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Liverpool, Australia

Holdgate A.,Emergency Medicine Research Unit
Cochrane database of systematic reviews (Online) | Year: 2012

Patients with paroxysmal supraventricular tachycardia frequently present to the Emergency Department. Where vagal manoeuvres fail, the two most commonly used drugs are adenosine and calcium channel antagonists. Both are known to be effective but both have a significant side-effect profile. To examine the relative effects of adenosine and calcium channel antagonists and, if possible, to determine which is most appropriate for the management of supraventricular tachycardia. Studies were identified from The Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, Issue 2, 2010, MEDLINE (1966 to May Week 1 2010) and EMBASE (1980 to 2010 week 19). The searches were originally run in June 2006 and updated and re-run in May 2010. Bibliographies of identified studies were also examined. No language restrictions were applied. Randomised trials comparing adenosine and a calcium channel antagonist in patients of any age with supraventricular tachycardia, where one of the defined outcomes was reported. Outcomes of interest were: reversion rate, mortality, time to reversion, rate of relapse, major and minor adverse events, length of hospital stay and patient satisfaction. Two authors independently checked the results of searches to identify relevant studies. Dichotomous outcomes were reported as Peto Odds ratios and continuous outcomes as weighted mean differences. A total of ten trials were identified (two new trials were identified through the updated search in May 2010), all of which used verapamil as the calcium antagonist. In the pooled analysis there was no significant difference in reversion rate between the two drugs. Time to reversion was slower for verapamil than adenosine in all studies that reported this outcome, but the data were not suitable for combining. Relapse rates were higher for adenosine compared with verapamil (OR 0.25, 95% CI 0.07 to 0.99. P=0.05). Minor adverse events such as nausea, chest tightness, shortness of breath and headache were reported much more frequently in patients treated with adenosine with 10.8 % of patients reporting at least one of these events, compared with 0.6% of those treated with verapamil (OR 0.15, 95% CI 0.09 to 0.26, P<0.001). Hypotension was reported exclusively in the verapamil treatment group (4/214), and occurred in none of the patients treated with adenosine (OR 10.8, 95% CI 1.46 to 80.22, P=0.02). Adenosine and verapamil are both effective treatments for supraventricular tachycardia in the majority of patients. There is a high incidence of minor but unpleasant side effects and a greater risk of relapse in patients treated with adenosine while some patients treated with verapamil may develop significant hypotension. Patients should be fully informed of these risks prior to treatment.

Nugus P.,University of New South Wales | Holdgate A.,Emergency Medicine Research Unit | Fry M.,University of Technology, Sydney | Forero R.,University of New South Wales | And 2 more authors.
Academic Emergency Medicine | Year: 2011

Objectives: In this hypothesis-generating study, we observe, identify, and analyze how emergency clinicians seek to manage work pressure to maximize patient flow in an environment characterized by delayed patient admissions (access block) and emergency department (ED) crowding. Methods: An ethnographic approach was used, which involved direct observation of on-the-ground behaviors, when and where they happened. More than 1,600 hours over a 12-month period were spent observing approximately 4,500 interactions across approximately 260 emergency physicians and nurses, emergency clinicians, and clinicians from other hospital departments. The authors content analyzed and thematically analyzed more than 800 pages of field notes to identify indicators of and responses to pressure in the day-to-day ED work environment. Results: In response to the inability to control inflow, and the reactions of inpatient departments to whom patients might be transferred, emergency clinicians: reconciled urgency and acuity of conditions; negotiated and determined patients' admission-discharge status early in their trajectories; pursued predetermined but coevolving pathways in response to micro- and macroflow problems; and exercised flexibility to reduce work pressure by managing scarce time and space in the ED. Conclusions: To redress the linearity of most literature on patient flow, this study adopts a systems perspective and ethnographic methods to bring to light the dynamic role that individuals play, interacting with their work contexts, to maintain patient flow. The study provides an empirical foundation, uniquely discernible through qualitative research, about aspects of ED work that previously have been the subject only of discussion or commentary articles. This study provides empirical documentation of the moment-to-moment responses of emergency clinicians to work pressure brought about by factors outside much of their control, establishing the relationship between patient flow and work pressure. We conceptualize the ED as a dynamic system, combining socioprofessional influences to reduce and control work pressure in the ED. Interventions in education, practice, policy, and organizational performance evaluations will be supported by this systematic documentation of the complexity of emergency clinical work. Future research involves testing the five findings using systems dynamic modeling techniques. © 2011 by the Society for Academic Emergency Medicine.

Raman S.,Child Protection | Holdgate A.,Emergency Medicine Research Unit | Torrens R.,Emergency Medicine Research Unit
Child Abuse Review | Year: 2012

Previous studies have suggested that child abuse and neglect (CAN) is under recognised and under reported. Our aims were to examine and compare child protection (CP) knowledge, confidence and practice of frontline clinicians in general practice and hospital settings in South Western Sydney (SWS). We surveyed doctors and nurses in general practice and in the emergency department (ED) in a district in SWS using a validated questionnaire. Of the 113 responses, 62 were general practitioners (GPs), 9 practice nurses, 26 ED nurses and 16 ED doctors. The confidence level with identifying CAN was moderate, with a significant difference between groups. The majority (59%) had made previous CP reports, few suspected but decided not to report; reporting rates differed significantly. A majority (80%) reported some CP training; of the 22 with no training, 21 were GPs and practice nurses. Of those reporting some training, more than 70 per cent of ED nurses, GPs and practice nurses felt their training was inadequate, compared with 19 per cent of ED doctors. There are significant differences in confidence and practice between frontline clinicians in primary care and ED. Targeted CP training should be provided for all frontline clinicians with particular emphasis on primary care GPs. © 2011 John Wiley & Sons, Ltd.

Holdgate A.,Emergency Medicine Research Unit | Holdgate A.,University of New South Wales | Shepherd S.A.,Emergency Medicine Research Unit | Huckson S.,National Health Research Institute
EMA - Emergency Medicine Australasia | Year: 2010

Objectives: Fractured neck of femur is a common ED problem and poor pain management in this patient group can contribute significantly to their morbidity. The present study aims to describe current practices for managing pain in patients with fractured neck of femur in Australian ED and to identify real or potential barriers to providing analgesia. Methods: Hospitals were invited to participate in a retrospective medical chart audit of patients with fractured neck of femur. At each site, 20 cases were randomly selected from the previous 12 months. Patient demographics, timing, type and method of analgesia in ED, use of pain scales and perceived barriers to analgesia were extracted from the medical chart. Results: Data on 646 patients were collected from 36 hospitals in five Australian states. Most patients were elderly with a preponderance of women. One hundred and eighty-five (28.6%) patients had no record of analgesia administration in the ED and almost half of these had also not received prehospital analgesia. Intravenous morphine was the most frequently used analgesic and only 45 patients received a nerve block in the ED. The median time to first analgesia was 75 min after ED arrival. The most commonly reported barriers reported were cognitive impairment and language difficulties. Conclusions: Oligoanalgesia for fracture neck of femur in Australian ED is common and time to analgesia tends to be relatively slow. Regional techniques are infrequently used despite their recognized efficacy. Strategies for improving pain management in this cohort of ED patients need to be explored. © 2009 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Au E.H.K.,University of New South Wales | Au E.H.K.,Emergency Medicine Research Unit | Holdgate A.,University of New South Wales | Holdgate A.,Emergency Medicine Research Unit
Injury | Year: 2010

Objective: Past research on trauma teams has largely focused on the outcomes of severely injured patients. Few studies have looked at patients who have activated the trauma team but are discharged home directly from the Emergency Department. The aim of this study was to examine the characteristics and outcomes of these patients following discharge. Methods: All adult Emergency Department discharged trauma patients who were contactable by telephone 7-14 days post-discharge and spoke English were eligible for the study. A 10-min questionnaire was conducted covering their perceptions of Emergency Department care, return to activities, discharge and follow-up care, missed injuries and pain management. Data were also collected on their age, sex, injuries and length of stay in the Emergency Department. Results: Over the 169-day study period, 158 trauma patients were discharged from Liverpool hospital, which formed 30.1% of all patients treated by the trauma team. Of these, 106 patients were contactable and 100 completed the follow-up questionnaire. They suffered mainly minor injuries but stayed a median 341 min in the Department. Most patients (87%) reported that their health had impacted on their daily activities and about half of all full-time workers remained off work for 1 week or more. A small number of patients had missed fractures or other serious injuries. Two-third of patients visited a medical practitioner after discharge and 8 required further specialist and/or in-patient care. Conclusion: Most trauma patients discharged from the Emergency Department continue to suffer significant morbidity after their departure from hospital and require further medical care. A small number of patients also had significant missed injuries. This suggests that more comprehensive discharge and follow-up care for these patients is warranted. Crown Copyright © 2009.

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