Sunshine Hospital

ABSTRACTObjectiveTo develop a clearer understanding of what ‘quality in emergency care’ means from the perspective of patients and families to assist with the development of consumer‐informed measures of quality for emergency care in an Australian setting.MethodsQualitative analysis of transcripts from three semi‐structured focus groups, with 24 participants recruited using purposive sampling from a pre‐existing consumer expert Safer Care Victoria (SCV) panel. The focus groups were audio‐recorded, transcribed and de‐identified. Thematic analysis was performed using NVivo software.ResultsSix major themes were identified: Staff‐patient interactions, Provision of information, Time spent in the ED, Emotional experience, Needs of specific groups and Perception of the emergency care system. Patient and carer experiences of accessing emergency care are highly influenced by the nature of their interactions with staff and the ease and accessibility of information exchange. Prolonged ED wait times are a negative experience; however, this can be improved with attention to symptom management, comfort and privacy. The needs of priority patient groups (e.g., patients with disabilities or people of older age) may be frequently overlooked in ED settings. Participants in this study reported that many of the negative aspects of emergency care they experienced may be attributed to the system being overburdened/staff having insufficient time.ConclusionsConsumer‐informed measures of quality in emergency care should address staff‐patient interactions, emotional experience, information provision, time spent in the ED and be sensitive to the needs of priority groups.

Situs inversus totalis (SIT) is a rare congenital condition characterized by the mirror-image reversal of thoracic and abdominal organs. Its incidence is between 0.04% and 0.30%. Patients with SIT presenting with cholelithiasis pose diagnostic and technical challenges, particularly during laparoscopic cholecystectomy (LC), due to reversed anatomic landmarks and difficulties in orientation. We conducted a retrospective review of 12 patients with SIT who underwent LC between September 2006 and April 2023 at our tertiary center. Preoperative evaluation included hematology, liver function tests, ultrasonography, cardiac, and pulmonary assessments. Surgeries were performed under general anesthesia using a modified French technique in mirror-image configuration. A harmonic scalpel (ultracision) was used for dissection in all cases. Out of 5375 LCs performed during the study period, 12 were in patients with SIT (prevalence: 0.22%). All procedures were completed laparoscopically without conversion. One case required port site modification for optimal clip application. Two patients underwent gallbladder decompression, and one developed postoperative ileus, which resolved conservatively. No intraoperative complications, bile duct injuries, or mortalities were observed. Laparoscopic cholecystectomy in SIT patients is safe and feasible when performed by experienced surgeons. Modifications in surgical technique and port placement are essential to accommodate the reversed anatomy. Preoperative planning and intraoperative vigilance are key to minimizing complications and achieving outcomes comparable to anatomically normal patients.

BackgroundMobile stroke units (MSUs) accelerate prehospital acute stroke care and improve outcomes. Both onboard and telemedicine neurologist models of care are used but have not been directly compared.MethodsMSU-TELEMED was a randomized, open-label, blinded-endpoint trial comparing onboard neurologist care to a telemedicine care model for people presenting to an MSU with suspected stroke. MSU care was prospectively randomized by day to onboard versus telemedicine care. The primary outcome was a hierarchical composite outcome using a win-odds approach that prioritized: (1) safety, (2) scene-to-treatment-decision time, and (3) percentage of the total case time the neurologist spent in direct care (higher values denote better resource use). Every participant in each group was compared to those in the other, resulting in a “win/tie/loss” distribution for telemedicine compared to onboard.ResultsA total of 275 participants were assigned to telemedicine (n=135) or onboard (n=140) neurologist care groups. The primary outcome of win/tie/loss distribution favored the telemedicine model (76%/4%/20%) with an adjusted win odds of 3.5 (95% confidence interval [CI], 2.4–5.1). Safety events were similar (13% telemedicine vs. 12% onboard, risk ratio 0.9; 95% CI, 0.5–1.8). Median scene-to-treatment-decision time was 19 minutes in the telemedicine group and 13 minutes in the onboard group (adjusted difference in median time 4 minutes; 95% CI, 1.9–5.9). The median percentage of the neurologist’s time directly involved in patient care was 100% in the telemedicine group and 33% in the onboard group (adjusted difference in median percentage 63 percentage points; 95% CI, 53–74).ConclusionsCompared to an onboard model, an MSU telemedicine model of care was superior based on a composite hierarchical outcome of safety, scene-to-treatment-decision time, and percentage of the neurologist’s time spent in direct care. (Funded by the Sylvia and Charles Viertel Charitable Foundation and the Medical Research Future Fund “Golden Hour”; ClinicalTrials.gov number, NCT05991310.)

ABSTRACTAimTo evaluate the relationship between the Bröset Violence Checklist and additional risk factors identified in prior research by our team to determine which combination best predicted an emergency response to a violent incident in an emergency department.DesignA prospective observational study was used to collect data about a single cohort of adult patients admitted in August 2024.MethodNurses who use the Bröset Violence Checklist as part of routine observations scored eight additional violence indicators and recorded security incidents.ResultsData from 5634 observations, 1762 patients, and 68 emergency incidents was analysed using a combination of descriptive and inferential statistics to evaluate the relationship between factors and incidents. Seven factors correlated significantly with violence (p < 0.05). Three factors (verbal threats, physical threats, and attacking objects) were excluded as they represent manifestations of violence rather than predictive indicators. Receiver Operating Characteristics analysis of the combination of the remaining four factors (history of violence, drug and/or alcohol influence, agitation/restlessness, and imposed restrictions) revealed an Area Under the Curve of 0.98.ConclusionThe findings were integrated to develop a revised instrument—the Aggression and Violence Evaluation of Risk Tool. This new tool demonstrates equivalent predictive capability to the Bröset Violence Checklist, yet it is simpler and easier to use.ImpactContext‐specific violence assessment schemes are needed to strengthen risk mitigation strategies. The Aggression and Violence Evaluation of Risk Tool incorporates unique situational risks developed specifically for emergency departments. It has the potential to effectively ameliorate violence risk and enhance worker and patient safety.Reporting MethodSTROBE has been followed.ImplicationsThe findings produced an instrument that can be translated to emergency departments to reduce the prevalence of violence.Patient or Public ContributionLimited patient and public involvement comprising observations of adult patients in an emergency department in Melbourne, Australia.

The lung-protective and injurious potential of spontaneous breathing effort during positive pressure ventilation (PPV) in adults is well understood but has never been defined in the preterm lung. To determine the role of synchronous and asynchronous breathing during PPV on lung injury. Steroid-exposed intubated preterm lambs (n = 59; 126-130 days gestation) were randomly allocated to receive (1) fully synchronized PPV or (2) asynchronous PPV or apnoeic PPV for 90 minutes from birth using an otherwise standardized lung-protective PPV strategy. Breathing was supported with caffeine, doxapram, and stimulation. Lung mechanics, gas exchange, and regional ventilation and aeration characteristics were measured during PPV. Lung tissue and bronchoalveolar fluid were taken for histology and proteomic analysis. Clinical characteristics and gas exchange were similar. Each PPV strategy generated unique flow and pressure characteristics that were associated with different lung proteome expression. Overall, asynchronous breathing created the most injury, the least developed alveolar morphology, and 5-fold more dependent lung differentially expressed proteins (compared to synchronous and apnoeic PPV). Synchronous and apnoeic PPV resulted in similar morphology and minimal acute injury. At study completion, dynamic compliance and gravity-dependent center of ventilation were better in the synchronous PPV group compared to the apnoeic PPV group, with a mean (95% CI) difference of 0.26 (0.08-0.43) mL/kg/min and 3.6% (1.0%-6.1%), respectively (analysis of variance). Different breathing efforts during PPV support of the preterm lung create complex lung states, each with unique and measurable injury events. This offers the potential to develop lung-protective strategies that target minimizing breathing-related injury.

Abstract Introduction Measuring circadian timing informs the diagnosis of Insomnia and Delayed Sleep–Wake Phase Disorder (DSWPD) in adults, however this has not been studied in adolescents. This study examined circadian timing of sleep in adolescents, including those meeting diagnostic criteria for insomnia and DSWPD. Methods Participants were a community sample of adolescents (n = 125, age M ± SD = 13.52 ± 1.04) who completed a diagnostic sleep interview (SCISD) to assess whether they met subthreshold or threshold insomnia or DSWPD criteria. Participants completed two weeks of sleep–wake monitoring during school term, with circadian phase measured via salivary dim light melatonin onset [DLMO] on the last Friday of sleep monitoring. Results Twenty (16%) adolescents met insomnia criteria (n = 7 threshold, n = 13 subthreshold), 14 (11.2%) DSWPD criteria (n = 9 threshold, n = 5 subthreshold), and 91 (72.8%) did not meet any criteria for either. In adolescents who met insomnia criteria, DLMO occurred at 20:57h ± 1.16 (range 18:56–00:00h), with sleep onset occurring 1.73h ± 1.31 after DLMO (range -1.78- 3.5h). In adolescents who met DSWPD criteria, DLMO occurred at 21:05 ± 1.12 (range 19:17–23:43h), with sleep onset occurring 2.38h ± 1.18 after DLMO (range 0.44-4.02h). For those who met no criteria for either condition, DLMO occurred at 20.60 ± 1.22 (range 18.02-23.68h), with sleep onset occurring 1.97 ± 1.22 after DLMO (range -1.54-5.67h). Twelve participants initiated sleep before or within 30 minutes of their DLMO time (n = 2 insomnia, n = 2 DSWPD, n = 8 no symptoms). Discussion We observed large inter-individual variability in circadian timing and phase angle in adolescents meeting diagnostic criteria for insomnia and DSWPD, indicating limited differentiation in circadian timing using diagnostic interviews.