j:ema2008_20

Ultrasonic cardiac output monitor (USCOM)
still problematic with technical difficulties needing more studies
accuracy depends upon obtaining accurate VTI and valve diameter measurements, and certain assumptions are made:
- degree angle between US beam and direction of blood flow is near zero degrees & remains constant
- the cross-sectional area of the vessel remains constant throughout systole despite changes in BP or CO.
intrathoracic air such as in ventilated patients reduces acoustic signal which may result in poor flow signals.

although adenosine is efficacious in Rx of stable SVT, it is no more efficacious than cheaper alternatives.
it has a possible role in 1st line Rx of unstable SVT & is generally safe & effective when used to Rx &/or Dx wide complex tachycardias.
there is a small risk of inducing serious arrhythmias, such as prolonged AV blockade and VF
evidence that recommended initial doses of 100ug/kg for infants may be too low but adequate for children and adults.

NSW-based study looking at predictors for failed SSU (Short Stay Unit) or EDOU (ED Observation Unit) patients who then require admission to a inpatient ward bed instead of being discharged home from the SSU or EDOU.
860 adult patients admitted to the EDOU during the study (10.3% of all their adult presentations) with failed observation rate 16.9%
predictive factors noted:
- inability to mobilise in ED prior to transfer to the EDOU (Odds Ratio 2.4-9.5)
- requiring active Rx in EDOU rather than just observation or investigation (Odds Ratio 1.1-2.4)
- requiring referral to inpatient unit prior to transfer to the EDOU (Odds Ratio 3.4-11.4)
- requiring referral to allied health while in EDOU (Odds Ratio 1.1-2.6)
factors found NOT to be predictive:
- age - although age > 80yrs has been found to predict 30day re-admission rate in other studies
- diagnosis - although they presumably had strict admission criteria
- polypharmacy
- poly-comorbidities

Bendigo Hospital in regional Victoria
implementation of streaming model fails to impact percentage of patients who did not wait to be seen (DNW) although apparently reversed the downward trend of 4hr discharges and 8hr admit to ward KPIs.
streaming model involves triage nurse deciding which stream patient should go down:
- “gold stream” - patient likely to require complex care and thus allocated to one of 12 “gold stream” cubicles
- “blue stream” - triage 3-5 patients likely to require less complex care and unlikely to be admitted and thus allocated to one of 5 “blue stream” cubicles

Bankstown Hospital, NSW
census: 40,000pts/yr, 25% paed.
introduction of a Fast Track streaming model based on patient complexity with additional dedicated staffing and physical resources which resulted in:
- reduction in mean waiting time from 55 to 32min
- reduction in mean Rx time from 209-191min
- improved wait time KPI with benchmark being met 77% of the time, up from 59%
- DNW rate halved from 6.2% to 3.1%

majority of first-aid presentations were of low acuity with only a small number requiring ambulance transport to hospital.