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Biomedical subjects

George A Jelinek

Publications and source records attributed to George A Jelinek.

18 recordsLinked to original sources
PubMed2006

The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments.

OBJECTIVE: To examine the relationship between hospital and emergency department (ED) occupancy, as indicators of hospital overcrowding, and mortality after emergency admission. DESIGN: Retrospective analysis of 62 495 probabilistically linked emergency hospital admissions and death records. SETTING: Three tertiary metropolitan hospitals between July 2000 and June 2003. PARTICIPANTS: All patients 18 years or older whose first ED attendance resulted in hospital admission during the study period. MAIN OUTCOME MEASURES: Deaths on days 2, 7 and 30 were evaluated against an Overcrowding Hazard Scale based on hospital and ED occupancy, after adjusting for age, diagnosis, referral source, urgency and mode of transport to hospital. RESULTS: There was a linear relationship between the Overcrowding Hazard Scale and deaths on Day 7 (r=0.98; 95% CI, 0.79-1.00). An Overcrowding Hazard Scale>2 was associated with an increased Day 2, Day 7 and Day 30 hazard ratio for death of 1.3 (95% CI, 1.1-1.6), 1.3 (95% CI, 1.2-1.5) and 1.2 (95% CI, 1.1-1.3), respectively. Deaths at 30 days associated with an Overcrowding Hazard Scale>2 compared with one of <3 were undifferentiated with respect to age, diagnosis, urgency, transport mode, referral source or hospital length of stay, but had longer ED durations of stay (risk ratio per hour of ED stay, 1.1; 95% CI, 1.1-1.1; P<0.001) and longer physician waiting times (risk ratio per hour of ED wait, 1.2; 95% CI, 1.1-1.3; P=0.01). CONCLUSIONS: Hospital and ED overcrowding is associated with increased mortality. The Overcrowding Hazard Scale may be used to assess the hazard associated with hospital and ED overcrowding. Reducing overcrowding may improve outcomes for patients requiring emergency hospital admission.

Adolescent↗
PubMed2006

Impact of streaming "fast track" emergency department patients.

OBJECTIVE: Fast track systems to stream emergency department (ED) patients with low acuity conditions have been introduced widely, resulting in reduced waiting times and lengths of stay for these patients. We aimed to prospectively assess the impact on patient flows of a fast track system implemented in the emergency department of an Australian tertiary adult teaching hospital which deals with relatively few low acuity patients. METHODS: During the 12-week trial period, patients in Australasian Triage Scale (ATS) categories 3, 4 and 5 who were likely to be discharged were identified at triage and assessed and treated in a separate fast track area by ED medical and nursing staff rostered to work exclusively in the area. RESULTS: The fast track area managed 21.6% of all patients presenting during its hours of operation. There was a 20.3% (-18 min; 95%CI, -26 min to -10 min) relative reduction in the average waiting time and an 18.0% (-41 min; 95%CI, -52 min to -30 min) relative reduction in the average length of stay for all discharged patients compared with the same period the previous year. Compared with the 12-week period before the fast track trial, there was a 3.4% (-2.1 min; 95%CI, -8 min to 4 min) relative reduction in the average waiting time and a 9.7% (-20 min; 95%CI, -31 min to -9 min) relative reduction in the average length of stay for all discharged patients. There was no increase in the average waiting time for admitted patients. This was despite major increases in throughput and access block in the study period. CONCLUSION: Streaming fast track patients in the emergency department of an Australian tertiary adult teaching hospital can reduce waiting times and length of stay for discharged patients without increasing waiting times for admitted patients, even in an ED with few low acuity patients.

Aged↗
PubMed2006

Blood cultures ordered in the adult emergency department are rarely useful.

OBJECTIVES: Although blood cultures are commonly ordered in the emergency department, there is controversy about their utility. This study aimed to determine the usefulness of blood cultures in the management of patients presenting to a tertiary adult teaching hospital emergency department in Perth, Western Australia. METHODS: A detailed chart review was undertaken of all blood cultures taken in our emergency department over a 2-month period. All patients within the hospital having blood cultures taken were identified; from this group, blood cultures originating from the emergency department were reviewed. Data were collected concerning patient demographics, culture indication, vital signs, culture outcome, disposition and alterations in management resulting from the blood culture. RESULTS: 218 blood cultures were ordered from the emergency department during the study period. This represented 4.0% (218/5478) of the total number of patients seen. Of the 218 cultures, only 30 were positive (13% of the study population), with 16 (7.3%) probable contaminants and 14 (6.4 %) true positives. No anaerobic isolates were identified. Of the 14 significantly positive blood cultures, the result influenced management in six patients, resulting in a useful culture rate of 2.8% (6/218). CONCLUSION: Blood cultures are ordered on a significant number of patients seen in the emergency department but rarely alter management. Our findings in conjunction with other studies suggest that eliminating blood cultures in immunocompetent patients with common illnesses such as urinary tract infection, community acquired pneumonia and cellulitis, may significantly reduce the number of blood cultures, producing substantial savings without jeopardizing patient care. This needs prospective study and validation.

Adolescent↗
PubMed2006

Community senior first aid training in Western Australia: its extent and effect on knowledge and skills.

OBJECTIVE: To define the extent of Senior First Aid training in a sample of the Western Australian community, and to evaluate the effect of previous training on first aid knowledge and skills. METHODS: A telephone survey of a random sample from suburban Perth and rural Western Australia; and practical assessment of first aid skills in a subsample of those surveyed. RESULTS: 30.4% of respondents had completed a Senior First Aid certificate. Trained individuals performed consistently better in theoretical tests (p=0.0001) and practical management of snakebite (p=0.021) than untrained. However, many volunteers, both trained and untrained, demonstrated poor skills in applying pressure immobilisation bandaging and splinting the limb adequately despite electing to do so in theory. CONCLUSIONS AND IMPLICATIONS: Overall knowledge and performance of first aid skills by the community are poor, but are improved by first aid training courses.

Age Factors↗
PubMed2006

B-type natriuretic peptide in the diagnosis of heart failure in the emergency department.

B-type natriuretic peptide (BNP) is increasingly being used as a diagnostic marker in the diagnosis of heart failure. Here we evaluate the evidence base for its utility in the ED. Clinical trials suggest that it is more accurate than clinical acumen especially when emergency physicians have diagnostic problems. BNP appears more accurate than any clinical findings or radiological signs. In conjunction with considered clinical judgement, knowledge of its limitations and variable cut-off points, BNP can be of considerable utility to the emergency physician.

Age Factors↗
PubMed2005

CPR before defibrillation in out-of-hospital cardiac arrest: a randomized trial.

OBJECTIVE: Current resuscitation guidelines recommend that defibrillation be undertaken as soon as possible in patients suffering a cardiac arrest where the cardiac rhythm is either ventricular fibrillation (VF) or ventricular tachycardia (VT). Evidence from animal and clinical studies suggests that outcomes may be improved if a period of cardiopulmonary resuscitation (CPR) is given prior to defibrillation. The objective of this study was to determine if 90 seconds of CPR before defibrillation improved survival. METHODS: Patients suffering non-paramedic witnessed VF/VT cardiac arrest were randomized to receive either 90 seconds of CPR before defibrillation (treatment) or immediate defibrillation (control). The study was carried out in Perth, Western Australia between June 2000 and June 2002. The primary endpoint was survival to hospital discharge with secondary endpoints of return of spontaneous circulation (ROSC) and survival at 1 year. RESULTS: A total of 256 patients underwent randomization. Baseline characteristics including response intervals were similar in both groups. Survival to hospital discharge in the CPR first group was 4.2% (5/119) compared with 5.1% (7/137) for the immediate defibrillation group (OR 0.81; 95%CI. 0.25-2.64). No difference in those achieving ROSC was observed between the groups (OR 1.16; 95% CI 0.49-2.80). CONCLUSION: Ninety seconds of CPR before defibrillation does not improve overall survival in patients suffering VF/VT cardiac arrests. Further studies to evaluate various aspects of this treatment strategy are required as published outcomes to date are inconclusive.

Adolescent↗
PubMed2005

A double-blind, randomized trial of intravenous versus intramuscular antivenom for red-back spider envenoming.

OBJECTIVE: To compare the efficacy of intravenous versus intramuscular antivenom (AV) in the treatment of Red-back spider (RBS) envenoming. METHODS: Randomized, double-dummy, double-blind, multicentre trial of patients with red-back spider envenoming requiring AV treatment recruited from five hospital EDs in Western Australia. RESULTS: Thirty-five patients were recruited; two were excluded; 33 were available for initial analysis, but two who were unblinded after one ampoule of trial AV and given i.v. AV had limited data; 31 remained in the study and had more complete data. After AV, pain scores for both i.m. and i.v. groups improved rapidly. At 24 h, the i.v. group was better with a 55% absolute difference (76% vs. 21%; 95% CI 25-85% difference) in the proportion pain-free. There were no safety issues. CONCLUSIONS: Red-back spider antivenom was initially effective by both i.m. and i.v. routes. The study generates the hypothesis that at 24 h, significantly more patients are pain-free with i.v. administration. Definitive recommendations on the optimal route of administration of RBS AV await the results of further studies.

Adolescent↗
PubMed2005

Patient delay and use of ambulance by patients with chest pain.

OBJECTIVE: To identify the reasons why patients with chest pain delay in seeking hospital medical care and do or do not use an ambulance. METHODS: One hundred and fifty-one patients with an ED diagnosis of acute myocardial infarction or angina were interviewed about demographic characteristics, medical history, symptom onset, time taken before deciding to call an ambulance or go to hospital (delay time) and transport used. Multiple logistic regression determined independent predictors of late presentation (delay time>30 min) and ambulance use. RESULTS: One hundred and twelve (74.2%, 95% CI 67.0-81.0%) patients delayed more than 30 min. Independent predictors of late presentation were: seeing a general practitioner (GP) (P=0.001), having prior heart problems (P=0.009) and symptoms occurring at night (P=0.036). Eighty-one (54.7%, 95% CI 47.0-63.0%) patients used an ambulance. Predictors of ambulance use were increased age (P=0.025) and having ambulance insurance (P=0.018), although there was interaction between these variables. CONCLUSIONS: Education programmes should continue to emphasize that chest pain is a potential medical emergency and an ambulance should be called. GPs should consider developing an action plan to manage patients presenting with chest pain.

Ambulances↗
PubMed2003

Jellyfish envenoming syndromes: unknown toxic mechanisms and unproven therapies.

Interest in envenoming syndromes caused by Australian jellyfish has been intense since the deaths in early 2002 of two tourists in Queensland, attributed to the Irukandji syndrome. We review current knowledge of these envenoming syndromes, mechanisms of venom action and therapy, focusing on the deadly box jellyfish, Chironex fleckeri, and the array of jellyfish thought to cause the Irukandji syndrome. Current understanding of jellyfish venom activity is very limited, and many treatments are unproven and based on anecdote.

Animals↗
PubMed2002

Identification of PLA(2) and alpha-neurotoxin proteins in the venom of Pseudonaja affinis (dugite).

The Western brown snake Pseudonaja affinis (dugite), common to the Perth area of Western Australia, possesses one of the most lethal venoms in the world. Little is known, however, about the toxic protein constituents of the venom, other than those causing coagulopathic and procoagulant effects. The current study was therefore undertaken in order to identify other protein constituents and activities present. Crude venom induced a contraction in rat tracheal preparations through phospholipase A(2) (PLA(2)) activity, as shown by the complete and partial inhibition of contraction by PLA(2) inhibitors 4-bromophenacyl bromide and quinacrine. Further, a reduced degree of smooth muscle contraction in the presence of the leukotriene receptor antagonist SKF104353 suggested that this effect was mediated by leukotriene metabolites. The venom-induced contraction did not reoccur upon a second administration of the venom, despite the muscle retaining its contractile function and appearing histologically undamaged. Chromatographic separation of the protein constituents of the venom showed that PLA(2) activity was associated with all protein fractions. A low-molecular-weight component of the venom was further investigated through N-terminal sequencing and found to possess high identity to the short-chain alpha-neurotoxin family of toxins. Venom activity on cultured rat cardiac myocytes and cultured cortical neurons was also examined. The crude venom was found to temporarily inhibit the beating of the cardiac myocytes, after which the beating resumed erratically. Cortical neurons, however, were irreversibly affected, showing concentration-dependent cell death.

Amino Acid Sequence↗
PubMed2002

Community competence in cardiopulmonary resuscitation.

The aim of this study was to determine community application of cardiopulmonary resuscitation (CPR) skills in an emergency, and, thus, assess the value of training programmes in raising community competence. A cross-sectional telephone survey of the Western Australian population was chosen randomly (n = 803). An urban sub-sample (n = 100) performed a practical demonstration of CPR skills using a simulated collapse scenario using a recording manikin as the victim. Performance was assessed by two observers using pre-determined criteria. Of all respondents, 64% had been trained in CPR. Practical and theoretical assessment scores were significantly better in trained versus untrained participants. The number of times a person was trained in CPR was more effective for retention and competence than time since last trained. Degree of training and theoretical competence were less in those aged over 65 years or with heart disease in the household. Theoretical competence poorly reflected practical performance in many tasks. This study provides a comprehensive database of CPR training and performance, and highlights future directions to ensure appropriate and cost-effective training. Specific factors to be addressed include increasing frequency of training, targeting of high-risk groups, simplification in teaching, and emphasising early activation of the emergency medical system.

Australia↗
PubMed2002

Thrombolysis for acute myocardial infarction in Australasia 1999.

OBJECTIVE: To describe revascularization practice for acute myocardial infarction in a sample of Australasian hospitals during 1999. DESIGN: Survey for the 1999 calendar year. SETTING: Hospitals with Australasian College for Emergency Medicine-accredited emergency departments in Australia and New Zealand. PARTICIPANTS: Forty-eight hospitals of 80 surveyed (60%), comprising 15 tertiary and 33 non-tertiary hospitals. MAIN OUTCOME MEASURES: Time from arrival in emergency department to initiation of thrombolytic therapy, site of therapy, agent used, mortality and intracranial haemorrhage rates. RESULTS: Approximately 30% of patients with acute myocardial infarction had revascularization therapy. Sixty-two per cent of patients receiving thrombolytics were given this treatment in the emergency department, the remainder in the coronary care unit. Overall median door-to-needle times were 35.0 min emergency department versus 48.3 min coronary care unit. Streptokinase was used for 58.3% of thrombolysis. In-hospital mortality of thrombolysed patients was 6.7% in the emergency department versus 4.3% in the coronary care unit with intracranial haemorrhage rates of 0.8% emergency department and 0.7% coronary care unit. CONCLUSIONS: Overall times to thrombolysis and outcome rates in this sample were within internationally reported figures. Emergency department times were shorter than in coronary care unit.

Aged↗
PubMedDate not supplied

Time for change.

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Emergency Medicine↗
PubMedDate not supplied

Cross reactivity between venomous, mildly venomous, and non-venomous snake venoms with the Commonwealth Serum Laboratories Venom Detection Kit.

OBJECTIVE: Studies have noted the relatively common occurrence of positive urine results with the Commonwealth Serum Laboratories Venom Detection Kit (VDK) when testing patients with suspected snakebite who are not envenomed. Possible explanations have been false positive test results or subclinical envenoming. We investigated a third possibility, that there is potential for the venom (or saliva) from mildly venomous and non-venomous snakes to give a positive reading with the VDK. METHODS: Venoms/saliva from three non-venomous and seven mildly venomous snake species were tested in the laboratory with the VDK, along with control venoms from four of the five major snake genera (Brown snake, Tiger snake, Death adder and Black snake). RESULTS: Two of the venom/saliva samples, from Gould's hooded snake (Parasuta gouldii), a mildly venomous snake, and the Black-headed python (Aspidites melanocephalus), a non-venomous snake, caused a positive test for the tiger snake genus. There was also cross-reactivity between black snake venoms and the tiger snake well of the VDK. CONCLUSIONS: This study provides a further possible explanation for 'false positive' VDK results, that is venom/saliva presence or absorption from mildly or non-venomous snakes and cross reactivity with venomous snakes on VDK testing. It has implications for antivenom use should it ever be required for more severe envenoming syndromes from mildly or moderately venomous snakes, and for further research. It reinforces the practice of only using VDK testing in patients who show definite evidence of envenoming.

Animals↗
PubMedDate not supplied

Antivenom dosing in 35 patients with severe brown snake (Pseudonaja) envenoming in Western Australia over 10 years.

OBJECTIVE: To investigate the doses of antivenom administered to adult patients with severe brown snake envenoming. DESIGN AND SETTING: Review of charts from Western Australian adult teaching hospitals, December 1991 to December 2001. PATIENTS: 35 patients with severe brown snake envenoming, defined prospectively as afibrinogenaemia (< 0.3 g/L) after a bite by a brown snake (genus Pseudonaja). MAIN OUTCOME MEASURE: The dose of antivenom required to neutralise venom, defined prospectively as the dose of antivenom given before the return of detectable fibrinogen levels. RESULTS: Of 88 patients with brown snake envenoming admitted over the 10 years, at least 35 had severe envenoming. Afibrinogenaemia persisted for 10 hours (range, 1.4-68 hours) after the first dose of antivenom; in four patients afibrinogenaemia lasted more than 24 hours. The dose of antivenom given before venom neutralisation ranged from one to 23 ampoules. In two-thirds of cases, venom was neutralised with five ampoules, and 89% had venom neutralised with 10 ampoules. Two patients died, and another had serious bleeding complications. Another patient died during the study period from intracerebral haemorrhage, but did not have fibrinogen levels measured. CONCLUSIONS: Patients received initial doses of antivenom too small to neutralise circulating venom, and remained afibrinogenaemic for prolonged periods, with serious consequences. The authors now use 10 ampoules as an initial dose in severe brown snake envenoming.

Animals↗