there was capacity to assess patients in one of three existing negative pressure rooms. On 25 January, the first patient with COVID‐19 in Australia, who had arrived in Melbourne on a flight from Guangzhou, was confirmed. The Victorian Department of Health and Human Services informed all passengers on the flight of their possible contact with the patient, leading to a significant surge in presentations to the Royal Melbourne Hospital. Box 1 presents an overview of the challenges in managing high consequence infectious diseases and details of our coordinated approach. Key components that can be used by other services are detailed below. Governance Unlike other major incident responses, which tend to be short‐lived, response to an outbreak requires a sustained response that will inevitably have an impact on other clinical services. A governance process that includes executive sponsors and senior clinical leaders is essential. The Royal Melbourne Hospital COVID‐19 response leveraged an existing code brown (external emergency) pandemic subplan and clinical code yellow (internal infectious disease emergency) plans as a governance framework. A governance group including medical and nursing executives and senior clinicians from the ED, infectious diseases, infection prevention services and microbiology meet regularly. A single standard operating procedure exists on our hospital intranet that provides all clinically relevant information for frontline health care workers (eg, personal protective equipment guidelines, current case definitions, patient assessment algorithms). It is updated frequently given the dynamic situation and, thus, functions as a living document for staff. This document provides 24/7 access to an authoritative source that supports junior and senior staff alike to feel confident in their practices and approach. Infrastructure Establishment of a fever clinic. A particular design feature that may be adopted by other facilities is the rapid establishment of an out‐of‐department fever clinic. In response to the first surge of patients, we rapidly repurposed the nearby hospital transit lounge, which was closed for the weekend, into a fever clinic (Box 2). The clinic received its first patient within 2 hours of notification from the Victorian Department of Health and Human Services of the first local case. In its first 7 days, we assessed 109 patients. We discharged over 90% of patients within 4 hours of arrival. We retain this model as patient numbers continue to increase. In this model of care, patients are physically segregated from the rest of the ED into a dedicated rapid assessment and treatment space from their arrival, limiting exposure to other patients. The main benefit of this approach is that cases yet to be identified can be an important contributor to nosocomial transmission; therefore, early separation and detection are vital.4,5 However, immediate recognition of cases is difficult due to unfamiliarity with the disease, overlap in clinical presentation with more common illnesses, and due to patient wait times. Our fever clinic model of care was based on the success of this model in Toronto and Taiwan during the severe acute respiratory syndrome (SARS) outbreak,6 where no transmission was reported in these facilities despite hospital exposure being implicated in the majority of cases in these regions (eg, it was the presumed source of exposure for 72% of patients in Toronto7,8). It has also been reported as an effective strategy for triaging patients in Wuhan for COVID‐19.9 Similar approaches appear to have been used in other countries, but detailed descriptions are not yet available in the literature. In Australia, segregation of major incident patients was exemplified by the Royal Darwin Hospital, which functioned as the forward receiving hospital for medically evacuated patients during the 2002 Bali bombings.4 The benefits of establishing a fever clinic include: protecting an existing environment for the maintenance of business continuity; facilitating protocolised interventions for spatially clustered groups of patients; providing a physical location to send additional disaster resources without cluttering areas of core business; and enhancing record‐keeping. Limitations of our approach include the additional staffing required, operational impact of loss of transit lounge, staff unfamiliarity with the location of resources (such as resuscitation trolleys), and a slightly further distance from resuscitation bays if patients deteriorate. Moreover, we were also concerned about the risk of stigmatisation of patients who are seen to be segregated from the main ED waiting room cohort. Implementation of electronic self‐registration and self‐screening. A surge related to an emerging infectious disease provided our clerks’ department with a confluence of unique administrative and logistical challenges. These included: a high proportion of patients came from a non‐English speaking background; contact tracing and follow‐up requires accurate registration and an extended suite of contact details, but usual disaster response medical records protocols generate only anonymised patient registrations; non‐clinical staff (ward clerks) unfamiliar with personal protective equipment would be required to extensively interview patients to confirm details at some point; patients came in bursts, producing delays in registration; manual screening paperwork and registration papers provide a potential fomite for disease transmission; and our ED is paper‐free under usual circumstances. We developed a novel solution to this problem, leveraging the fact that over 91% of Australian citizens and over 96% of Chinese citizens own a smartphone5,10 and converted an initial paper‐based bilingual screening tool to an online one. This is hosted using the research electronic data capture (REDCap) tool (www.projectredcap.org).11 Patients are directed to a secure website optimised for use on a smartphone. The registration portal is free to use. They answer questions regarding their epidemiological risk (such as a detailed travel history, or being a health care worker), clinical risk factors (such as being immunocompromised) and symptoms. Results are immediately fed to remote clinical computers where ward clerks can register the patient without direct patient contact and clinicians can see screening information before their clinical encounter. While not yet tested under a pandemic scenario, we anticipate this method of self‐registration may be particularly useful in the event of a significant surge in patient numbers. Triage sieve and sort of patients can be rapidly undertaken by clinicians who are fed real‐time registration data. Compared with usual mass casualty principles, the inclusion of epidemiological data in the electronic tool is valuable for triage in this setting to screen out the relatively high proportion of patients with perceived, but not actual epidemiological risk factors. Our REDCap infrastructure is available in the Supporting Information for adaptation by other health services. Conclusion The importation of emerging infections into Australia is rare, and onward transmission is rarer still. As the Royal Melbourne Hospital received a surge in patients who required screening for COVID‐19 relatively early during the current outbreak, our recent observations may provide opportunities for other hospitals to enhance their preparedness and response plans. We prioritise prevention of nosocomial transmission (using a scalable, separated fever clinic) early planning for worsening surge (adopting scalable solutions) and clear clinical governance (providing malleable and accessible centralised resources). Box 1 – Elements of the Royal Melbourne Hospital clinical response Element of response Challenges Approach used Clinical governance Multiple clinical units involved, with tangible impacts on business as usual activity and frequent changes to the model of care and the expectations Where possible, we operated within existing plans and policies. Daily executive and head of unit level huddles were instituted initially, and then stepped down to weekly as needed, producing hospital agreement on messaging and expectations of all teams and sharing of information between executive, infectious diseases (ID), infection prevention services (IPS) and emergency medicine (EM). COVID‐19 multidisciplinary working groups were formed within the ED and ID clinical units Infrastructure A space was needed to accommodate the extra patients while maintaining infectious isolation among them, and between them and the rest of the ED census A graduated response used with existing ED negative pressure rooms used for small numbers, a cohort subwaiting area was created when several patients were present in the ED at once, and a separate fever clinic was created in the nearby transit lounge used for surge response Infection prevention and control practices Transmission dynamics are incompletely understood and there is a risk of nosocomial amplification (especially during aerosolising procedures) Education sessions, posters, and videos used to reinforce PPE training; nebulisers removed from dedicated treatment space; hand sanitiser stations; PPE stations and infectious waste bins deployed; and a SOP employed for aerosolising procedures (Supporting Information) Clinical care (including triage, assessment and testing) There is rapidly evolving understanding of clinical and epidemiological characteristics of the disease. Staff lack familiarity with the disease and with the roles performed (concierge nurse, fever clinic doctor), while the normal ED and hospital functions need to continue alongside Creation of a SOP including clinical algorithms for triage, assessment and biological sampling as a living document hosted on the hospital intranet, and updated as needed and used as a single source of truth for clinical staff. Gradual transition to algorithm‐driven assessment by junior medical staff to free up senior staff for unwell patients. Action cards with role descriptions were provided in the SOP for all fever clinic staff Communication with patients Initially, most patients were Mandarin‐speaking Bilingual signage (English and Mandarin) deployed in the fever clinic, and bilingual patient resources and screening questionnaire generated. Discharge information sheets specific to different tiers of risk were translated into Mandarin and provided to all patients discharged from the fever clinic Human resources Maintenance of staff competence and confidence essential for safety and prevention of absenteeism Regular education sessions to provide updated clinical information and epidemiology, train in PPE, and answer questions COVID‐19 = coronavirus disease 2019; ED = emergency department; PPE = personal protective equipment; SOP = standard operating procedure. Box 2 – Floor plan of the Royal Melbourne Hospital fever clinic and guiding principles for a fever clinic COVID‐19 = coronavirus disease 2019; PPE = personal protective equipment; SOP = standard operating procedure.

Amanda M Rojek · Martin Dutch · David Camilleri · Emma Gardiner · Emma Smith · Caroline Marshall · Kirsty L Buising · Nicola Walsham · Mark Putland

The coronavirus disease 2019 (COVID‐19) pandemic is pushing health systems to, and possibly beyond, their limits.1 In Italy, the exponential rise in case numbers has caused a corresponding rise in demand for intensive care unit (ICU) beds.2 To determine how many ICU beds will be required in Australia, we propose a simple model of an uninterrupted pandemic process based on the local situation in late March 2020, and compare this model with recent data from the Lombardy.3 The uninterrupted exponential growth scenario In queueing theory, Little's law4 describes the relationship between the number of patients in a system (L) and the mean arrival rate (λ) and length of time the patient remains in the system (W) as: L = λW If a tertiary hospital has a steady state rate of 20 new admissions of patients with confirmed COVID‐19 per day, of whom one requires ICU admission5 (λ) for a mean 10 days (W), the hospital ICU will need at least 10 beds to accommodate these patients. If, however, the number of new confirmed cases increases by 20% each day (in late March 2020, the number was increasing in Australia by 23% each day6), and 100 cases are confirmed on one day, about 120 will be confirmed on the next. This increase in the daily rate of 20 new cases will mean one extra ICU admission per day, and the need for at least 10 further ICU beds. That is, the total number of ICU beds needed will be about 10% of the number of confirmed cases, or 50% of the number of new cases during the exponential growth phase of the epidemic. Approximately 2300 ICU beds are available in Australia;7 if public health measures fail to curb the rate of growth in case numbers, the national ICU capacity would be exceeded when the number of COVID‐19 cases reaches 23 000. Other sources8 have estimated that Australia could cope with as many as 44 580 COVID‐19 cases, but this would grant only a 3‐day extension before ICU capacity was exceeded. In our exponential growth scenario, commencing with 100 confirmed cases on day 1, 31 ICU beds would be required by day 7 and 119 by day 14 (Box 1). In sensitivity analyses, ICU bed capacity is sufficient even after 30 days if the ICU admission rate is reduced to 2.5%, but would be exceeded by day 26 were the ICU admission rate as high as 10%. It is important to note that our model describes a particularly serious scenario, and that actual outcomes will be modified by parameters not included in the model, including potential lags between diagnosis, hospital admission, and transfer to intensive care, and the proportion of true positive results among people tested for infecton. Is the modelled scenario plausible? To evaluate how realistic the uninterrupted exponential growth scenario is, we compared exponential and linear growth models with recent data for the Lombardy in Italy.9 Using piecewise regression models, the increase in the number of ICU patients during days 1–14 was exponential (R2 = 0.96); from day 15, ICU admissions continued to rise steeply, but the increase was linear (R2 = 0.99) (Box 2). To determine the reason for the change in growth rate at day 15, we compared the ICU admission and mortality rates for patients hospitalised with COVID‐19. The mortality rate during days 1–14 was fairly constant at about 8.8%, but rose dramatically from day 15 to a mean 23%. Most deaths during the first 14 days were probably of patients in intensive care, but we suspect that from day 15 patients died partly because of the lack of access to ICU beds as demand exceeded the capacity of the system to provide them, as indicated by the fall in ICU admission rate (Box 3). Conclusion While the assumptions of our model can be debated, the exponential increase in Australian cases until late March suggested that it described a realistic clinical scenario consistent with overseas data available at that time. The exponential increase in case numbers and subsequent demand for ICU beds could have overwhelmed the capacity of even the largest Australian hospitals if SARS‐CoV‐2 transmission had not been as drastically reduced as it appears to have been by the successful public health measures enacted by the federal and state governments and the adherence to these measures by the Australian public. The rate of ICU admissions per positive case may be lower in Australia than reported for Italy and China — because of healthier underlying demographic conditions, a greater number of detected milder cases, or both — but this would not change the overall implications of the model. Australia must maintain measures to strictly control the rate of new cases and continue to improve our ICU surge capacity, lest we squander the chance to avoid an Italian fate. Box 1 – Intensive care unit (ICU) bed demand, by time and proportion of patients with confirmed COVID‐19 who require intensive care Box 2 – Intensive care unit (ICU) admission rate in the Lombardy: actual and modelled Box 3 – Intensive care unit (ICU) admission rate and mortality for all patients with COVID‐19 admitted to hospitals in the Lombardy

Hamish DD Meares · Michael P Jones

Introduction: This statement was planned on 11 March 2020 to provide clinical guidance and aid staff preparation for the coronavirus disease 2019 (COVID‐19) pandemic in Australia and New Zealand. It has been widely endorsed by relevant specialty colleges and societies. Main recommendations: Generic guidelines exist for the intubation of different patient groups, as do resources to facilitate airway rescue and transition to the “can't intubate, can't oxygenate” scenario. They should be followed where they do not contradict our specific recommendations for the COVID‐19 patient group. Consideration should be given to using a checklist that has been specifically modified for the COVID‐19 patient group. Early intubation should be considered to prevent the additional risk to staff of emergency intubation and to avoid prolonged use of high flow nasal oxygen or non‐invasive ventilation. Significant institutional preparation is required to optimise staff and patient safety in preparing for the airway management of the COVID‐19 patient group. The principles for airway management should be the same for all patients with COVID‐19 (asymptomatic, mild or critically unwell). Safe, simple, familiar, reliable and robust practices should be adopted for all episodes of airway management for patients with COVID‐19. Changes in management as a result of this statement: Airway clinicians in Australia and New Zealand should now already be involved in regular intensive training for the airway management of the COVID‐19 patient group. This training should focus on the principles of early intervention, meticulous planning, vigilant infection control, efficient processes, clear communication and standardised practice.

David J Brewster · Nicholas Chrimes · Thy BT Do · Kirstin Fraser · Christopher J Groombridge · Andy Higgs · Matthew J Humar · Timothy J Leeuwenburg · Steven McGloughlin · Fiona G Newman · Chris P Nickson · Adam Rehak · David Vokes · Jonathan J Gatward