ASEM Best Paper Prizes 2008
"Advanced Airway Equipment Usage, Perceived and Desired Competency, and Training"
A survey of Fellows and Trainees of ACEM
Authors: Julian Willcocks and Wayne Hazell, Middlemore Hospital
Background: Airway management is vital in critically ill patients. A recent survey of adult Australian emergency departments accredited for training with the Australasian College for Emergency Medicine (ACEM) documented the range of airway equipment in these departments.
Objective: The aims were to describe, in relation to different types of airway equipment, Fellow and trainee: 1. frequency of use and training; 2. self perceived current competency, 3. perceived requirement for end of training competency.
Methods: A questionnaire was created using a web based interface. Emails were sent to Fellows and trainees of the Australasian College for Emergency Medicine with a link to the survey.
Results: In total 577 fellows (53%) and 572 trainees (39%) responded. Only curved and straight blades, bougies, stylets and laryngeal masks were used commonly. Fellows had more training than trainees on mannequins, simulators or animal models with all equipment (overall P<0.0001). Trainees rated themselves less than competent more frequently with all commonly and frequently used devices (P<0.0001). There was a marked difference of opinion between Fellows and trainees on end of training competency. 34% of Fellows and 44% of trainees did not know whether an airway skills course was offered in their region.
Conclusions: Difficult airway equipment is used less than standard advanced airway equipment and perceived competency is lower. Clearer ACEM fellowship curriculum advanced airway learning objectives could be considered. Greater awareness of airway courses is needed. There may be a need for standardization of equipment across departments and regions.
"A Descriptive Study of Inter-Hospital Transfer Involving ED Patient’s to a Tertiary Hospital in the Perth Metropolitan Area"
Authors: Lucia Gillman, ED RN, Associate Professor Daniel Fatovich, Associate Professor Ian Jacobs
Introduction: Inter-hospital transfers are a significant workload for the Emergency Department (ED) and maintaining quality of care is important to optimise patient outcome. There is a lack of published data about the quality of transfer care provided locally.
Objectives: To describe adverse events associated with interhospital transfer of critically ill ED patient’s to a tertiary facility in the Perth metropolitan area and describe need for critical interventions in the first hour following transfer.
Method: A retrospective audit of inpatient and ambulance records for a random sample (n=400) of critically ill inter-hospital ED transfers to Royal Perth Hospital (RPH). The clinical condition of transferred patients was compared on departure from the referring ED and on arrival to RPH using Medical Emergency Team criteria to identify clinically significant deterioration. An expert panel examined each episode where deterioration occurred, or critical interventions were required within the first hour following transfer, to determine if deterioration was potentially preventable.
Results: Eight (2%) of the 400 patients experienced clinically significant deterioration during transfer. Critical interventions or procedures were required in 33 (8%) patients. After excluding those interventions not available at the referring facility, or those related to the reason for referral, there were 12 (3%) patient’s in which interventions could have been initiated prior to arrival to improve patient stability. All of these interventions related to the management of airway, breathing or circulation.
Conclusion: The rate of clinically significant deterioration during ED inter-hospital transfer was low suggesting transfer care in the population sampled was acceptable. Delayed interventions in 3% of patients highlights the need for vigilance in transfer and identifies areas for improvement. Whilst we accept that decision making in transfer is complex and influenced by numerous factors the use of a structured approach to patient management is recommended to guide management
This presentation discusses the findings from two studies, one completed, the other, an on-going prospective study which commenced in May 2008. The first study reports on the findings of a quantitative, retrospective service evaluation. It compared a simple, single person, conscious sedation-free technique to reduce anterior glenohumeral dislocations, called the Oxford Chair Technique (OCT), with the Traditional Methods of Reduction (TMR) currently implemented. The second, a prospective study which commenced in May 2008, has similar objectives, however, limitations and weaknesses of this first study were addressed.
Author: Stuart Smith, Emergency Nurse Practitioner, Lyell McEwin Hospital, Adelaide
Objectives: The first objective was to examine whether the OCT can reduce anterior glenohumeral dislocations. Secondary objectives examined how the OCT compared, using set factors, against the TMR currently used. The fundamental comparisons being analysed was in terms of time taken for treatments.
Study One: Of the 61 cases in which the OCT was used 38 attempts to reduce the dislocation were successful, an overall success rate of 62%. Statistically significant differences were found with the mean time from arrival to discharge (OCT 141 v. TMR 254 minutes, p<0.001); mean time between the first diagnostic x-ray and post reduction x-ray (OCT 70 v TMR 102 minutes, p<0.003) and the mean time between the post reduction x-ray and discharge (OCT 51 v. TMR 119 minutes, p<0.001).
No patients treated with the OCT required conscious sedation compared to 90% of patients treated with TMR (p<0.001). Only 38% of patients treated with the OCT had morphine administered compared to 90% of patients treated with TMR (p<0.001).
Study Two: Of the 16 cases in which the OCT was used 14 attempts to reduce the dislocation were successful, an overall success rate of 87%. For 57% (n=8) of patients this was their first glenohumeral dislocation. An Emergency Nurse Practitioner (ENP) successfully performed 64% (n=9) of the reductions. The median time between seeing a Dr/ENP and being ready for the post reduction x-ray 49 minutes; the median time between seeing a Dr/ENP and being ready for discharge was 95 minutes; the median arrival to discharge time was 150 minutes (275 minutes with TMR). Finally, the mean time to reduce the dislocation was 6 minutes.
No complications were reported with the OCT.
Conclusions: When reduction was successful using the OCT there were overwhelming time saving benefits to the patient with subsequent logistical benefits to the Emergency Department (ED). This simple method of glenohumeral dislocation reduction allows other allied health care professionals to perform this skill, in this case ENPs. This subsequently enables Medical Officers to be released to manage more critically ill and complex patients presenting to the ED.