Point of care troponin decreases time in the emergency department for patients with possible acute coronary syndrome: A randomised controlled trial

Objective: To determine the effect of cardiac troponin I testing with a point-of-care (POC) device versus central laboratory on length of stay (LOS) in emergency department (ED) patients presenting with possible acute coronary syndromes (ACS). Methods: A 12-week randomised controlled trial at two metropolitan ED in eastern Australia with a combined annual census of 80 000. Participants were all patients presenting with possible ACS. Exclusions were a diagnosis of ACS before arrival, ST elevation and failure to wait for complete assessment. Randomisation was by week when POC was made available. Primary outcome was LOS from patient arrival to physical departure from the ED. The proportion of patients meeting a government target of less than 8 h stay was compared. Analysis was by intention to treat. Results: Despite underutilisation of POC, LOS was shorter during weeks when it was available. The time savings translates into approximately 48 minutes (95% CI 12 to 84) per average LOS of almost 7 h, which did not reach statistical significance (p=0.063), or an absolute increase of 10% (95% CI 4.3 to 16.6) in the number of people discharged from the ED within the target LOS of less than 8 h, which did reach significance (p=0.007). These savings were more pronounced in the setting without 24 h central laboratory availability. Conclusions: POC testing for troponin in the ED tended to reduce the LOS for possible ACS patients. The degree of this benefit is likely to be markedly dependent on its acceptance and uptake by attending personnel, and on the ED setting in which it is used

Opportunistic childhood vaccinations in emergency: are we really missing anyone?

Objectives: Every health service presentation of a child should be considered an opportunity to ensure optimal immunisation. Measures to limit missed opportunities for vaccination in local emergency departments (ED) should reflect the scale of opportunity and parental support of immunisation service delivery strategies. Methods: The vaccination status of every child aged less than seven years that presented to a tertiary hospital ED over a three month period was identified using the Australian Childhood Immunisation Register (ACIR). Contra-indications to vaccination were determined from medical records. A telephone survey or posted survey was conducted with parents of eligible children to confirm ACIR status and whether they would have consented to receiving vaccinations during their presentation. ED records were reviewed for vaccination history recording and ACIR records were reviewed, after interview, to confirm parental reports that initial ACIR status was incorrect. Results: Nine per cent (215/2399) of children were identified as incompletely vaccinated according to ACIR. Forty-seven children were excluded. Of the remaining 168 children, 95 parents (57%) participated. Thirty-eight children had no contra-indications and their parents would have consented to vaccination during their ED presentation. The vaccination status of 82% (78/95) was recorded in ED records, but was incorrect in 35 cases. Forty parents indicated that the ACIR record was incorrect and this was confirmed in 36 cases (90%). Conclusions: There were missed opportunities to vaccinate a small proportion of children in ED. Parents provided a more accurate timely history of immunisation status than ACIR and thus ED staff should ensure that parents are always asked whether their child is fully vaccinated and provide or encourage vaccination

A randomised controlled trial of hot water (45˚C) immersion versus ice packs for pain relief in bluebottle stings

OBJECTIVE: To investigate the effectiveness of hot water immersion for the treatment of Physalia sp. (bluebottle or Portuguese Man-of-War) stings. \ud \ud DESIGN: Open-label, randomised comparison trial. Primary analysis was by intention to treat, with secondary analysis of nematocyst-confirmed stings. One halfway interim analysis was planned. SETTING: Surf lifesaving first aid facilities at two beaches in eastern Australia from 30 December 2003 to 5 March 2005. \ud \ud PARTICIPANTS: 96 subjects presenting after swimming in the ocean for treatment of an apparent sting by a bluebottle. \ud \ud INTERVENTIONS: Hot water immersion (45˚C) of the affected part versus ice pack application. \ud \ud MAIN OUTCOME MEASURES: The primary outcome was a clinically important reduction in pain as measured by the visual analogue scale (VAS). Secondary outcomes were the development of regional or radiating pain, frequency of systemic symptoms, and proportion with pruritus or rash on follow-up. RESULTS: 49 patients received hot water immersion and 47 received ice packs. The two groups had similar baseline features, except patients treated with hot water had more severe initial pain (VAS [mean +/- SD]: 54 +/- 22 mm versus 42 +/- 22 mm). After 10 minutes, 53% of the hot water group reported less pain versus 32% treated with ice (21%; 95% CI, 1%-39%; P = 0.039). After 20 minutes, 87% of the hot water group reported less pain versus 33% treated with ice (54%; 95% CI, 35%-69%; P = 0.002). The trial was stopped after the halfway interim analysis because hot water immersion was shown to be effective (P = 0.002). Hot water was more effective at 20 minutes in nematocyst-confirmed stings (95% versus 29%; P = 0.002). Radiating pain occurred less with hot water (10% versus 30%; P = 0.039). Systemic effects were uncommon in both groups. CONCLUSIONS: Immersion in water at 45 degrees C for 20 minutes is an effective and practical treatment for pain from bluebottle stings