[Show abstract][Hide abstract] ABSTRACT: To use an automated Classification of Hospital Acquired Diagnoses (CHADx) reporting system to report the incidence of hospital-acquired complications in inpatients and investigate the association between hospital-acquired complications and hospital length of stay (LOS) in multiday-stay patients.
Retrospective cross-sectional study for calendar years 2010 and 2011.
South Metropolitan Health Service in Western Australia, which consists of two teaching and three non-teaching hospitals.
Incidence of hospital-acquired complications and mean LOS for multiday-stay patients.
Of 436 841 inpatient separations, 29 172 (6.68%) had at least one hospital-acquired complication code assigned in the administrative data, and there were a total of 56 326 complication codes. The three most common complications were postprocedural complications; cardiovascular complications; and labour, delivery and postpartum complications. In the subset of data on multiday-stay patients, crude mean LOS was longer in separations for patients with hospital-acquired complications than in separations for those without such complications (17.4 days v 5.4 days). After adjusting for potential confounders, separations for patients with hospital-acquired complications had almost four times the mean LOS of separations for those without such complications (incident rate ratio, 3.84; 95% CI, 3.73-3.96; P < 0.001).
An automated CHADx reporting system can be used to collect data on patients with hospital-acquired complications. Such data can be used to increase emphasis on patient safety and quality of care and identify potential opportunities to reduce LOS.
The Medical journal of Australia 10/2013; 199(8):543-7. · 2.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: • Paracetamol is commonly used in deliberate self poisoning (DSP) and this requires blood sampling to refine risk assessment. If saliva concentrations agreed with plasma concentrations, then this could support the development of non-invasive testing. Our pilot work supports this hypothesis, but was largely confined to nontoxic concentrations.
• We found agreement between the indications for treatment of paracetamol DSP based on plasma and saliva paracetamol concentrations. Saliva may hold promise as a non-invasive method to risk stratify paracetamol poisoning.
Paracetamol is commonly used in deliberate self poisoning (DSP) and requires blood sampling to refine risk assessment. We aimed to test the agreement between plasma and saliva paracetamol concentrations in the toxic range in DSP.
Contemporaneous paired plasma and saliva paracetamol concentrations were measured. Saliva was collected using a Sarstedt Salivette® device and the concentration was measured using a colorimetric method.
Fifty-six patients (44, 78% female) median age 26 years (IQR 20-41) were enrolled. The median reported paracetamol ingestion was 10 g (IQR 6-14). Specimens were collected at a median of 4 h (IQR 4-5.3) post ingestion. The median plasma and saliva paracetamol concentrations were 29 mg l(-1) (IQR 8-110) and 38 mg l(-1) (IQR 10-105) respectively [mean difference 8 mg l(-1) , 95% confidence interval (CI) 2, 14]. Lin's concordance correlation was 0.97 (95% CI 0.96, 0.98). There were 15 patients who were treated with N-acetylcysteine. Their median reported paracetamol ingestion was 14 g (IQR 10-23) and samples were collected at a median of 4 h post ingestion. The median plasma and saliva paracetamol concentrations were 167 mg l(-1) (IQR 110-200) and 170 mg l(-1) (IQR 103-210) respectively (mean difference 15 mg l(-1) , 95% CI -4, 35). Lin's concordance correlation was 0.94 (95% CI 0.88, 0.99). No patient needing treatment would have been missed using saliva concentrations only.
The agreement between the indications for treatment of paracetamol DSP based on plasma and saliva paracetamol concentrations extends into the toxic range, but with slightly lower agreement. Saliva may hold promise as a non-invasive method to risk stratify paracetamol poisoning.
British Journal of Clinical Pharmacology 11/2011; 74(1):154-60. · 3.69 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Little is known about patient perceptions of the lethality of their overdose. Our aim was to compare patient perceptions with the risk assessment of clinical toxicologists.
A prospective observational study of overdose patients presenting to a tertiary hospital. Eligible patients were surveyed once they were medically fit for psychiatric evaluation. Descriptive data were collected, including the Pierce Suicide Intent Scale (SIS). In response to 'how dangerous did you think this overdose was when you took the tablets?' patients marked a 10 cm VAS, with 0 = would be harmless, 10 = certain to cause death. A panel of clinical toxicologists independently made a risk assessment on a 10 cm VAS, with 0 = non-toxic ingestion and 10 = uniform lethality even with full medical intervention.
Of 202 patients enrolled, 118 (58.4%, 95% CI 51-65) were female; median age 33 years (interquartile range [IQR] 24-42). One hundred and three (51%, 95% CI 44-58) stated it was their intention to kill themselves and 44 (21.8%, 95% CI 16-28) wrote a suicide note. They most commonly used their own prescription medications (141, 69.8%, 95% CI 63-76). The median patient visual analog scale (VAS) was 5.8 (IQR 2.3-8.3) and median toxicology VAS was 1.4 (IQR 0.6-2.8); this difference was statistically significant (P < 0.0001). The correlation between the patient visual analog scale (VAS) and Pierce SIS (median 8.5/25 [IQR 4-12]) was strong (r= 0.73, P < 0.0001).
Patient perceptions of the lethality of their overdose are correlated with their suicidal intent as measured on the Pierce SIS, with a significant mismatch between patient perceptions and the toxicological risk assessment.
Emergency medicine Australasia: EMA 10/2011; 23(5):580-6. · 0.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine the prevalence of occult brain abnormalities in magnetic resonance imaging of active amphetamine users.
Prospective convenience study in a tertiary hospital emergency department (ED). Patients presenting to the ED for an amphetamine-related reason were eligible for inclusion. We collected demographic data, drug use data, and performed a mini-mental state examination (MMSE).
The proportion of patients with an abnormality on their MRI scan.
Of 38 patients enrolled, 30 had MRI scans. Nineteen were male and their mean age was 26.7 +/- 5.4 years (range 19-41 years). The mean age of first amphetamine use was 18 years (range 13-26 years). Sixteen patients used crystal methamphetamine (mean amount 2.5 g/week), nine used amphetamine ("speed") (mean amount 2.9 g/week), and 23 used ecstasy (mean amount 2.3 tablets/week). Marijuana was smoked by 26 (mean amount 5.9 g/week), and 28 drank alcohol (mean amount 207 g/week). The median MMSE score was 27/30 (interquartile range, 26-29). Abnormalities on brain MRI scans were identified in six patients, most commonly an unidentified bright object (n = 4).
In this pilot study of brain MRI of young people attending the ED with an amphetamine-related presentation, one in five had an occult brain lesion. While the significance of this is uncertain, it is congruent with evidence that amphetamines cause brain injury.
The Medical journal of Australia 09/2010; 193(5):266-8. · 3.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The editorial by Wallin and Fladby highlights the clinical importance of white matter hyperintensities on magnetic resonance imaging as a marker of small vessel disease in elderly people.1 Prevalence ranges from 11-21% at age 64 …
BMJ Clinical Research 12/2009; 341. · 14.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We aimed to describe the characteristics, clinical course, management and outcome of patients presenting to Perth teaching hospitals after envenoming by Tiger snakes. We undertook a chart review from six Perth teaching hospitals over a 16 year period from 1990 to 2005. Data were collected by a trained investigator using a preformatted data abstraction tool. We included patients bitten in the appropriate geographical area, with defibrination coagulopathy and positive Venom Detection Kit result for Tiger snake or response to specific antivenom. Of 381 charts reviewed, 23 patients were envenomed by a Tiger snake. The mean age was 36 years, 83% were male and all were bitten on a limb. First aid was applied poorly and all patients were symptomatic on presentation. Six patients developed rhabdomyolysis, one renal failure, four clinical bleeding, three neurotoxicity, one non-fatal respiratory arrest and one fatal cardiac arrest. All patients received antivenom, 13 received adrenaline premedication, with two mild allergic reactions developing in non-premedicated patients. The average dose of antivenom was four ampoules. Mean hospital stay was 2.6 days. This is the largest series of Tiger snake envenoming reported in Australia. Only one patient of 23 (4%) died, despite all patients being significantly envenomed. With rapid antivenom treatment and modem emergency and intensive care management, most patients envenomed by Tiger snakes survive.
Anaesthesia and intensive care 08/2009; 37(4):613-8. · 1.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Many patients present to dental clinics for treatment of painful conditions. Prior to seeking treatment, many of these patients will self-medicate with non-prescription analgesics (NPA), and some will unintentionally overdose on these products. The objective of this study is to describe the use of NPA among dental patients.
All adult patients presenting to an urban dental clinic during a two-week period in January and February of 2001 were approached to participate in this research project. Trained research assistants using a standardized questionnaire interviewed patients. Patient demographics and the NPA usage over the 3 days preceding the office visit were recorded. We defined a supra-therapeutic dose as any dose greater than the total recommended daily dose stated on package labeling.
We approached 194 patients and 127 participated. The mean age of participants was 35.5 years, 52% were male. Analgesic use preceding the visit was reported by 99 of 127 patients, and most (81/99) used a NPA exclusively. Fifty-four percent of NPA users were taking more than one NPA. NPA users reported using ibuprofen (37%), acetaminophen (27%), acetaminophen/aspirin combination product (8%), naproxen (8%), and aspirin (4%). Sixteen patients reported supra-therapeutic use of one or more NPA (some ingested multiple products): ibuprofen (14), acetaminophen (3), and naproxen (5).
NPA use was common in patients presenting to a dental clinic. A significant minority of patients reported excessive dosing of NPA. Ibuprofen was the most frequently misused product, followed by naproxen and acetaminophen. Though mostly aware of the potential toxicity of NPA, many patients used supra-therapeutic dosages.
BMC Oral Health 01/2009; 8:33. · 1.15 Impact Factor
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[Show abstract][Hide abstract] ABSTRACT: To determine the correlation between plasma and saliva paracetamol levels following paracetamol deliberate self-poisoning.
Paired plasma and saliva paracetamol levels were measured. Saliva analysis was performed contemporaneously using a colorimetric method.
21 patients (76% female) mean age 28.3 +/- 12.9 years (range 15-55) were enrolled. Mean reported paracetamol ingestion was 10.3 g (range 2-20 g). Specimens were collected at a mean of 6.2 +/- 3.1 hours post-ingestion (range 4-13 hours) and mean plasma and saliva paracetamol levels were 48 mg/L and 62 mg/L respectively (mean difference 14; 95% CI 5-22; p < 0.004); Pearson's correlation r = 0.95 (p < 0.0001). No patient needing treatment would have been missed using saliva levels only.
There is concordance between the indications for treatment of paracetamol deliberate self-poisoning based on plasma and saliva paracetamol levels. Saliva paracetamol levels are typically higher than plasma levels. Further studies involving larger numbers of patients, comparing plasma and saliva paracetamol levels in patients with potentially toxic plasma paracetamol concentrations, would be useful in determining the potential clinical value of this method.
[Show abstract][Hide abstract] ABSTRACT: Paracetamol is involved in a large proportion of accidental paediatric exposures and deliberate self-poisoning cases, although subsequent hepatic failure and death are both uncommon outcomes. The optimal management of most patients with paracetamol overdose is usually straightforward. However, several differing nomograms and varying recommendations regarding potential risk factors for hepatic injury introduce complexity. In order to reconcile management advice with current Australasian clinical toxicology practice, revised guidelines have been developed by a panel of clinical toxicologists consulting to the poisons information centres in Australia and New Zealand using a workshop and consultative process. This article summarises the rationale for the recommendations made in these new guidelines.
The Medical journal of Australia 04/2008; 188(5):296-301. · 3.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Tiagabine is an anticonvulsant acting by selective inhibition of neuronal and glial gamma-aminobutyric acid uptake, resulting in increased gamma-aminobutyric acid-mediated inhibition in the brain. Few reports in the literature describe the clinical course of severe tiagabine intoxication. A 44-year-old woman presented after deliberate self-poisoning with 100 tiagabine 15 mg tablets (1,500 mg; 25 mg/kg). Serum tiagabine level was 4,600 microg/L (1,725 mmol/L) at presentation, 20 times levels associated with therapeutic dosing. Intoxication was manifested by profuse vomiting, coma, myoclonus, generalized rigidity, bradycardia, hypertension, hypersalivation and generalized piloerection within 2 h of ingestion. The patient was intubated and management was supportive. Coma lasted until 10 h post-ingestion, but recovery was complicated by severe agitated delirium lasting 12 h. The patient recovered fully within 26 h of ingestion. Tiagabine deliberate self-poisoning was associated with the rapid onset of coma and an unusual toxidrome. Recovery, although complicated by agitated delirium, was complete within 26 h.
Emergency medicine Australasia: EMA 01/2008; 19(6):556-8. · 1.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe the prevalence, characteristics and outcomes of amphetamine-related presentations to a tertiary hospital emergency department (ED).
Prospective observational study of amphetamine-related presentations to the ED of the Royal Perth Hospital (RPH), an adult, inner-city, tertiary referral hospital, between 3 August and 2 November 2005. For all patients presenting to the ED, the treating doctors were automatically prompted by the computerised data entry system to consider amphetamine use.
Proportion of ED presentations related to amphetamine use; demographic features and usage practices of amphetamine users; characteristics of presentations and admissions; associated psychiatric illnesses and use of other drugs.
Over the study period, there were 13 125 presentations, of which 156 (1.2%) were judged to be causally related to amphetamine use. Of those 156 patients, over half were habitual drug users (89 [57.1%] used amphetamines at least weekly), and the majority were men (111 [71.2%]). The mean age was 28 years (range, 16-55 years). Presentations were of high acuity: 104 patients [66.7%] were rated 1, 2 or 3 on the Australasian Triage Scale; 50 (32.1%) arrived by ambulance; and 25 (16.0%) arrived with police. The mean time spent in the ED was 6 h (range, 0.5-24 h). Fifty patients (32.1%) required sedation, and the likelihood of requiring sedation increased almost threefold if the heart rate was over 100 beats/min on presentation. Sixty-two patients (39.7%) were admitted and 58 (37.2%) required psychiatric evaluation. Repeat attendance was common, with 71 patients (45.5%) having previous amphetamine-related presentations to the RPH ED.
Amphetamine-related presentations comprise 1.2% of all ED attendances and have a major impact on hospital EDs. Patients are often agitated and aggressive, require extensive resources, and frequently re-attend. The burden of amphetamine-related illnesses on EDs is likely to increase in the future.
The Medical journal of Australia 05/2007; 186(7):336-9. · 3.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A 29-year-old woman presents shortly after a massive overdose of carbamazepine controlled-release tablets. In anticipation of coma, she is electively intubated to safely enable gastrointestinal decontamination with nasogastric activated charcoal. She is admitted to the intensive care unit for ongoing supportive care, and further doses of activated charcoal are prescribed to enhance elimination of carbamazepine. Carbamazepine levels remain high and haemodialysis is carried out to further enhance elimination. Her coma resolves as levels fall, but clinical progress is complicated by anticholinergic delirium, ileus and bowel obstruction from charcoal concretions. She survives to medical discharge on day 12.
Emergency Medicine Journal 12/2006; 23(11):869-71. · 1.78 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: An asymptomatic 18 month old child presents to the emergency department of a small district hospital shortly after ingesting two unidentified tablets. A small number of pharmaceuticals and illicit drugs may produce life threatening toxicity in a small child if ingested even in one or two dose units and the onset of toxicity may be delayed for some agents. Following risk assessment, a rational management plan is devised and the child is carefully monitored. The patient is observed overnight and discharged home the following day.
Emergency Medicine Journal 10/2006; 23(9):718-20. · 1.78 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A teenager ingests 375 mg of glipizide and 14.5 g of melformin intentionally in a small country town. She presents to the local medical facility with symptoms and signs of hypoglycaemia. Using a risk assessment based approach, the management of suiphonylurea and metformin overdose is discussed. Sulphonylurea overdose invariably results in profound hypoglycaemia that requires resuscitation with IV dextrose and the use of octreotide as an antidote. Metfonnin overdose rarely causes problems.
Emergency Medicine Journal 08/2006; 23(7):565-7. · 1.78 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Early assessment and management of poisoning constitutes a core emergency medicine competency. Medical and psychiatric emergencies coexist; the acute poisoning is a dynamic medical illness that represents an acute exacerbation of a chronic underlying psychosocial disorder. The emergency physician must use an approach that ensures early decisions address potentially time critical interventions, while allowing management to be tailored to the individual patient's needs in that particular medical setting. This article outlines a rationale approach to the management of the poisoned patient that emphasises the importance of early risk assessment. Ideally, this approach should be used in the setting of a health system designed to optimise the medical and psychosocial care of the poisoned patient.
Emergency Medicine Journal 06/2006; 23(5):396-9. · 1.78 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although clinical trials of the antipsychotic amisulpride revealed no cardiac adverse effects, four patients with severe cardiac toxicity after overdose were reported to Australian poisons information centres in 2004-2005. All four had QT prolongation over 500 ms, two had rate-dependent bundle branch block, two developed torsades de pointes, and one died after cardiac arrest. Pending further studies, we recommend electrocardiogram assessment until at least 16 h after amisulpride overdose and, if QT interval is prolonged, cardiac monitoring until the patient is clinically well and conduction intervals are normal.
The Medical journal of Australia 05/2006; 184(7):354-6. · 3.79 Impact Factor